National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan - 2014

National survey for noncommunicable disease risk factors and mental health using approach in Bhutan – 2014

WHO STEPS

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia. National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan, 2014. 1. Tobacco use - statistics and numerical data. 2. Alcohol Drinking – statistics and numerical data. 3. Diet - statistics and numerical data. 4. Cardiovascular diseases statistics and numerical data. 5. Uterine Cervical Neoplasms. 6. Suicide - statistics and numerical data. 7. Surveys and questionnaires. I. Bhutan. ISBN 978-92-9022-500-3 (NLM classification: WA 900)

Contributors: Tandin Dorji, Wangchuk Dukpa, Karma Doma, Dorji Pelzom, Mongal Sing Gurung, Lubna Bhatti, Dhirendra N Sinha, Renu Garg and Naveen Agarwal.

© World Health Organization 2015 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from SEARO Library, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: searolibrary@who.int). 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. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. 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. This publication does not necessarily represent the decisions or policies of the World Health Organization. Printed in India

Contents List of figures........................................................................................................................................... v List of tables..........................................................................................................................................viii Acronyms..............................................................................................................................................xiv Message ............................................................................................................................................... xv Foreword ............................................................................................................................................. xvii Acknowledgement................................................................................................................................xix Executive summary................................................................................................................................xxi 1. Introduction........................................................................................................................................1 2. Methods..............................................................................................................................................3 3. Background characteristics .................................................................................................................7 STEP 1: Behavioural measurements 4. Tobacco use........................................................................................................................................9 5: Alcohol consumption.........................................................................................................................15 6. Dietary habits....................................................................................................................................20 7. Dietary salt .......................................................................................................................................23 8. Physical inactivity...............................................................................................................................27 9. History of raised blood pressure.........................................................................................................31 10. History of raised blood glucose........................................................................................................33 11. History of raised total cholesterol.....................................................................................................34 12. History of cardiovascular diseases....................................................................................................35 13. Lifestyle advice................................................................................................................................36 14. Mental health..................................................................................................................................37 15. Family history of chronic disease conditions.....................................................................................41 STEP 2: Physical measurements 16. Physical measurements....................................................................................................................42 STEP 3: Biochemical measurements 17. Biochemical measurements..............................................................................................................45 18. Combined risk factors and cardiovascular diseases risk prediction....................................................48

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19. Discussions and recommendations...................................................................................................50 Bibliography..........................................................................................................................................54 Annexes 1. Data tables.....................................................................................................................................56 2. STEPS Instruments........................................................................................................................107 3. Fact sheet – Risk factors................................................................................................................122 4. Fact sheet – Tobacco....................................................................................................................125

List of figures Figure 3.1: Figure 4.1: Figure 4.2: Figure 4.3 Figure 4.4 Figure 4.5 Figure 4.6 Figure 4.7 Figure 4.8 Figure 4.9 Figure 5.1 Figure 5.2 Figure 5.3 Figure 5.4 Figure 5.5 Figure 5.6 Figure 5.7 Figure 5.8 Figure 6.1 Figure 6.2 Figure 6.3 Figure 6.4 Figure 6.5 Respondents by age, sex and residence ................................................................... 7 Percentage of current tobacco users by age groups, residence and sex.................... 9 Percentage of current tobacco smokers by age groups, residence and sex............. 10 Percentage of current smokers smoking by product and sex................................... 10 Proportion of never smokers, former smokers, non-daily and daily users of smoked tobacco products by sex............................................................................ 11 Percentage of current smokeless users by age groups, residence and sex............... 11 Proportion of never users, past users, non-daily and daily users of smokeless tobacco products classified by sex.......................................................... 12 Percentage of smokeless tobacco products using by current smokeless tobacco users ........................................................................................ 12 Percentage of respondents who reported being exposed to second-hand smoke at home or in the workplace classified by sex.......................... 13 Percentage of respondents who noticed information in the media about the dangers of smoking or that encourages quitting during past 30 days............... 14 Alcohol consumption status by sex......................................................................... 15 Having stopped drinking due to health reasons...................................................... 15 Frequency of alcohol consumption in the past 12 months...................................... 16 Frequency of alcohol consumption in the past 7 days among current (past 30 days) drinkers............................................................................... 16 Percentage of respondents drinking pure alcohol at different levels among all respondents on average per occasion classified by sex........................... 17 Percentage current (past 30 days) drinkers with different drinking levels classified by sex...................................................................................................... 17 Heavy episodic drinking on a single occasion at least once during the past 30 days.......................................................................................... 18 Consumption of unrecorded alcohol by sex, age and residence of respondents...... 19 Mean number of days fruits are consumed in a typical week by age, sex and residence....................................................................................... 20 Mean number of days vegetables are consumed in a typical week by age, sex and residence....................................................................................... 20 Mean number of servings of fruits consumed on average per day classified by sex, age and residence of respondents ............................................................. 21 Mean number of servings of vegetables consumed on average per day classified by sex and age of respondents............................................................................... 21 Mean number of servings of fruits and/or vegetables consumed on average per day by sex, age and residence of respondents................................ 22

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Figure 6.6 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7.4 Figure 7.5 Figure 7.6 Figure 7.7 Figure 8.1 Figure 8.2 Figure 8.3 Figure 8.4 Figure 8.5 Figure 8.6 Figure 8.7 Figure 9.1 Figure 9.2

Number of servings of fruit and/or vegetables on an average per day.................... 22 Percentage of adults who always or often add salt when cooking or preparing food at home classified by age and sex of respondents.......................... 23 Percentage of adults who always or often add salt before eating or when eating classified by age, sex and residence of respondents........................... 23 Percentage of adults who always or often consumed processed foods high in salt classified by age, sex and residence of respondents.............................. 24 Self-reported quantity of salt consumed................................................................. 24 Percentage of those who agreed with the importance of lowering salt in diet........ 25 Steps taken on a regular basis to reduce salt intake............................................... 25 Type of oil or fat most often used for meal preparation in households................... 26 Percentage not meeting WHO recommendations on physical activity for health..... 27 Level of total physical activity.................................................................................. 28 Mean minutes spent on physical activity on average per day ................................. 28 Percentage of respondents not doing any work-, transport-, or recreation-related physical activity........................................................................... 29 Contribution of work-, transport- and recreation-related physical activity to total activity....................................................................................................... 29 Percentage of respondents not engaging in vigorous physical activity.................... 30 Mean and median minutes spent on sedentary activity on a typical day................. 30 Blood pressure measurement and diagnosis among adults..................................... 31 Proportion of adults currently taking drugs (medication) for raised blood pressure prescribed by a doctor or health worker among those diagnosed, by sex and age................................................................ 31 Percentage of previously diagnosed hypertensive respondents who visited or received treatment from a traditional healer........................................................... 32

Figure 9.3

Figure 10.1 Blood sugar measurement and diagnosis................................................................ 33 Figure 11.1 Total cholesterol measurement and diagnosis......................................................... 34 Figure 12.1 Percentage of respondents having ever had a heart attack or chest pain from heart diseases or a stroke............................................................................... 35 Figure 12.2 Percentage of respondents currently taking aspirin/statins on a regular basis to prevent or treat heart disease............................................................................ 35 Figure 13.1 Lifestyle advice by doctor or health worker............................................................. 36 Figure 13.2 Percentage of female respondents who have ever had a screening test for cervical cancer among all female respondents........................................................ 36 Figure 14.1 Percentage of respondents who seriously considered attempting suicide in the preceding 12 months among all respondents......................................................... 37 Figure 14.2 Percentage of respondents who sought professional help among those who had considered attempting suicide in the preceding 12 months..................... 37

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Figure 14.3 Percentage of respondents who made a plan about how to attempt suicide in the preceding 12 months.................................................................................... 38 Figure 14.4 Percentage of respondents who have ever attempted suicide among all respondents....................................................................................................... 38 Figure 14.5 Percentage of respondents who have ever had anyone in their close family attempt suicide.................................................................................... 39 Figure 14.6 Percentage of respondents who have ever had anyone in their close family commit suicide.................................................................................... 39 Figure 14.7 Percentage of different methods used the last time suicide was attempted among those female respondents who have ever attempted suicide..... 40 Figure 15.1 Percentage of people with a family member who has been diagnosed with a chronic disease condition............................................................................. 41 Figure 16.1 BMI classifications of respondents by sex and age (excluding pregnant women) and residence........................................................... 42 Figure 16.2 Mean waist and hip circumference (cm) of respondents by sex ............................. 43 Figure 16.3 Mean blood pressure among all respondents, including those currently on medication for raised blood pressure, classified by age, sex and residence of respondents........................................................................... 43 Figure 16.4 Percentage of respondents with raised blood pressure by sex................................. 44 Figure 17.1 Mean fasting blood glucose (mg dl) classified by age, sex and residence................ 45 Figure 17.2 Percentage of respondents with raised blood glucose, including those on medication, classified by age, sex and residence..................................................... 46 Figure 17.3 Percentage of respondents with impaired fasting glycaemia, classified by sex, age and residence........................................................................ 46 Figure 17.4 Percentage of respondents with raised cholesterol, including those on medication, classified by sex, age and residence................................................ 47 Figure 17.5 Mean intake of salt classified by sex, age and residence ........................................ 47 Figure 18.1 Summary of risk factors.......................................................................................... 48 Figure 18.2 Percentage of respondents in age group 40–69 years with a 10-year CVD risk >30% or with existing CVD.............................................................................. 49

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List of tables Annex 1 Background characteristics Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Tobacco use Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 4.18 Percentage of current smokers by sex, age and residence of respondents.............. 58 Smoking status....................................................................................................... 58 Current daily smokers among smokers................................................................... 59 Mean age started smoking and mean duration of smoking among current daily smokers.................................................................................. 59 Manufactured cigarette smokers among daily smokers.......................................... 59 Manufactured cigarette smokers among current smokers...................................... 59 Mean amount of tobacco used by daily smokers by type........................................ 59 Percentage of current smokers smoking by products, sex and age......................... 60 Percentage of daily smokers smoking given quantities of manufactured or hand-rolled cigarettes per day................................................................................. 60 Former daily smokers (who don’t smoke currently) among respondents................. 60 Former daily smokers (who don’t smoke currently) among ever daily smokers....... 60 Mean years since cessation..................................................................................... 60 Current smokers who have tried to stop smoking in the last 12 months................. 61 Current smokers who have been advised by doctor to stop smoking...................... 61 Percentage of current users of smokeless tobacco by sex, age and residence of respondents........................................................................................ 61 Percentage of smokeless tobacco use history by sex and age................................. 61 Former daily smokeless tobacco users (who don’t use tobacco currently) among all respondents........................................................................................... 62 Former daily smokeless tobacco users (who don’t use tobacco currently) among ever daily users........................................................................................... 62 Age group and sex of respondents......................................................................... 55 Mean number of years of education....................................................................... 55 Highest level of education by sex and age.............................................................. 55 Marital status of respondents by sex and age......................................................... 56 Employment status of respondents by sex and age................................................ 56 Proportion unpaid work and unemployed among respondents by age and sex....... 57 Per capita annual income........................................................................................ 57

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Table 4.19 Table 4.20 Table 4.21 Table 4.22 Table 4.23 Table 4.24 Table 4.25 Table 4.26

Mean times per day smokeless tobacco used by daily smokeless tobacco users by type............................................................................................. 62 Percentage of current users of smokeless tobacco using each of the following products........................................................................................... 63 Percentage of current tobacco users by sex, age and residence of respondents...... 63 Daily tobacco users................................................................................................. 63 Exposed to second-hand smoke in home and workplace during the past 30 days.......................................................................................... 64 Percentage of all respondents who noticed information in media about the dangers of smoking or that encourages quitting during the past 30 days......... 64 Percentage of current smokers who noticed health warnings on cigarette packages during the past 30 days............................................................ 65 Percentage of current smokers who noticed health warnings on cigarette packages during the past 30 days that thought about quitting due to the health warnings they saw......................................................... 65 Average price paid for 20 manufactured cigarettes, based on the last manufactured cigarette purchase (in Ngultrum)............................................... 65

Table 4.27

Alcohol consumption Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Alcohol consumption status by sex and age........................................................... 66 Stop drinking due to health reasons....................................................................... 66 Frequency of alcohol consumption in the past 12 months...................................... 67 Mean number of drinking occasions in the past 30 days among current (past 30 days) drinkers........................................................................................... 67 Mean number of standard drinks per drinking occasion among current (past 30 days) drinkers........................................................................................... 67 Percentage of respondents drinking at high-end, intermediate and lower-end level among all respondents of pure alcohol on average per occasion by sex and age................................................................................... 68 Percentage of current (past 30 days) drinkers with different drinking levels............ 68 Mean maximum number of standard drinks consumed on one occasion in the past 30 days................................................................................................. 68 Six or more drinks on a single occasion at least once during the past 30 days among total population............................................................................. 69 Mean number of times with six or more drinks during a single occasion in the past 30 days among current drinkers............................................................ 69 Frequency of alcohol consumption in the past 7 days............................................. 69 Mean number of standard drinks and unrecorded alcohol consumed on average per day in the past 7 days among current drinkers.................................... 70 Consumption of unrecorded alcohol by sex, age and residence of respondents...... 70

Table 5.7 Table 5.8 Table 5.9 Table 5.10 Table 5.11 Table 5.12 Table 5.13

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Table 5.14 Table 5.15 Table 5.16 Table 5.17 Table 5.18 Table 5.19

Percentage of unrecorded alcohol from all alcohol consumed during past 7 days... 70 Unrecorded alcohol consumption during the past 7 days by type........................... 71 Frequency of not being able to stop drinking once started during the past 12 months among past 12 month drinkers............................................... 71 Frequency of failing to do what was normally expected from you during the past 12 months among past 12 month drinkers.................................... 72 Frequency of needing a first drink in the morning to get going during the past 12 months among past 12 month drinkers.................................... 72 Frequency of family/partner problems due to someone else’s drinking during the past 12 months among all respondents................................... 73

Dietary habits Table 6.1 Table 6.2 Table 6.3 Table 6.4 Dietary salt Table 7.1 Table 7.2 Table 7.3 Table 7.4 Table 7.5 Table 7.6 Table 7.7 Table 7.8 Table 7.9 Salt consumption habits......................................................................................... 77 Percentage of people who think they consume far too much or too much salt....... 77 Self-reported quantity of salt consumed................................................................. 78 Percentage of respondents who agree with the importance of lowering salt in diet................................................................................................ 78 Percentage of respondents who think that consuming too much salt could cause serious health problems....................................................................... 79 Mean salt intake (g/day) by age, sex and residence................................................ 79 Techniques used on a regular basis to reduce salt intake........................................ 79 Type of oil or fat most often used for meal preparation in household..................... 80 Mean number of meals eaten outside a home........................................................ 80 Mean number of days fruit and vegetables consumed in a typical week................. 74 Mean number of servings of fruit and/or vegetables on average per day by sex, age and residence of respondents.............................................................. 74 Number of servings of fruit and/or vegetables on average per day......................... 75 Less than five servings of fruit and/or vegetables on average per day.................... 76

Physical inactivity Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 8.5 Table 8.6 Metabolic equivalent (MET).................................................................................... 81 Not meeting WHO recommendations on physical activity for health....................... 81 Level of total physical activity according to former recommendations..................... 81 Mean and median minutes of total physical activity on average per day................. 82 Mean minutes spent in work-, transport- and recreation-related physical activity on average per day........................................................................ 83 Median minutes spent on average per day in work-, transport- and recreation-related physical activity........................................................................... 83

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Table 8.7 Table 8.8 Table 8.9 Table 8.10

Percentage of respondents classified as doing no work-, transport- or recreational-related physical activity........................................................................ 84 Percentage of work, transport and recreational activity contributing to total activity....................................................................................................... 84 Percentage of respondents not engaging in vigorous physical activity.................... 85 Minutes spent in sedentary activities on average per day........................................ 85

Blood pressure Table 9.1 Table 9.2 Table 9.3 Table 9.4 Table 9.5 Table 9.6 Blood pressure measurement and diagnosis........................................................... 86 Currently taking drugs (medication) for raised blood pressure prescribed by doctor or health worker among those diagnosed.............................................. 86 Percentage of previously diagnosed hypertensive respondents who have visited or received treatment from a traditional healer............................................ 87 Mean blood pressure among all respondents, including those currently on medication for raised blood pressure...................................................................... 87 Percentage of respondents with raised blood pressure........................................... 88 Percentage of respondents with treated and/or controlled of raised blood pressure among those with raised blood pressure(SBP >140 and/or DBP > 90 mmHg) or currently on medication for raised blood pressure.................. 89 Mean heart rate (beats per minute) of respondents by sex and age....................... 89

Table 9.7

Blood glucose Table 10.1 Table 10.2 Table 10.3 Table 10.4 Table 10.5 Blood sugar measurement and diagnosis................................................................ 90 Percentage of respondents currently taking oral medication and insulin prescribed for diabetes among those previously diagnosed.......................... 90 Percentage of respondents who have sought advise or treatment from a traditional healer for diabetes among those previously diagnosed....................... 90 Mean fasting blood glucose results including those currently on medication for diabetes (non–fasting recipients excluded) by sex, age and residence..................... 91 Categorization of respondents into blood glucose level categories and percentage of respondents currently on medication for raised blood glucose (non–fasting recipients excluded) by sex and age............................. 91

Abnormal lipids Table 11.1 Table 11.2 Table 11.3 Mean total cholesterol among respondents including those currently on medication for raised cholesterol....................................................................... 93 Percentage of respondents with raised total cholesterol or on medication for raised cholesterol by sex and age...................................................................... 93 Total cholesterol measurement and diagnosis among respondents in last 12 month by sex and age..................................................................................................... 94

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Combined risk factors and cardiovascular disease risk prediction Table 12.1 Table 12.2 Table 12.3 Table 12.4 Summary of Combined Risk Factors........................................................................ 95 Percentage of respondents having ever had a heart attack or chest pain from heart disease or a stroke, by age and sex....................................................... 95 Percentage of respondents currently taking asprin/statins regularly to prevent or treat heart disease............................................................................ 96 Percentage of respondents aged 40–69 years with a 10–year cardiovascular disease (CVD) risk >30% or with existing CVD................................. 96

Lifestyle advice by health care provider Table 13.1 Table 13.2 Percentage of respondents who received lifestyle advice from a doctor or health worker during the past three months among all respondents.................. 97 Percentage of female respondents who have ever had a screening test for cervical cancer among all female respondents................................................... 98

Mental health Table 14.1 Table 14.2 Table 14.3 Table 14.4 Table 14.5 Table 14.6 Table 14.7 Table 14.8 Percentage of respondents who seriously considered attempting suicide in the last 12 months among all respondents......................................................... 99 Percentage of respondents who sought professional help among those who considered attempting suicide in the past 12 months............................................. 99 Percentage of respondents who made a plan about how to attempt suicide in the past 12 months............................................................................................ 99 Percentage of respondents who have ever attempted suicide among all respondents........................................................................................................... 99 Percentage of respondents who have attempted suicide in the past 12 months among those who have ever attempted suicide.................................. 100 Percentage of different methods used the last time suicide was attempted among those respondents who have ever attempted suicide:Women.................. 100 Percentage of respondents who sought medical care the last time they attempted suicide among those who have ever attempted suicide............... 100 Percentage of respondents who were admitted to the hospital due to the last time they attempted suicide among those who sought medical care for having ever attempted suicide......................................................................... 100 Percentage of respondents who have ever had anyone in their close family attempt suicide.......................................................................... 101

Table 14.9

Table 14.10 Percentage of respondents who have ever had anyone in their close family die from suicide......................................................................... 101 Family history of chronic disease conditions Table 15.1 Percentage with a family member who has been diagnosed with a chronic disease condition........................................................................... 102

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Overweight and obesity Table 16.1 Table 16.2 Table 16.3 Table 16.4 Table 16.5 Table 16.6 Table 16.7 Table 16.8 Mean height (cm) of respondents by sex and age................................................ 103 Mean weight (kg) of respondents by sex and age................................................ 103 Mean BMI (kg/m2) of respondents by sex and age............................................... 103 BMI classifications of respondents by sex and age................................................ 104 Percentage of respondents (excluding pregnant women) classified as overweight (BMI>25)......................................................................... 104 Mean waist circumference (cm) of respondents by sex and age........................... 105 Mean Hip circumference (cm) of respondents by sex and age.............................. 105 Mean waist / hip ratio among respondents by age and sex.................................. 105

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Acronyms BMI BP CI COPD CVD DALYs DBP body mass index blood pressure confidence interval chronic obstructive pulmonary disease cardiovascular disease disability-adjusted life years diastolic blood pressure

dl decilitre EA GYTS HDL enumeration areas Global Youth Tobacco Survey High-density lipoproteins

Hg mercury HLM JDWNRH MET mmol/L NCD NGO PDA PEN PHC PI PPS PSU SBP SEARO SSU WHA WHO WHO FCTC high-level meeting Jigme Dorji Wangchuk National Referral Hospital metabolic equivalents of task millimoles per litre noncommunicable disease nongovernmental organization personal digital assistant WHO Package of Essential NCD primary health care principal investigator probability proportionate to size primary sampling unit systolic blood pressure (WHO) South-East Asia Regional Office secondary sampling unit World Health Assembly World Health Organization WHO Framework Convention on Tobacco Control

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Message Noncommunicable diseases (NCDs) are the most common cause of morbidity and mortality worldwide and in the South-East Asia Region. Planning for NCD control needs persuasive evidence generated through a strong monitoring system and surveillance of NCD risk factors. The standard protocol of the STEPs Noncommunicable Disease Risk factors survey is an opportunity to strengthen strategies to control NCDs and compare them nationally or internationally at different time intervals. WHO welcomes the initiative of Bhutan’s Ministry of Health to undertake the Stepwise NCD risk factors survey, including physical measurement and biochemical investigations at the national level. This report, based on survey results, is historical, as it presents key findings from the nationally representative survey in Bhutan and provides new insights into the health status of Bhutan’s population. It is also praiseworthy that the Ministry of Health is promoting collaboration and multisectoral approaches through integrated surveillance to address major NCD risk factors. We commend Bhutan’s efforts to control NCDs. This survey is an example of Bhutan’s commitment. The WHO Regional Office for South-East Asia is committed to supporting and facilitating the STEPs survey and NCD-related surveillance activities in all Member States. We hope that Bhutan will use the rich data contained in this document to further strengthen its NCD control programme and improve the well-being of its population.

Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region

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ROYAL GOVERNMENT OF BHUTAN MINISTRY OF HEALTH THIMPHU: BHUTAM P.B. BOX: 726

Foreword The increasing trend of Non-Communicable Diseases worldwide is leading to huge stresses on health service resources. Bhutan, like its South Asian neighbours, is also seeing an increasing trend in NCDs. While infectious diseases continue to be a cause of concern this double burden of diseases due to increasing NCDs further taxes the scarce health resources and questions the sustainability of free healthcare that the Bhutanese enjoy. Although a STEPs survey was carried out in 2007, it was restricted to Thimphu urban area and did not provide nationally representative data. Therefore, this nationwide STEPs survey has been conducted at a most opportune time. The data generated will not only form the baseline for achieving the targets set in the Global NCD Action Plan but also guide the NCD Prevention and Control Programme in adopting the best strategies. It gives me great pleasure in releasing the report of the Bhutan STEPs survey 2014. The findings of the survey highlight the issues at hand. Salt consumption is very high, almost double the WHO recommended limit. Alcohol intake is very high, with 42.4% current drinkers and 22.4% binge drinkers. Although smoking is low (7.4%) use of smokeless tobacco is very high at 19.7%. Consumption of fruits and vegetables is low and almost half of the adult Bhutanese population (aged 18 to 69 years) do not engage in vigorous physical activity. A third of the adult population (aged 18 to 69 years) has high blood pressure but do not take medication. The information generated by the Survey will be of immense help to us in planning and designing appropriate strategies for prevention and control of NCDs so that they do not become a public health concern.

TASHI DELEK!

TANDIN WANGCHUK MINISTER

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Acknowledgement The Department of Public Health would like to thank the following for their support and contribution in successfully completing this nationwide STEPs survey: (1) (2) The health workers who tirelessly worked as enumerators and supervisors in carrying out the survey and ensuring a very high response rate. Leanne Riley and Dr Lubna Bhatti from WHO Headquarters, Geneva, Dr Dhirendra N Sinha, Dr Renu Garg, Mr Naveen Agarwal from WHO SEARO, Delhi, and Prof. Anand Krishnan, AIIMS, New Delhi, for their help in designing the survey and data analysis. The WHO, for providing financial, logistical and technical support for conducting the Survey. The working group: tt tt tt tt tt

(3) (4)

Tandin Dorji, Chief, Non-Communicable Diseases Division, Dept. of Public Health Wangchuk Dukpa, Sr. Program Officer, Lifestyle Related Diseases Division Karma Doma, Deputy Chief Program Officer, Lifestyle Related Diseases Division Dorji Pelzom, Sr. Statistician, Health Research and Epidemiology Unit Mongal Sing Gurung, Research Officer, Health Research and Epidemiology Unit

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Executive summary The emerging pandemic of noncommunicable diseases (NCDs) is creating major health challenges globally. The burden of NCDs is also increasingly affecting developing countries such as Bhutan. As is the case with other low- and middle-income countries, Bhutan faces a triple burden of disease: communi­ cable diseases, re-emerging diseases and escalated prevalence of noncommunicable eases, cancer, chronic obstructive pulmonary diseases and diabetes diseases. Cardiovascular dis­ have been identified by the World Health Organization (WHO) as the four major NCDs occurring worldwide. These diseases are driven by various forces, including ageing, rapid unplanned urbanization, and the globalization of unhealthy lifestyles. Most NCDs are the result of four particular behaviours (tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol) that lead to four key metabolic/physiological changes (raised blood pressure, overweight/obesity, raised blood glucose and raised cholesterol levels). To reduce NCDs it is important to focus on decreasing the risk factors as­ sociated with these diseases, and mapping the epidemic of NCDs and their risk factors. In Bhutan, the first NCD risk factor survey was conducted in 2007–2008 in urban Thimphu to determine the preva­ lence of modifiable behavioural risk factors at the subnational level; however, this survey did not cover biological risk factors. Against this backdrop, the current study was logical risk factors – the first ever of conducted in 2014 to collect national baseline data on bio­ its kind – and determine the distribution of modifiable behavioural risk factors (NCD risk factors) among the population.

Method This national NCD risk factor survey was conducted as a cross-sectional study from March to June 2014. Prior to data collection, ethical approval was sought from the independent Research Ethics Board of Health. The main objective of the survey was to estimate the prevalence of major NCD risk factors among the different population strata in Bhutan. A sample size of 2912 was used to represent the target population (18–69 year-old adults) in Bhutan. Multi­ stage cluster sampling using a mix of probability proportionate to size (PPS) and systematic random sampling was applied, using the sampling framework from Bhutan’s Census 2005, to select the participants. The primary sampling unit (PSU) of this survey was the “Geogs”, or blocks, in rural areas and towns in urban. Sixty three PSUs in rural areas and 53 in urban were selected. Twenty households were selected from each cluster using systematic sampling. One participant out of the eligible candidates (18–69 years) in each selected household was chosen to take part in the survey using the Kish method. The survey was conducted using the WHO Stepwise Noncommunicable Disease Risk Factor Survey( STEPS) methodology, which consists of three steps for measuring NCD risk factors including physical and biochemical measurements. Sociodemographic and behavioural information were collected in STEP I. Behavioural information included tobacco use, harmful alcohol consumption, low fruit and vegetable intake, history of raised blood pressure and blood glucose levels, and the degree of dietary salt consumption. Physical measurements such as height, weight and blood pressure were collected in STEP II. Biochemical measurements were collected in STEP III using sess fasting blood glucose and total cholesterol levels. Data were collected the dry chemistry to as­

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electronically using personal digital assistants (PDAs). Data cleaning was done using SPSS 16.0 and analysis undertaken using Epi Info 3.5.1 using prior developed analysis commands. Descriptive weighted analysis was also undertaken along with complex sample analysis.

Response rate Of the 2912 targeted respondents, 2822 (96.9%) participated in STEP I and 2816 (96.7%) in STEP II. In STEP III the response rate was lower: 93.5% for blood measurements and 89.9% for urine collection for population salt intake estimation.

Background characteristics Among the 2822 respondents who participated in the survey, 1074 (38.1%) were men and 1748 (61.9%) women. The median number of years of completed schooling was 3.8 years for men and 2.8 years for women. With regard to marital status, 80.7% of respondents were married at the time of the survey. With regard to employment status, 27.7% of respondents were involved in unpaid work, 55.2% were self-employed, 5.3% were non-government employees and 11.7% were government employees.

Tobacco use The prevalence of tobacco use, both smoked and smokeless combined, was 24.8%. Nearly one third of men (33.6%) use either form of tobacco; however, among women this proportion was 13.6%. The prevalence of tobacco smoking among respondents was 7.4% (10.8% for men and 3.1% for women). This proportion increased with age among both sexes. Likewise, the prevalence of current daily smoking was 4.3% overall (men 6.0%, women 2.1%). On average, respondents started to smoke at the age of 18.9 years. About 84.1% of current daily smokers smoked manufactured cigarettes. The prevalence of smokeless tobacco use was 19.7% (men 26.5%, women 11.0%). Around 95.5% of current users consumed chewing tobacco and snuff by mouth followed by 6.1% chewing betel quid. Nearly one in five respondents (20.7%) at home and a quarter (24.6%) of respondents at the workplace had been exposed to second-hand smoke during the 30 days preceding the survey.

Alcohol consumption Nearly half of all men (50.0%) and one third of women (32.8%) surveyed drank alcohol in the preceding 30 days. Among those who drank in the preceding 12 months, 16.9% (men 20.4%, women 10.7%) drank daily. More three in ten men (29.0%), and nearly one in seven women (14.1%) were binge (heavy) drinkers (≥60 g of pure alcohol for men or ≥40 g for women on a single occasion). About 58% of alcohol consumed was home-brewed or from other unrecorded sources. Consumption of “unrecorded alcohol” was higher in rural areas than urban areas (64.2% versus 42.4%).

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Fruit and vegetable consumption The surveyed population ate fruit on an average of 1.7 days in a typical week. Vegetable consumption was relatively greater than fruit with these being eaten on an average of 5.6 days in a typical week. The quantity of intake was measured by servings: one serving of fruit was defined to be equal to a medium-sized banana or apple or equivalent and one serving of vegetables to one cup of green leafy vegetables or half a cup of cooked vegetables). WHO recommends that an adult should consume five or more servings of fruit or vegetables a day. However, only 33.1% of respondents had had the recommended 5 servings of fruits and/or vegetables in a day.

Physical activity Only 6.4% of adults did not meet WHO recommendations on physical activity for health (i.e. <150 minutes of moderate-intensity physical activity per week or its equivalent).

Dietary salt and oil Bhutanese adults consume 9 grams of salt per day, almost double the WHO recommended level of 5g/day. Around 7.8% of respondents always or often added salt before eating or while eating. Consumption of processed foods high in salt was significantly higher in urban areas than rural areas (18.8% v. 7.5%). Nearly one in 10 (11.1%) of respondents always or often consumed processed food containing high amounts of salt. The majority of respondents (92.1%) agreed that high salt consumption has adverse health effects. In the majority (97.1%) of households, vegetable oil was the most often used medium of oil or fat for the preparation of meals.

Cervical cancer screening One in six (64.1%) women aged 30–49 years have ever had a screening test for cervical cancer.

Overweight and obesity Mean body mass index (BMI) was 24.0. One third of respondents were found to have normal weight; 17.7% were overweight and 6.2% were found to be obese. Mean waist circumference was 81.9 cm for men and 79.5 cm for women.

Raised blood pressure (hypertension) Around 31.3% of the study population had never had their blood pressure measured. The prevalence of raised blood pressure or hypertension (SBP ≥140 and/or DBP ≥90), excluding those on medication, was 32.9% (men 33.6%, women 32.0 %). This figure rose to 35.7% (men 35.5%, women 35.9%) when those currently using medication were included.

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Raised blood glucose (diabetes mellitus) Around 84.6% of respondents had never had their blood glucose measured. The prevalence of diabetes within the preceding 12 months was 1.3% (men 1.1%, women 1.5%). Among those with diabetes, 35% were receiving insulin and 4.8% were taking oral drugs for diabetes. The prevalence of impaired fasting glycaemia (IFG) [defined as a plasma venous value of blood glucose ≥110 mg/dl to <126mg/dl] was 10.7% (men 11.4%, women 10.0%). The prevalence of diabetes mellitus, based on plasma venous value of blood glucose ≥126 mg/dl and including those on medication, was 6.4% (men 6.5%, women 6.3%).

Abnormal lipids The prevalence of raised total cholesterol (plasma venous value ≥190 mg/dl) including those currently on medication was 12.5% (men 11.9%, women 13.3%).

Combined risk factors The prevalence of combined risk factors was calculated using five risk factors: tt tt tt tt tt

current daily smoking, intake of less than five servings of fruit and/or vegetables per day, a low level of physical activity, overweight (BMI ≥25 kg/m2), and raised blood pressure (BP) (SBP ≥140 and/or DBP ≥90 mmHg or currently on medication for raised BP).

Only 12.7% of respondents did not have any of these risk factors, and 13.5% have three to five risk factors. The proportion of respondents in the age group 40–69 years with a 10-year CVD risk of ≥30% was found to be 1.8% (men 1.5%, women 2.2%).

Conclusion It can be inferred from these results that NCD risk factors such as use of tobacco and alcohol, unhealthy diet including high dietary salt consumption, and high blood pressure are highly prevalent among Bhutanese adults. Unless urgent and targeted interventions are made to prevent, treat and control noncommunicable diseases and their risk factors, the burden of NCDs could become unbearable in Bhutan. There is an urgent need for multisectoral interventions to prevent and control these risk factors. There are several good policies in place to control NCDs in Bhutan. There is an urgent need for effective implementation of these policies.

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1. Introduction Noncommunicable diseases (NCDs) are currently the leading cause of mortality causing 68% of all deaths globally. NCDs are largely due to four major diseases: cardiovascular diseases (CVDs), cancers, diabetes and chronic respiratory diseases. The four main NCDs share common modifiable behavioural risk factors, namely tobacco use, unhealthy diet, lack of physical activity and the harmful use of alcohol. These lead to biological risk factors such as raised blood sugar, overweight and obesity, raised blood pressure, and raised cholesterol. NCDs not only pose a tremendous health burden but also have serious social and economic consequences. Low- and middle-income countries bear the brunt of NCDs due to their fragile health systems, weak regulatory mechanisms, and limited human and financial resources. Bhutan, like many other low- and middle-income countries, is facing a transition from the disease burden due to communicable diseases to that of noncommunicable diseases. According to WHO estimates, NCDs accounted for 55% of all deaths in Bhutan in 2011. Data reported from health facilities in Bhutan indicate that mortality from NCDs increased from 25 835 cases to 35 875 between 2003 and 2007 alone. The rise in NCDs in Bhutan reflects underlying demographic and socioeconomic changes and the increase in exposure to a set of key behavioural and biological risk factors. Recognizing the emerging threat of NCDs, Bhutan adopted a National Policy and Strategy Framework on the Prevention and Control of NCDs in 2009. More recently, a multisectoral national action plan has been drafted taking into account the global and regional action plan for the prevention and control of NCDs. The existing policy and national action plan take a holistic approach to primary prevention of NCDs and provision of early detection and treatment services. Legislation related to risk factors of NCDs is advanced, but mainly focused on tobacco-related aspects. Such legislation includes a ban on import, sale and all forms of advertising of tobacco products. A policy on the harmful use of alcohol is in the draft stages. There are also public awareness campaigns on healthy nutrition and the benefits of physical activity. A pilot programme aimed at NCD prevention and control (called WHO PEN) has been implemented in two districts of Bhutan and there are plans to scale it up to the national level. The need for a comprehensive national surveillance and monitoring framework to measure progress towards the national goals and targets for prevention and control of NCDs is well recognised and artiuclated in national policy documents. Currently, however, there is no nationally representative data, or established systems for ongoing collection of data, to guide NCD-related policy and programme decision-making. The magnitude of morbidity, mortality and economic loss resulting from NCDs in Bhutan calls for a concerted effort to strengthen NCD surveillance. WHO recommends the STEP-wise approach to strengthen NCD surveillance in low- and middle-income countries. Developed by WHO in 2004, STEPS has been used worldwide in many resource-limited countries and has produced reliable and robust data on key NCD risk factors to guide the national response. WHO has identified eight major risk factors (four behavioural and four metabolic) that play a major role for developing noncommunicable diseases which have been included in the STEPS risk factor surveillance. The basis of selection of these risk factors is:

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tt tt tt tt

these have the greatest impact on NCD mortality and morbidity; modification is possible through effective prevention; measurement of these risk factors have been proven to be valid; and measurements can be obtained using appropriate ethical standards.

Rationale and objectives Available studies on NCD risk factors in Bhutan include a subnational 2007 STEPS survey (Thimphu city) and the Global Youth Tobacco Survey (GYTS) for students aged 13–15 years, latest in 2013. The 2007 STEPS survey was limited to urban Thimphu and did not collect information on the biological risk factors, namely raised blood glucose and raised blood cholesterol. Accordingly, more current and reliable nationwide data are needed on prevalence of NCD risk factors for planning and expanding NCD interventions, setting national targets, and monitoring changes over time. In addition to the use of data for the national NCD programme, Bhutan is obligated to report to these data to WHO’s World Health Assembly and Regional Committee sessions in 2015, 2020, 2025 as a follow-up to the related resolutions adopted by the Health Assembly and the regional committees. In view of the critical need for data for planning and monitoring, the Ministry of Health of the Royal Government of Bhutan undertook a nationwide survey in 2014 using the WHO STEPwise approach. The survey was to determine the prevalence of key behavioural and biological risk factors for NCDs in adult men and women aged 18–69 years. The specific objectives of the survey were to: tt tt tt tt

describe the current levels of risk factors for NCDs in adults aged 18 to 69 years in Bhutan, help track the direction and magnitude of trends in NCD risk factors, track the key indicators related to suicide in the country, collect data for projecting likely future demands for health services related to NCD prevention and management, and to support the planning and evaluation of NCD policy and programme interventions.

tt

This report outlines the methodology and results of the survey and recommends future actions for the prevention and control of noncommunicable diseases in Bhutan. The report is intended to be used by national stakeholders including the Ministry of Health and other sectors, developmental partners, research institutions, nongovernmental organizations, the media and the public.

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National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

2. Methods Overview of scope Using the WHO STEPS survey methodology, a national cross-sectional survey was carried out to obtain nationally representative data of the adult population, aged 18 to 69 years, in Bhutan. The WHO STEPS survey protocol was used: STEP 1 included a face-to-face interview of participants to assess behavioural risk factors and health history related to NCDs; STEP 2 involved physical measurements to assess blood pressure, height, weight, waist and hip circumference; and STEP 3 enabled the assessment of fasting blood glucose, total cholesterol and urinary sodium using chemistry analysis and rapid diagnostic tests.

Sample design and sample size The Sample size to estimate the number of households to be surveyed with 95% confidence was calculated using the following formula and assumptions.

Where: Z = level of confidence measure; it represents the number of standard errors away from the mean. This describes the uncertainty in the sample mean or prevalence as an estimate of the population mean (normal deviate if alpha equals 0.05, then Z = 1.96 for 95% confidence level) P = baseline level of indicators. It is the estimated proportion of one of the indicators related to the risk factors currently being measured. The prevalence of overweight and obesity was 52.8% from the last STEPS survey carried out in Thimphu which was the closest value to 50%. d = margin of error. The expected half width of the confidence interval is taken 0.05 for this study

Four domains were chosen based on male and female and two age groups – younger (18– 39 years) and older (40–69 years) – which would provide four age/sex estimates. Taking into account the number of domains and ensuring enough representation by either age-sex groups or urban-rural in males and females, and with a design effect of 1.5 to address the issue of cluster sampling, the expected sample size was as below:

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Assuming an expected 80% response rate, the final required sample size was 2912.

� (rounded to 2912 for logistical ease)

Sampling procedure To achieve a nationally representative sample, a multistage sampling method was used to select enumeration areas, households and eligible participants at each of the selected households in three stages. The 2005 National Census was chosen as the basis for the sampling frame, with “Geogs” (blocks) in rural areas and towns in urban areas forming the primary sampling units (PSUs). Since the population distribution for urbanicity is 70:30 (rural:urban), 63 PSUs in rural and 14 PSUs in urban areas were chosen. PSUs were selected through the probability proportionate to size (PPS) sampling using the number of households in each PSU. Two secondary sampling units (SSUs) for every rural PSU and 4 SSUs for every urban PSU were selected. This led to the selection of 126 SSUs from rural and 56 SSUs from urban areas. This was also carried out by PPS sampling, using the number of households in each SSU. A total of 16 households from each SSU (both rural and urban) were selected using systematic random sampling. The sampling frame for this was the list of households with a unique identification number (ID) developed by the enumerators for the survey. At the household level, the Kish sampling method was used to randomly select one eligible member (aged 18–69 years) of the household for the survey. The Kish method ranks eligible household members in order of decreasing age, starting with males and then females, and randomly selects a respondent using the automated program for Kish selection in the handheld personal digital assistant (PDA).

Time frame The Bhutan STEPS Survey was conceptualized and planned from February 2014. By March 2014 protocols had been developed; ethical clearance sought from the Research Ethics Board for Health(REBH); logistics and implementation plans developed and all government approvals acquired. Training of enumerators was carried out from 1–5 April 2014 and field data collection started from 8 April 2014. The field work was completed by June 2014. Data management and analysis was carried out between July and September 2014, and the factsheet launched in November 2014.

Ethical clearance Ethical clearance for the survey was obtained from the Research Ethics Board for Health, Bhutan. Participation in the survey was voluntary. The survey administrator obtained two copies of written informed consent forms from the participant. One consent form was used for STEPS 1 and 2, and a separate consent form for STEP 3. After obtaining the informed consent, the interview and physical measurements (STEP 1 and STEP 2) were administered at the household level. Interviews were conducted in a manner that ensured confidentiality and the privacy of the survey respondents.

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National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Field work Eight survey teams were formed. Each team comprised 1 superviser (for planning and checking the completeness of questionnaires and undertaking some interviews/measurement), 3 survey administrators (for all 3 STEPS) and one driver. All survey team members were health workers, so that teams could easily undertake the anthropometric measurements and collect blood for biochemical measurements.

Adaptation of survey tools and training materials The generic WHO STEPS survey protocol and tools were adapted to local conditions in Bhutan.

Training of survey administrators and supervisers A five-day training of the survey teams was conducted from 1–5 April 2014. The training focused on teaching field workers the key aspects of recruitment of respondents, systematic sampling of households, use of the Kish method for random selection of participants from households, conducting interviews, adherence to research ethics, use of PDAs for interview and electronic data collection, conducting STEP 3 tests, accurately keeping records of interviews conducted, ensuring quality control of all field processes including questionnaires, other forms and specimens. Team supervisers were further trained on supervision of household selection at the village level, checking and correcting interview data, reviewing completed questionnaires, monitoring interviews and problem-solving in the field.

Pilot-test of field procedures A 1-day practical training in field work in Thimphu was conducted for the survey teams. This included the conduct of interviews, taking physical measurements and collection of blood samples for dry chemistry. The pilot-testing was conducted to assess the applicability of the questionnaires, gauge the reactions of the respondents to the survey procedures, assess the relevance of the field manual, estimate the time needed to administer each questionnaire, check the sequencing or flow of questions and ascertain the content validity of the questions after translation.

Field activities Immediately after the training, survey teams were allocated to the chiwog/enumeration areas where they would go to conduct the survey. Each team administered the STEP 1 (Questionnaire) and STEP 2 (Physical measurements) on the first visit to a household. The participants were then asked to fast overnight i.e. not consume any food or drinks (except water) after 10 p.m. the previous night until the blood sample was collected in the morning. A container was provided to collect urine samples prior to the beginning of the fast. Participants were asked to go to the testing centre set up by the survey team (located in the vicinity) the next morning. Here the blood samples were taken and the urine samples delivered to the survey team. Urine samples were sent by the survey team to the Jigme Dorji Wangchuk National Referral Hospital Laboratory (JDWNRH) in Thimphu for analysis of sodium and creatinine to determine mean population salt intake.

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Publicity plan A media campaign was launched to inform the public about the Bhutan STEPS survey. Daily and weekly broadcasts on radio and television, respectively, were carried out for information. At the community level, details of the survey were communicated through the dzongkhag health services, health centre staff and village health workers.

Data management Data entry Survey data were entered directly into HP iPAQ handheld devices (PDAs) by each member of the survey team to record the respondents’ answers to the STEP 1 interview and the physical and biochemical results from STEP 2 and 3. The results from the urine analysis of sodium and creatinine were separately recorded by the JDWNRH laboratory. The WHO eSTEPS software was used on the PDAs to record the survey data. A storage device (SD card) was fitted into every PDA to ensure that a backup of the data remained in case of any device failures. Data from PDAs were downloaded into a single master database following completion of the fieldwork. Data cleaning and weighting were undertaken prior to data analysis, following the guidance provided by WHO in the eSTEPS manual. This included checking ranges and combinations of variables, detecting and handling missing data, and detecting and handling outliers. Data was weighted to make the sample representative of the target population (adults in Bhutan aged 18 to 69 years). Weights were calculated to adjust for the following aspects: probability of selection (sample weight), non-response (non-response weight), and differences between the sample population and target population (population weight). From these, an overall weight was calculated for each step of the survey and applied to the final dataset.

Data analysis Data analysis was carried out in Epi Info 3.5.1, using STEPS tools and analysis commands developed by WHO and adapted for use by the Bhutan survey team. WHO provided technical support for data analysis and report writing.

Reporting Following completion of data analysis, a factsheet on NCD was generated with the support of WHO in November 2014. The WHO guidelines on developing STEPS site reports were used as the basis for developing the survey report. This included a main survey report and set of data tables. The survey report generated simple descriptive statistics with means, proportions and frequency distributions. A 95% confidence interval (CI) was used as a measure of precision on the estimated population parameters.

Reporting and disseminating of results A dissemination workshop will be planned to communicate the results of the survey at the national level. Copies of the report will be shared with all stakeholders involved in multisectoral actions to address NCDs in Bhutan.

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3. Background characteristics Response rates Out of the targeted 2912 respondents, 2822 (96.9%) participated in STEP I (behavioural measurement); and 2816 (96.7%) participated in STEP 2 (physical measurements). For STEPS 3 (biochemical measurement), the response rate for fasting blood glucose test excluding nonfasting respondents was 93.5% (2724 respondents), that for total cholesterol levels was 94.8% (2761 respondents), and for urine collection for salt estimation was 89.9% (2618 respondents).

Demographic information results Data from 2822 respondents aged between 18–69 years was included in the analysis. Of them, 38.1% were men and 61.9% women; 69.2% were from rural areas and 30.8% from urban, and 52.1% were aged 18–39 years while 47.9% were aged 40–69 years (Figure 3.1 and Annex 1, Table 3.1). Figure 3.1: Respondents by age, sex and residence 100 90 80 70 Percentage 60 50 40 30 20 10 0 18–39 years 40–69 years 18–69 years Rural Urban 34.0 42.4 38.1 39.7 34.4 Women Men 66.0 57.6 61.9 60.3 65.6

The mean number of years of completed education among all respondents was 3.2 years (n=2715), and the same was 3.8 years for men and 2.8 years for women (Annex 1, Table 3.2). Out of 2819 respondents, 62.6% had no formal schooling, 13.5% had less than primary school, 8.9% had completed primary school, 6.5% had completed secondary school, 5.4% had completed high school, 2.1% had completed college/university, and 1.0% had completed postgraduate degree studies (Annex 1, Table 3.3).

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Among the respondents (n=2820), 80.7% were currently married, 1.3% were separated, 4.2% were divorced, 5.7% were widowed, 0.1% were in cohabitation, and 8.0% had never been married (Annex 1, Table 3.4). With regard to employment status, 11.7% of respondents were government employees, 5.3% were nongovernment employees, 55.2% were self-employed, and 27.7% did not have paid employment. More women (36.8%) did not have paid employment than men (13.0%). The percentage of government employees was higher for men (23.0%) than women (4.8%) (Annex 1, Table 3.5). Out of the 782 respondents who did not have paid employment, 1.9% were non-paid, 7.5% were students, 71.5% were homemakers, 2.2% were retired, 15.3% were able-to-work unemployed, and 1.5% were not-able-to-work unemployed (Annex 1, Table 3.6). The reported mean per capita annual income of respondents was Nu. 67 622.70 (Annex 1, Table 3.7).

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STEP 1: Behavioural measurements 4. Tobacco use The frequency and patterns of tobacco use were analysed by age, sex, forms of tobacco (smoked and smokeless), and place of residence.

Current tobacco use Of all 2820 respondents, 24.8% were current tobacco users (includes smoked and smokeless). More men use tobacco (33.6%) than women (13.6%). More men aged 18–39 years (38.1%) were tobacco users than men aged 40–69 years (25.2%). There was no significant difference in tobacco use by residence (Figure 4.1). Figure 4.1: Percentage of current tobacco users by age groups, residence and sex 50 45 40 35 Percentage 30 25 20 15 10 5 0 18 –39 years 40 –69 years Rural Urban Total 12.4 16.0 26.8 25.2 21.1 15.3 10.3 13.6 38.1 35.6 32.8 25.3 33.6 Men Women Both sexes

23.7

24.8

Current tobacco smoking Overall, 7.4% of the respondents reported current use (past 30 days) of smoked tobacco products such as cigarettes, cigars or pipes. The percentage of current smoking was higher among men (10.8%) compared with women (3.1%). The percentage of current smoking was higher among younger men aged 18–39 years (14.5%) compared with older men aged 40–69 years (3.8%). The percentage of current smoking was higher among urban residents compared with rural residents (11.0% versus 5.8%) (Figure 4.2).

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Figure 4.2: Percentage of current tobacco smokers by age groups, residence and sex 25 Men 20 16.7 15 14.5 11.0 10 9.5 8.3 5.8 5 3.1 3.8 3.1 3.5 2.3 4.7 3.1 10.8 7.4 Women Both sexes

Percentage

0 18 –39 years 40 –69 years Rural Urban Total

Among current smokers, the most common smoked tobacco product was manufactured cigarette smokers (74.2%), followed by bidi (18.9%) (Figure 4.3). Figure 4.3: Percentage of current smokers smoking by product and sex 100 90 80 70 Percentage 60 50 40 30 20 10 0 Manufactured cigarette Hand-roll cigarette Bidi Cigars, cheroots, cigarillos Others 10.9 22.1 13.0 20.4 11.9 4.6 18.9 9.8 5.6 5.6 8.3 6.1 77.2 60.8 74.2 Men Women Both sexes

Of all respondents, 4.3% were current daily smokers while 3.1% were current non-daily smokers. 19.6% of the non-smokers were former smokers (Figure 4.4). The mean age of starting to smoke was 18.9 years and the mean duration of smoking was 13.0 years (Annex 1, Table 4.4). Among current smokers, 69.0% have tried to stop smoking in last 12 months. More women (82.1%) have tried to stop smoking than men (66.0%) (Annex 1, Table 4.13).

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Figure 4.4: Proportion of never smokers, former smokers, non-daily and daily users of smoked tobacco products by sex 100 90 80 70 Percentage 60 50 40 30 20 10 0 26.7 19.6 4.8 6.0 Men Never smokers 10.4 1.0 2.1 Women Former smokers Non-daily users Both sexes Daily users 3.1 4.3 62.5 73.0 86.4

Current smokeless tobacco use As shown in Figure 4.5, 19.7% of respondents were current users of smokeless tobacco products such as snuff, chewing tobacco or betel quid with tobacco. One fourth of men (26.5%) reported currently using any smokeless tobacco products compared with 11.0% of women. Among women, smokeless tobacco use was twice as much in rural areas than urban. Figure 4.5: Percentage of current smokeless users by age groups, residence and sex 50 Men 40 Women Both sexes

Percentage

30

28.6 22.7 20.3

27.4 21.5 18.7

24.4

26.5 19.7 15.8

20

13.5 10 9.7

13.5 6.1

11.0

0 18 –39 years 40 –69 years Rural Urban Total

Of 2820 respondents, 18.5% were current daily users of smokeless tobacco. More men (25.2%) were current daily users of smokeless tobacco than women (9.9%). Of the total

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respondents, 12.9% used smokeless tobacco in the past but have stopped using it at the time of the survey (Figure 4.6). Figure 4.6: Proportion of never users, past users, non-daily and daily users of smokeless tobacco products classified by sex 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Never used 25.2 13.9 1.3 11.5 1.1 9.9 Women Past users Non-daily users 12.9 1.2 18.5 59.5 77.4 67.4

Both sexes Daily users

Most common type of smokeless tobacco consumed was chewing tobacco and snuff by mouth (95.5%), followed by betel quid with tobacco (6.1%) (Figure 4.7). Among smokeless tobacco users, on average, snuff by mouth/chewing tobacco was used 12.4 times per day, betel quid with tobacco was used 0.6 times per day, and snuff by nose was used 0.3 times per day (Annex 1, Table 4.9). Figure 4.7: Percentage of smokeless tobacco products using by current smokeless tobacco users 100 90 80 70 Percentage 60 50 40 30 20 10 0 Chewing tobacco/Snuff by mouth Snuff by nose Betel quid Other 3.6 3.7 3.7 4.6 10.9 6.1 5.9 96.4 92.7 95.5 Men Women Both sexes

2.4

3.3

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Exposure to second-hand smoke (SHS) One fifth of all respondents (20.7%) reported being exposed to second-hand smoke at home during the 30 days preceding the survey. One fourth (24.6%) of respondents were exposed to second-hand smoke in the workplace during the 30 days preceding the survey (Figure 4.8). Figure 4.8: Percentage of respondents who reported being exposed to second-hand smoke at home or in the workplace classified by sex 50 Home Workplace

40

Percentage

30 20.7 20

29.0 24.6 20.7 19.1 20.7

10

0 Men Women Both sexes

Tobacco policy During the past 30 days preceding the survey, 21.0% of respondents noticed information about the dangers of smoking or information that encourages quitting in newspapers or magazines; 64.3% noticed such information on television; and 44.4% heard such information over the radio. While there was no significant difference between gender and age group of the respondents with regard to the information being noticed on television or radio, a significantly higher percentage of respondents from the younger age groups noticed information in newspapers or magazines as compared with respondents from the older age groups. The figures for these two were 24.3% and 14.1% respectively (Figure 4.9, Annex 1, Table 4.24). Among the current smokers 69.8% noticed health warnings on cigarette packages during the 30 days preceding the survey. Of this group, 84.3% had thought about quitting due to the health warnings they saw on cigarette packages (Annex 1, Tables 4.25 and 4.26). The average price paid for 20 manufactured cigarettes, based on the last cigarette purchased, was Ngultrum 269.3 (95% CI: 162.9-375.7) (Annex 1, Table 4.27).

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Figure 4.9: Percentage of respondents who noticed information in the media about the dangers of smoking or that encourages quitting during past 30 days 100 90 80 70 60 Percentage 50 40 30 20 10 0 Men Women Both sexes 25.2 15.4 21.0 45.5 43.0 44.4 64.3 64.3 64.3 Newspapers or magazines Television Radio

One third of the respondents (31.8%) were advised to stop smoking by a health-care provider in the past 12 month (Annex 1, Table 4.14).

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5: Alcohol consumption Consumption of alcohol In Bhutan, 39.0% of all respondents had never consumed any alcohol (lifetime abstinence). More women (49.8%) reported lifetime abstinence as compared with men (30.6%). Half of the men (50%) reported being current drinkers of alcohol (past 30 days) as compared with 32.8% of women. There was no significant difference between the younger and the older age groups (Figure 5.1, Annex 1, Table 5.1). Figure 5.1: Alcohol consumption status by sex 100 30.6 49.8 Percentage 60 12.1 7.4 40 50.0 32.8 9.3 8.2 42.4 10.8 7.7

80

39.0 Lifetime abstainer Past 12 months abstainer Drank in past 12 months, not current Current drinker

20

0 Men Women Both sexes

Among former drinkers who had abstained over the past 12 months, 57.9% had stopped drinking due to a negative impact of drinking on their health or following the advice of a doctor or other health worker. This percentage was similar among men and women but was significantly higher in older respondents aged 40–69 years than in younger ones aged 18–39 years (75.8% versus 47.2%) (Figure 5.2, Annex 1, Table 5.2). Figure 5.2: Having stopped drinking due to health reasons 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 47.8 58.1 46.2 57.5 47.2 57.9 75.9 75.7 75.8 18–39 years 40–69 years Total

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Frequency of alcohol consumption Among respondents who had consumed alcohol in the past 12 months preceding the survey, 16.9% had had at least one standard alcoholic drink daily. The frequency of daily drinking was significantly higher in men than women (20.4% versus 10.7%) (Figure 5.3, Annex 1, Table 5.3). Figure 5.3: Frequency of alcohol consumption in the past 12 months 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men 12.2 6.7 20.4 29.3 16.1 27.4 24.0 11.5 10.4 4.2 10.7 Women 5.8 16.9 Both sexes 16.7 34.7 14.7 15.2 <once a month 1-3 days/month 1-2 days/week 3-4 days/week 5-6 days/week Daily 23.2

Among the current (past 30 days) drinkers, 19.9% had consumed alcohol daily in the past 7 days, 8.3% had consumed alcohol on 5–6 days, 15.7% had consumed on 3–4 days, 41.1% had consumed over the last 1–2 days, and 14.9% did not consume alcohol in the past 7 days (Figure 5.4). Figure 5.4: Frequency of alcohol consumption in the past 7 days among current (past 30 days) drinkers 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 23.9 16.5 8.7 14.1 7.5 11.8 19.9 15.7 8.3 38.7 46.1 41.1 0 days 1–2 days 3–4 days 5–6 days Daily 12.2 20.5 14.9

Among current (past 30 days) drinkers, the average number of standard drinks consumed on a drinking occasion was 7.0 for men and 5.0 for women (Annex 1, Table 5.5).

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Level of alcohol consumption Of the 2756 respondents, 4.7% responded drinking at the high-end level (>60g of pure alcohol on average per occasion among men and >40g of pure alcohol on average per occasion among women). Another 2.2% of the respondents drank at the intermediate level (40–59.9g of pure alcohol on average per occasion among men and 20–39.9g of pure alcohol on average per occasion among women). A total of 34.3% of respondents drank at the lower-end level (<40g of pure alcohol on average per occasion among men and <20g of pure alcohol on average per occasion among women) (Figure 5.5, Annex 1,Table 5.6). Figure 5.5: Percentage of respondents drinking pure alcohol at different levels among all respondents on average per occasion classified by sex 50 45 40.6 40 35 30 Percentage 25 20 15 10 5 0 Men Women Both sexes 5.8 2.5 3.2 1.8 26.2 Men Women High-end <40g <20g Intermediate 40-59.9g 20-39.9g Lower-end >=60g >=40g 34.3

4.7 2.2

Among the current (past 30 days) drinkers, 11.3% reported high-end-level drinking, 5.4% were intermediate, and 83.3% were lower-end-level drinkers (Figure 5.6). Figure 5.6: Percentage current (past 30 days) drinkers with different drinking levels classified by sex 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 5.2 11.8 5.7 10.3 5.4 11.3 83.0 83.9 83.3 Women Men Lower-end <20g <40g Intermediate 40-59.9g 20-39.9g High-end >=40g >=60g

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The largest number of standard drinks consumed during a single occasion in the past 30 days among current (past 30 days) drinkers was on an average 8.2; with 9.2 drinks for men and 6.1 drinks for women (Annex 1, Table 5.8).

Heavy episodic drinking Heavy episodic drinking (binge drinking) was defined as having had six or more standard drinks on any occasion in the past 30 days at a single instance. Binge drinking was 22.4% among all adults; and was significantly higher in males (29%) than females (14.1%). Binge drinking was slightly higher in rural areas (24.1%) than urban areas (18.7%), though the difference was not significant (Figure 5.7). Figure 5.7: Heavy episodic drinking on a single occasion at least once during the past 30 days 50 45 40 35 Percentage 30 25 20 15 10 5 0 18 –39 years 40 –69 years Rural Urban Total 11.0 28.2 20.7 30.3 25.7 19.8 16.2 9.8 30.0 24.1 26.6 18.7 14.1 29.0 22.4 Men Women Both sexes

The mean number of drinking occasions among the current drinkers in the past 30 days was 8.5 (9.5 for men and 6.7 for women). The average number of standard drinks consumed on each occasion was 6.3 (7.0 in men and 5.0 in women) (Annex 1, Tables 5.4 and 5.5). The mean number of standard drinks per drinking occasion in the past 7 days among current drinkers was 2.4 (2.8 for men and 1.7 for women). The mean number of standard drinks of unrecorded alcohol in the past 7 days was 1.4 (1.5 for men and 1.3 for women) (Annex 1, Table 5.12).

Unrecorded alcohol consumption Overall, 57.9% respondents reported having consumed unrecorded alcohol. This proportion was similar among younger and older populations and among men and women. Consumption of unrecorded alcohol was significantly higher in the rural population (64.2%) than the urban population (42.4%) (Figure 5.8).

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Figure 5.8: Consumption of unrecorded alcohol by sex, age and residence of respondents 100 Men 80 62.0 60.4 64.6 63.5 64.2 58.4 56.8 57.9 42.6 42.1 42.4 40 Women Both sexes

Percentage

60

57.8

53.5 56.4

59.5

20

0 18-39 years 40-69 years Rural Urban Total

Overall, 47.6% of all alcohol consumed was unrecorded alcohol in the past 7 days (Annex 1, Table 5.14). Of the respondents who reported consuming unrecorded alcohol in the past 7 days, 50.1% had home-brewed spirits, 43.9% had home-brewed beer/wine and 5.3% had bought it from across the border (Annex 1, Table 5.15).

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6. Dietary habits Consumption of fruits and vegetables In a typical week, respondents reported eating fruits on 1.7 days. Among the sexes, both urban men and women have a significantly higher weekly consumption of fruits compared with their rural counterparts [urban women, 2.6 (95% CI 2.3–2.9), rural women, 1.6 (95% CI 1.3–1.8), urban men, 2.4 (95% CI 2.0–2.9), rural men, 1.2 (95% CI 1.0–1.5)]. People in urban areas have a higher level of fruit consumption in a typical week (urban 2.5, rural 1.4) (Figure 6.1, Annex 1, Table 6.1). Figure 6.1: Mean number of days fruits are consumed in a typical week by age, sex and residence 4 Men 3 Mean number 2.4 2 2.0 1.7 1.8 1.4 1 2.6 2.5 1.9 1.5 1.2 1.6 1.4 1.6 Women Both sexes

1.7

1.7

0 18 –39 years 40 –69 years Rural Urban Total

Consumption of vegetables was higher at a mean of 5.6 days in a week. Urban women also had a significantly higher weekly consumption of vegetables compared with their rural counterparts [urban women 5.9% (95% CI 5.6–6.2), rural women 5.3% (95% CI 5.1–5.5) (Figure 6.2, Annex 1, Table 6.1). Figure 6.2: Mean number of days vegetables are consumed in a typical week by age, sex and residence 7 6 5 Mean number 4 3 2 1 0 18 –39 years 40 –69 years Rural Urban Total 5.7 5.5 5.6 5.6 5.5 5.6 5.6 Men Women Both sexes

5.9 5.9 5.9 5.3 5.4

5.6 5.5 5.6

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The quantity of intake was measured by servings: one serving of fruit was defined as equal to a medium-sized banana or apple or equivalent and one serving of vegetables equal to one cup of green leafy vegetables or half a cup of cooked vegetables. The mean number of servings of fruit consumed in a day was 0.7. There was no difference by sex; however, people in urban areas consumed more servings of fruit (1.0) than rural areas (0.6) (Figure 6.3). Figure 6.3: Mean number of servings of fruits consumed on average per day classified by sex, age and residence of respondents 2.0 Men 1.5 Mean number 1.1 Women Both sexes

1.0 1.0 0.7 0.5 0.8 0.8 0.6 0.7

1.0 0.7 0.8 0.7

0.6

0.5

0.6 0.6

0.0 18 –39 years 40 –69 years Rural Urban Total

The mean number of servings of vegetables per day was 3.8. There was no difference by sex or residence in consumption of vegetable servings per day (Figure 6.4, Annex 1, Table 6.2). Figure 6.4: Mean number of servings of vegetables consumed on average per day classified by sex and age of respondents Men 5 4.2 4 Mean number 3 2 1 0 18 –39 years 40 –69 years Rural Urban Total 3.3 3.9 3.4 4.2 3.7 3.6 3.3 3.9 3.4 3.7 3.6 4.0 3.5 3.8 Women Both sexes

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The mean number of servings of fruits and/or vegetables per day was 4.5 (Figure 6.5). There was no difference by sex or residence in consumption of fruit and/or vegetables servings per day (Figure 6.5). Figure 6.5: Mean number of servings of fruits and/or vegetables consumed on average per day by sex, age and residence of respondents 6 5 4 Mean number 3 2 1 0 18 –39 years 40 –69 years Rural Urban Total 4.6 4.7 4.1 4.7 4.0 Men 4.5 4.4 4.4 Women 4.8 4.4 Both sexes 4.6 4.6 4.2 4.5

4.3

Two thirds of respondents (66.9%) ate less than five servings of fruits and/or vegetables, hence not meeting the WHO recommendation. There was no significant difference by sex or age groups in fruit and vegetable intake (Figure 6.6 and Annex 1, Table 6.4). Figure 6.6: Number of servings of fruit and/or vegetables on an average per day 100 90 80 70 Percentage 60 50 40 30 20 10 0 6.7 Men 7.6 Women 7.1 Total 27.4 32.1 29.5 29.9 30.7 30.3 >5 servings 3-4 servings 1-2 servings no fruit and/or vegetables 35.2 30.4 33.1

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7. Dietary salt The knowledge, attitude and behaviour of Bhutanese adults towards dietary salt consumption were assessed using structured questions.

Salt intake Four out of 10 (41.6%) respondents always or often added salt to their food when cooking or preparing foods at home. Figure 7.1: Percentage of adults who always or often add salt when cooking or preparing food at home classified by age and sex of respondents 50 45 40 35 Percentage 30 25 20 15 10 5 0 18 –39 years 40 –69 years Total 43.9 40.8 42.2 43.8 40.6 36.6 Men Women Both sexes 41.8 41.4 41.6

Nearly one in 10 respondents reported that they add salt always or often before eating or when eating (Figure 7.2). Figure 7.2: Percentage of adults who always or often add salt before eating or when eating classified by age, sex and residence of respondents Men 10 9 8 7 Percentage 6 5 4 3 2 1 0 18 –39 years 40 –69 years Rural Urban Total 7.9 9.0 8.4 6.6 6.9 6.7 5.5 8.2 7.8 8.0 7.2 Women 9.2 8.3 7.4 7.8 Both sexes

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Nearly one in 10 adults (11.1%) always or often ate processed foods high in salt content (Figure 7.3). The consumption of processed food high in salt is significantly lower among rural people compared with their urban counterparts and even by gender [both sexes rural 7.5% (5.6–9.5), both sexes urban 18.8% (15.1–22.6), rural men 7.2% (4.7–9.6), urban men 20.1% (14.2–26.0), rural women 8.0% (5.4–10.7), urban women 17.4% (14.1–20.7)]. The consumption of processed food high in salt is significantly higher among the younger age group and also among younger women (both sexes age group 18–39 13.6%, both sexes age group 40–69 6.4%, women 18–39 15.0%, women 40–69 4.1%) (Figures 7.3 and Annex 1, Table 7.1). Figure 7.3: Percentage of adults who always or often consumed processed foods high in salt classified by age, sex and residence of respondents 25 Men Women 20.1 20 15.0 Percentage 15 12.5 17.4 13.6 11.0 10 8.1 6.4 5 4.1 7.2 8.0 7.5 11.2 11.1 Both sexes

18.8

0 18 –39 years 40 –69 years Rural Urban Total

The self-reported quantity of salt consumed in relative measures was also assessed. Nearly seven in 10 (69.9%) respondents thought that they were using just the right amount of salt. Around 16% of respondents thought that they were using too much salt whereas 12.8% of respondents thought that they were using too little salt. Responses from men and women were not significantly different, as shown in Figure 7.4. Figure 7.4: Self-reported quantity of salt consumed 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men 16.4 0.6 15.5 Women 0.7 16.0 Total 0.7 Too much Far too much 70.3 69.4 69.9 Just Right Far too little Too Little 12.1 0.5 13.6 0.9 12.8 0.7

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Awareness on lowering salt intake Nearly two thirds (64.8%) of the respondents (men 66.2%, women 62.9%) thought that lowering salt in their diet would be very important. Around one third of the respondents (31.3%) thought it would be somewhat important. This proportion was a little higher among women (32.6%) than men (29.9%). Only 4.1% (men 3.8%, women 4.5%) thought lowering salt intake would not be at all important (Figure 7.5). Figure 7.5: Percentage of those who agreed with the importance of lowering salt in diet 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Total 66.2 62.9 64.8 Not important Somewhat important Very important 29.9 32.6 31.1 3.8 4.5 4.1

Of 2561 respondents, 92.1% thought consuming too much salt could cause a serious health problem (Annex 1, Table 7.5).

Actions to reduce salt intake The survey also assessed the various actions which were used by respondents regularly to control their salt intake. In order to control salt intake 40.3% respondents limited consumption of processed foods, 9.5% looked at the salt or sodium content on food labels, 7.4% bought low salt/sodium alternatives, 12.5% used spices other than salt when cooking, 28.1% avoided eating foods prepared outside of a home, and 10.1% took other steps specifically to control salt intake (Figure 7.6). Figure 7.6: Steps taken on a regular basis to reduce salt intake 50 40.2 40.4 40.3

40

Percentage

30

27.4

29

28.1

20 11.3 10 7.1 12.4 10.3 12.6 7.2 7.7 9.9 9.5 12.5 7.4 10.1

0 Men Limit consumption of processed foods Buy low salt alternatives Avoid eating outside Women Total Look at salt content on food labels Use spice other than salt Other thing to control salt 25

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Type of oil used for cooking In 97.1% of households, vegetable oil was the most often used type of oil or fat for meal preparation in the household. Butter was used in 2.3% of households, and 0.1% of households used other type of oil or fat (Figure 7.7). Figure 7.7: Type of oil or fat most often used for meal preparation in households

Vegetable oil 97.1%

Butter 2.3%

None in particular 0.4% Other 0.1%

Lard 0%

Eating outside the home On an average per week, adults consumed 0.9 meals (breakfast, lunch and dinner) that were not prepared at home (Annex 1, Table 7.9).

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8. Physical inactivity Physical activity of the survey population was assessed by evaluating the intensity and duration of activities undertaken during work, travel and recreation.

Not meeting WHO recommendations of physical activity As per the results of the survey, Bhutanese adults in the age group 18–69 are physically active, with only 6.4% of all adults not meeting WHO recommendations on physical activity for health (i.e. <150 minutes of moderate-intensity physical activity per week, or equivalent). Significantly higher percentages of women (9.6% CI 6.8–12.4) do not meet the WHO recommendations as compared with men (3.8% CI 2.5–5.0). While there is no difference between the two age groups, the percentage of respondents not meeting the requirement is significantly higher in urban areas (13.2%) then rural (3.2%) (Figure 8.1, Annex 1,Table 8.2). Figure 8.1: Percentage not meeting WHO recommendations on physical activity for health 25 Men Women Both sexes 18.6

20

Percentage

15 10.1 10 6.4 5 3.5 4.5 1.9 0 18 –39 years 40 –69 years Rural 8.7 6.4 4.9 3.2 8.4

13.2 9.6 6.4 3.8

Urban

Total

Physical activity by domain (work/household, transport and leisure time) Among all respondents, 77.8% reported low levels of total physical activity, 10.5% reported moderate level of total physical activity, and 11.7% reported high level of total physical activity. More men reported higher levels of total physical activity (83.2%) than women (70.9%). A significantly higher percentage of women (16.6% CI 13.5–19.8) reported low level of total physical activity as compared with men (7.7% CI 5.5–10.0) (Figure 8.2, Annex 1, Table 8.3). The mean minutes of total physical activity on average per day was 350.5 minutes. It was significantly higher for men (383.7 minutes, CI 357.3–410.2) than for women (308.3 minutes, CI 283.9–332.8). For all respondents, the median minutes of total physical activity on average per day was 330.0 minutes. The figure was 367.1 minutes for men and 274.3 minutes for women (Annex 1, Table 8.4).

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Figure 8.2: Level of total physical activity 100 90 80 70 Percentage 60 50 40 30 20 10 0 9.0 7.7 Men 12.4 10.5 16.6 Women 11.7 Both sexes 70.9 83.2 77.8 High Moderate Low

The mean time (minutes) spent in work-related physical activity on average per day was 274.5 minutes (293.4 for men and 250.6 for women). The mean minutes spent in transport-related physical activity on average per day was 56.9 minutes (61.8 for men and 50.6 for women); and the mean minutes spent in recreation-related physical activity on average per day was 19.1 minutes (28.5 for men and 7.2 for women). The mean minutes spent in recreation-related physical activity on average per day was significantly higher in younger group respondents (24.6 minutes) than older group respondents (8.5 minutes) (Figure 8.3, Annex 1, Table 8.5). Figure 8.3: Mean minutes spent on physical activity on average per day 350 300 250 Mean minutes 200 150 100 50 0 Men Women Both sexes Work-related Transport-related Recreation-related 61.8 28.5 7.2 50.6 56.9 19.1 293.4 274.5 250.6

Of all respondents, 13.8% said they did not engage in any work-related physical activity (12.1% for men and 16.0% for women), 38.3% did not perform transport-related physical activity (36.6% for men and 40.3% for women), and 73.6% did not do any recreational-related physical activity (61.5% for men and 89.0% for women). Significantly higher percentages (85.6%) of older respondents did not do recreational-related physical activity than respondents from the younger group (67.4%) (Figure 8.4, Annex 1, Table 8.7).

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Figure 8.4: Percentage of respondents not doing any work-, transport-, or recreation-related physical activity 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 12.1 16.0 13.8 36.6 40.3 38.3 61.5 No work-related physical activity No transport-related physical activity No recreation-related physical activity 89.0 73.6

Contribution of domain-specific physical activity to total physical activity When the composition of total physical activity of all respondents was analysed, 70.8% of the total activity was contributed by work activity, 20.3% was contributed by transport-related activity, and 8.9% was contributed by recreational activity. The contribution of recreational activity to the total corpus of activity for men was significantly higher (13.1%) than for women (3.2%), and was also significantly higher (10.9%) for the younger age group than the older group respondents (4.9%) (Figure 8.5, Annex 1, Table 8.8). Figure 8.5: Contribution of work-, transport- and recreation-related physical activity to total activity 100 90 80 70 Percentage 60 At leisure time 50 40 30 20 10 0 Men Women Both sexes 68.2 74.3 Transport-related 70.8 Work-realted 13.1 22.5 18.7 20.3 3.2

8.9

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Engagement in vigorous physical activities Nearly half (48.8%) of all respondents were not engaging in any vigorous physical activity. The percentage of women not engaging in vigorous physical activity was significantly higher (66.0%) than men (35.2%) (Figure 8.6, Annex 1, Table 8.9). Figure 8.6: Percentage of respondents not engaging in vigorous physical activity 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 31.2 43.3 35.2 47.4 68.1 62.0 66.0 51.6 48.8 18–39 years 40–69 years Total

Time spent being sedentary The mean minutes spent on sedentary activities in a typical day was 148.0 minutes (137.0 minutes for men and 161.9 for women) and the median minutes spent on sedentary activities in a typical day was 120.0 (the median minutes was the same irrespective of gender and age group) (Figure 8.7, Annex 1, Table 8.10). Figure 8.7: Mean and median minutes spent on sedentary activity on a typical day 180 161.9 160 140 Mean\Median 120 100 80 60 40 20 0 Mean Median Men Women Both sexes 137.0 120.0 120.0 120.0 148.0

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9. History of raised blood pressure The current health status and health-seeking behaviours of the study population related to high blood pressure were assessed by asking respondents about the history of blood pressure and their treatment history. In addition, blood pressure of the respondents (who consented) was also measured by trained health-care workers. Of all respondents, 31.3% had never had their blood pressure measured, 52.2% of them had it measured but not diagnosed with raised blood pressure, 4.9% of them were diagnosed with raised blood pressure but not within the preceding 12 months. Of all adults, 11.7% were diagnosed with raised blood pressure within the preceding 12 months. One fifth (19.9%) of the respondents aged 40–69 years were diagnosed with raised blood pressure within the past 12 months but only 7.3% of younger respondents aged 18–39 years were diagnosed with raised blood pressure within the preceding 12 months (Figure 9.1 and Annex 1, Table 9.1). Figure 9.1 Blood pressure measurement and diagnosis among adults 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 37.2 23.7 31.3 49.7 55.3 52.2 Diagnosed within past 12 months Diagnosed, not in past 12 months Measured, not diagnosed Never measured 9.1 3.9 14.9 6.1 11.7 4.9

Among those diagnosed with raised blood pressure, approximately one third (28.6%) were currently taking drugs (medication) for raised blood pressure that were prescribed by a doctor or health worker (Figure 9.2). Figure 9.2: Proportion of adults currently taking drugs (medication) for raised blood pressure prescribed by a doctor or health worker among those diagnosed, by sex and age 50 45 40 35 Percentage 30 25 20 15 10 5 0 Men 18–39 years Women 40–69 years Total 31 Both sexes 13.5 8.8 10.8 27.8 38.0 29.3 46.5 42.6

28.6

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Of those previously diagnosed with raised blood pressure (n=566), 9.4% had sought advice or received treatment from a traditional healer for raised blood pressure while 4.1% were currently seeking herbal or traditional remedies for raised blood pressure. However, more respondents aged 40–69 years seen traditional healer or taking traditional remedy for raised blood pressure as compared with respondents aged 18–39 years (14.3% v. 3.2% respectively seen traditional healer) and (6.5% v. 0.9% respectively were taking traditional remedies) (Figure 9.3, Annex 1, Table 9.3). Figure 9.3: Percentage of previously diagnosed hypertensive respondents who visited or received treatment from a traditional healer 20 18 16 14 Peercentage 12 10 8 6 4 2 0 18 –39 years 40 –69 years Seen a traditional healer Total 18 –39 years 40 –69 years Total 2.5 3.6 3.2 0.3 1.3 0.9 4.8 8.6 15.4 14.3 12.9 10.0 9.4 Men Women Both sexes

8.6 6.5 5.1 3.2 4.1

Taking herbal or traditional remedies

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10. History of raised blood glucose Of all respondents, 84.6% have never had their blood sugar measured, 13.8% were measured but were not diagnosed with raised blood sugar or diabetes, and 0.4% were diagnosed with raised blood sugar or diabetes but not within the past 12 months. A small fraction of adults (1.3%) were diagnosed with raised blood sugar or diabetes within the past 12 months. More (2.9%) respondents aged 40–69 years were diagnosed with raised blood sugar or diabetes than respondents aged 18–39 years (0.4%) (Figure 10.1 and Annex 1, Table 10.1). Figure 10.1: Blood sugar measurement and diagnosis 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 86.2 82.4 84.6 Diagnosed within past 12 months Diagnosed, but not in past 12 months Measured, not diagnosed Never measured 12.3 1.1 0.3 15.6 1.5 0.5 13.8 1.3 0.4

Among those previously diagnosed with diabetes, 35.0% were currently taking drugs (medication) prescribed for diabetes, and 4.8% are currently taking insulin prescribed for diabetes (Annex 1, Table 10.2). About 11.5% of those previously diagnosed with diabetes have consulted a traditional healer for diabetes while 2.4% of those previously diagnosed are currently taking herbal or traditional treatment for diabetes (Annex 1, Table 10.3).

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11. History of raised total cholesterol Most of the respondents (96.8%) had never had their cholesterol measured. Only 0.5% of the respondents mentioned that they were diagnosed with raised cholesterol within the preceding 12 months, 0.2% of respondents were diagnosed with raised cholesterol but not within the preceding 12 months, and 2.5% have been measured but were not diagnosed with raised cholesterol (Figure 11.1). Figure 11.1: Total cholesterol measurement and diagnosis 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 96.3 97.4 96.8 Diagnosed within past 12 months Diagnosed, but not in past 12 months Measured, not diagnosed Never measured 0.5 0.1 1.8 0.6 0.2 0.5 0.2

3.1

2.5

34

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12. History of cardiovascular diseases Of all the respondents (2819), 0.8% have had a heart attack, or chest pain from heart diseases (angina), or a stroke (cerebrovascular accident or incident). There is no significant difference here between age groups and gender (Figure 12.1, Annex 1, Table 12.2). Figure 12.1: Percentage of respondents having ever had a heart attack or chest pain from heart diseases or a stroke 18 – 39 years 1.0 0.9 0.8 0.7 Percentage 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Men Women Both sexes 0.8 0.8 0.8 0.9 0.8 40 – 69 years 0.9 0.8 0.8 0.8 Total

Among all the respondents and age groups, 0.1% are currently taking aspirin on a regular basis to prevent or treat heart disease and 0.1% are currently taking statins (lovastatin/simvastatin/ atorvastatin, or any other statin) on a regular basis to prevent or treat heart diseases. They are mainly in the age group 40–69 years (Figure 12.2). Figure 12.2: Percentage of respondents currently taking aspirin/statins on a regular basis to prevent or treat heart disease 1.0 Men Women Both sexes

0.8 Peercentage 0.5 0.4 0.3 0.3 0.1 0.0 0.0 0.0 0.0 18 –39 years 40 –69 years Taking aspirin Total 18 –39 years 40 –69 years Taking stains Total 0.2 0.1 0.0 0.1 0.0 0.0 0.0 0.1 0.0 0.2 0.1

0.5

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13. Lifestyle advice Of all respondents, 42.1% were advised by a doctor or health worker to quit using or not to start using tobacco; 49.8% were advised to reduce salt in the diet; and 56.2% were advised to eat at least five servings of fruits and/or vegetables each day. About 52.9% of respondents were advised to reduce fat in their diet; 41.3% were advised to start or do more physical activity; and 31.5% were advised to maintain a healthy body weight or to lose weight. There were no significant differences between gender and age groups (Figure 13.1 and Annex 1, Table 13.1). Figure 13.1: Lifestyle advice by doctor or health worker 56.9 55.6 56.2 Men 51.3 48.7 49.8 45.3 42.1 38.0 Women Both sexes

60 50 40 Percentage 30 20 10 0 Maintain a Start or do more healthy body physical activity weight or to lose weight 33.7 31.5 28.7 44.7

53.2 52.9 52.5 41.3 36.9

Reduce fat in the diet

Eat at least 5 Reduce salt in servings of fruits the diet and/or vegetables per day

Quit or don't start tobacco

Cervical cancer screening About half (50.7%) of the women who were interviewed (aged 18–69 years) have ever undergone a screening test for cervical cancer. There is no significant difference between the two age groups and place of residency (rural/urban). Among women aged 30–49 years, 64.1% in total – 73.2% from urban areas and 59.5 % from rural areas – reported being screened for cervical cancer (Figure 13.2 and Annex 1, Table 13.2). Figure 13.2 Percentage of female respondents who have ever had a screening test for cervical cancer among all female respondents 100 90 80 70 Percentage 60 50 40 30 20 10 0 30 –49 years 36 18 –69 years 59.5 73.2 64.1 55.4 48.3 50.7 Rural Urban Total

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

14. Mental health Of all respondents 2.4% had seriously considered attempting suicide in the preceding 12 months. Of them, 2.7% of respondents aged 18–39 years had seriously considered attempting suicide while 1.7% in the age group of 40–69 years had considered the same. The percentage of women who seriously considered attempting suicide in the last 12 months was significantly higher (4.2%) than their male counterparts (0.9%) (Figure 14.1, Annex 1, Table 14.1). Figure 14.1: Percentage of respondents who seriously considered attempting suicide in the preceding 12 months among all respondents 10 18 –39 years 8 40 –69 years Total

Percentage

6

5.0 4.2

4 2.7 2 2.7 1.7 1.0 0.9 0.9 2.4

0 Men Women Both sexes

Among those who considered attempting suicide in the preceding 12 months, 18.9% had sought professional help. Seeking professional help was reported in significantly more numbers among the younger age group as compared with the older (Figure 14.2, Annex 1, Table 14.2). Figure 14.2: Percentage of respondents who sought professional help among those who had considered attempting suicide in the preceding 12 months 50 18 –39 years 40 35.7 40 –69 years Total

Percentage

30 24.0 21.4 20 17.5 18.9 24.3

10 2.9 0.0 0 Men Women Both sexes 2.0

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37

Out of 2816 respondents, 1.3% had made a plan about how to attempt suicide in the preceding 12 months. More (2.7%) women had such a plan than men (0.2%) (Figure 14.3, Annex 1, Table 14.3). Figure 14.3: Percentage of respondents who made a plan about how to attempt suicide in the preceding 12 months 5 18 –39 years 4 40 –69 years Total

3.5 2.7

Percentage

3

2 1.1 1 0.2 0 Men Women 0.1 0.2

1.7 1.3 0.5

Both sexes

Among all female respondents, 1.4% had attempted suicide. None of the men had attempted suicide. Women only younger respondents aged (18–39 years) had attempted suicide (Figure 14.4, Annex 1, Table 14.4). Figure 14.4: Percentage of respondents who have ever attempted suicide among all respondents 3 18 –39 years 40 –69 years Total

2.1 2 Percentage 1.4

1

0.9 0.6

0.0 0

0.0 Men

0.0

0.0 Women

0.0 Both sexes

38

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Among the respondents, 1.5% have had someone in their close family (mother, father, brother, sister or children) who had attempted suicide and 1.8% have had someone in their close family who had committed suicide (Figures 14.5 and 14.6). Figure 14.5: Percentage of respondents who have ever had anyone in their close family attempt suicide 3 18 –39 years 2.3 2.0 2 Percentage 1.4 1.1 1 0.7 1.0 1.7 1.5 1.3 40 –69 years Total

0 Men Women Both sexes

Figure 14.6: Percentage of respondents who have ever had anyone in their close family commit suicide 4 18 –39 years 40 –69 years Total

3

2.7 2.3

Percentage

2 1.6 1.4 1.2 1 1.6

1.9 1.6

1.8

0 Men Women Both sexes

Of all respondents 28.1% used poisoning with pesticides to attempt suicide, following that 27.3% used overdose of medication; 9.1% used razor, knife or other sharp instrument and 5.9% used other poisoning items (Figure 14.7, Annex 1, Table 14.6).

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Figure 14.7: Percentage of different methods used the last time suicide was attempted among those female respondents who have ever attempted suicide

6% 9% 30%

other poisoning with pesticides overdose of medication

27% razor, knife or other sharp instrument 28% other poisoning

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15. Family history of chronic disease conditions Of all respondents, 11.9% said that a family member has been diagnosed with diabetes or high blood sugar, 34.2% said a family member has been diagnosed with raised blood pressure, 2.6% said a family member has been diagnosed with stroke, 4.5% have had a family member diagnosed with cancer or malignant tumor, 2.2% said a family member has been diagnosed with raised cholesterol, and 1.2% declared that a family member has been diagnosed with early myocardial infarction (Figure 15.1, Annex 1, Table 15.1). Figure 15.1: Percentage of people with a family member who has been diagnosed with a chronic disease condition 40 35 30 25 Percentage 20 15 10 5 0 Early myocardial infarction Raised cholesterol Cancer or malignant Stroke Raised blood pressure Diabetes or high blood sugar 1.1 1.4 1.2 2.5 1.7 2.2 4 5.1 4.5 2.6 2.7 2.6 12.7 11.9 11.3 Men Women Both sexes 34.9 34.2 33.7

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STEP 2: 16. Physical measurements Body mass index The mean body mass index (BMI) among all respondents excluding pregnant women was 24.0. Of all respondents, 3.4% were underweight (BMI <18.5), 63.6% showed normal weight (BMI 18.5–24.9), 26.7% were overweight (BMI 25.0–29.9), and 6.2% were obese (BMI >30.0). The prevalence of overweight in women (31.9%) was higher than in men (22.8%). Women (8.5%) were more frequently obese than men (4.5%). About 4.6% of those aged 18–39 years and 9.2% of all respondents aged 40–69 years were obese (Figure 16.1, Annex 1, Table 16.4). Figure 16.1: BMI classifications of respondents by sex and age (excluding pregnant women) and residence

Total Urban Both sexes Rural 40-69 years 18-39 years Total Urban Women Rural 40-69 years 18-39 years Total Urban Men Rural 40-69 years 18-39 years

3.4 2.8 3.7 2.8 3.7 2.8 2.6 2.9 1.4 3.6 3.9 3.0 4.2 4 3.8 0% 20% 52.2

63.6 35.7 68.8 57.1 67.2 56.8 46.6 61.8 52.8 59.0 68.8 56.8 73.9 60.4 73.3 40% 60% 33.7 38.6

26.7

6.2 9.3

22.7 30.9 24.5 31.9

4.8 9.2 4.6 8.5 12.2

Underweight (<18.5) Normal weight (18.5-24.9) Overweight (25.0-29.9) Obese (>30.0)

28.6

6.7 12.1

30.9 22.8 33.3 18.3 28.7 19.7 80%

6.5 4.5 6.9 3.5 6.9 3.2 100%

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Waist and hip circumference Of all respondents excluding pregnant women, the mean waist circumference was 81.9 cm for men and 79.5 cm for women. The mean hip circumference was 92.5 cm for men and 94.0 cm for women. The mean waist-to-hip ratio among all respondents excluding pregnant women was 0.9 for men and 0.8 for women (Figure 16.2, Annex 1, Table 16.8). Figure 16.2: Mean waist and hip circumference (cm) of respondents by sex 100 90 80 Mean circumference in cm 70 60 50 40 30 20 10 0 Waist Hip Men Women 81.9 79.5 92.5 94.0

Blood pressure (mmHg) The mean systolic blood pressure (SBP) among all respondents, including those currently on medication for raised blood pressure, was 126.2 mmHg. The mean diastolic blood pressure (DBP) among them, including those currently on medication for raised blood pressure, was 85.0 mmHg. Mean systolic and diastolic blood pressures were higher for older respondents aged 40–69 years than their younger counterparts (134.1 mmHg versus 121.9 mmHg and 89.8 mmHg versus 82.4 mmHg respectively) (Figure 16.3, Annex 1, Table 9.4). Figure 16.3: Mean blood pressure among all respondents, including those currently on medication for raised blood pressure, classified by age, sex and residence of respondents 180 160 125.1 117.9 121.9 133.4 135.0 134.1 128.1 125.5 127.0

Men

Women

Both sexes

140 120 Mean number 100 80 60 40 20 0

127.7 120.6 124.3

128.0 123.8 126.2

88.7 91.2 89.8

84.8 86.3 85.4

18 –39 years

40 –69 years

Rural

Urban

Total

82.5 82.3 82.4

18 –39 years

40 –69 years

Rural

84.2 83.7 84.0

Urban

Mean Systolic BP

Mean Diastolic BP 43

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

84.6 85.4 85.0

Total

Blood pressure and treatment Of all respondents, 32.9% had SBP >140 and/or DBP >90 mmHg, excluding those on medication for raised blood pressure. While there was no significant difference by gender, a significantly higher percentage of older age group respondents had SBP >140 and/or DBP >90 mmHg, as compared with younger age group respondents (47.9% versus 25.6%). Of 2816 respondents, 35.7% had SBP >140 and/or DBP >90 mmHg or were currently on medication for raised blood pressure. While there was no significant difference by gender, a significantly higher percentage of older age group respondents had SBP >140 and/or DBP >90 mmHg as compared to younger age group respondents (53.3% v. 26.3%). Out of 2660 respondents excluding those on medication for raised blood pressure, 10.6% of them have had SBP >160 and/or DBP >100 mmHg. While there was no significant difference by gender, a significantly higher percentage of older age group respondents had SBP >160 and/or DBP >100 mmHg as compared to younger age group respondents (18.9% v. 6.6%). Of 2816 respondents, 14.4% of them have SBP >160 and/or DBP >100 mmHg or are currently on medication for raised blood pressure (Figure 16.4 and Annex 1, Table 9.5). Figure 16.4: Percentage of respondents with raised blood pressure by sex 50 45 40 35 Percentage 30 25 20 15 10 5 0 SBP ≥140 and/or DBP ≥ 90 mmHg, no medication SBP ≥140 and/or DBP ≥ 90 SBP ≥160 and/or DBP ≥ 100 SBP ≥160 and/or DBP ≥ 100 mmHg or on medication mmHg, no medication mmHg or on medication

Men 33.6 35.5 35.9 35.7

Women

Both sexes

32.0 32.9

10.6 10.5 10.6

13.3

15.8

14.4

Of all respondents, 88.1% with high blood pressure (SBP>140 and/or DBP>90 mmHg) were not on medication (Annex 1, Table 9.6).

Heart rate The mean heart rate (beats per minute or bpm) of respondents was 73.8 beats per minute. While there was no significant difference between the two age groups the mean was significantly higher in women [76.4 bpm (CI: 75.5–77.2)] as compared with men [71.8 bpm (CI: 70.8–72.7)] (Annex 1, Table 9.7).

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STEP 3: 17. Biochemical measurements Fasting blood glucose The mean fasting blood glucose of all respondents, including those currently on medication for diabetes, was 88.8 mg/dl or 4.9 mmol/L. The mean fasting blood glucose for older respondents aged 40–69 years was 92.5 mg/dl or 5.1 mmol/L and 86.8 mg/dl or 4.8 mmol/L for younger respondents aged 18–39 years. There was no significant difference in mean fasting blood glucose between rural and urban respondents (Figure 17.1, Annex 1, Table 10.4). Figure 17.1: Mean fasting blood glucose (mg dl) classified by age, sex and residence 100 90 80 70 Percentage 60 50 40 30 20 10 0 18–39 40–69 Men Total Women Both sexes Rural Urban 86.7 87.0 86.8 92.5 92.5 92.5

88.7 88.9 88.8

88.4 88.7 88.6

89.3 89.2 89.3

Out of all respondents 10.7% had impaired fasting glycaemia1, 6.4% of the respondents had raised blood glucose or were currently on medication for diabetes2, and 0.6% were currently on medication for diabetes. There is no significant difference between men and women respondents; however, a significantly higher percentage of older respondents aged 40–69 years had impaired fasting glycaemia as compared with younger respondents aged 18–39 years (10.5% v. 4.3%). A significantly higher percentage of urban respondents aged 40–69 years had impaired fasting glycaemia as compared with rural respondents aged 18–39 years (8.5% vs 5.5%).

1 Impaired fasting glycaemia is defined as either plasma venous value of >6.1 mmol/L (110 mg/dl) and <7.0 mmol/L (126 mg/dl), or capillary whole blood value of >5.6 mmol/L (100 mg/dl) and <6.1 mmol/L (110 mg/dl). 2 Raised blood glucose is defined as either plasma venous value of >7.0 mmol/L (126 mg/dl) or capillary whole blood value of >6.1 mmol/L (110 mg/dl).

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A significantly higher percentage of older respondents aged 40–69 years had impaired fasting glycaemia as compared with younger respondents aged 18–39 years (13.2% v. 9.4%). There was no significant difference between rural and urban respondents with impaired fasting glycaemia (Figure 17.2 and 17.3, Annex 1, Table 10.5). Figure 17.2: Percentage of respondents with raised blood glucose, including those on medication, classified by age, sex and residence 14 12 10 Percentage 8 6 4 2 0 18-39 years 40-69 Years Rural Urban Total 4.9 3.4 5.7 5.5 5.3 4.3 9.6 11.7 10.5 9.5 8.5 7.5 6.5 6.3 6.4

Men

Women

Both sexes

Figure 17.3: Percentage of respondents with impaired fasting glycaemia, classified by sex, age and residence 16 14 12 10.2 10 Percentage 8 6 4 2 0 18-39 years 40-69 Years Rural Urban Total 8.5 9.4 13.5 12.7 13.2 11.3 9.7 10.6 11.4 10.5 11 11.4 10 10.7 Men Women Both sexes

Total cholesterol The mean total cholesterol among all respondents, including those currently on medication for raised cholesterol, was 146.1 mg/dl or 3.8 mmol/L. The mean total cholesterol is higher in respondents aged 40–69 years (156.1 mg/dl or 4.0 mmol/L) than in those aged 18–39 years (140.8 mg/dl or 3.6 mmol/L). There is no significant difference between the rural and urban respondents (Annex 1, Table 11.1).

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Of all respondents, 12.5% had raised total cholesterol (>5.0 mmol/L or >190 mg/dl) or were currently on medication for raised cholesterol. About 2.0% of them have total cholesterol of >6.2 mmol/L or >240 mg/dl or are currently on medication for raised cholesterol (Figure 17.4, Annex 1, Table 11.2). Figure 17.4: Percentage of respondents with raised cholesterol, including those on medication, classified by sex, age and residence 25 21.2 20 16.9 Percentage

Men 18.8

Women

Both sexes

15 11.8 10 9.2 9 9.1

13.2

12.4

13.5 12

12.7

13.3 11.9

12.5

5

0 18-39 years 40-69 Years Rural Urban Total

Salt intake Bhutan was the first STEPs survey country to undertake spot urine testing for sodium. The mean intake of salt was 9.0 grams per day (95% CI: 8.8–9.1). Mean salt intake for men was higher at 9.6 g/day (CI 9.4–9.8) as compared with women at 8.0 g/day (CI 7.9–8.2). There was also no significant difference between rural and urban respondents on this score (Figure 17.5, Annex 1, Table 7.6). Figure 17.5: Mean intake of salt classified by sex, age and residence 20 18 16 14 12 10 8 6 4 2 0 18–39 years 40–69 years Rural Urban Total 9.5 8.3 9.9 9.0 7.6 8.9 9.6 8.0 9.8 8.9 8.2 9.0 9.6 8.0 9.0 Men Women Both sexes

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18. Combined risk factors and cardiovascular diseases risk prediction Summary of combined risk factors All respondents were assessed for the following five risk factors: (1) (2) (3) (4) (5) current daily smoking less than five servings of fruits and/or vegetables per day not meeting WHO recommendations on physical activity for health (<150 minutes of moderate activity per week or equivalent) overweight or obese (BMI >25 kg/m2) raised BP (SBP >140 and/or DBP >90 mmHg or currently on medication for raised BP).

Overall, 13.5% of the respondents had three or more of the above-mentioned risk factors; 73.7% had 1–2 risk factors, and 12.7% of them did not have any of the risk factors (Figure 19.2). A higher proportion of older respondents aged 40–69 years had 3–5 risk factors (18.9%) than younger respondents aged 18–39 years (10.9%). Similarly, higher numbers of women (16.7%) had 3-5 risk factors than their male counterparts (11.2%). A significantly higher percentage of urban respondents (22.4%) had 3–5 risk factors compared with rural respondents (9.5%). However, a higher percentage of rural respondents (76.4%) had 1–2 risk factors than urban respondents (68.0%) (Figure 18.1, Annex 1, Table 12.1). Figure 18.1: Summary of risk factors 100 90 80 70 Percentage 60 50 40 30 20 10 0 18 –39 14.6 9.1 40 –69 12.7 Total No risk factor 14.2 Rural 1-2 risk factor 9.6 Urban 3-5 risk factors 15.3 Male 9.3 Female 74.7 72.0 73.7 76.4 68.0 73.5 74.0 10.7 18.9 13.5 9.5 22.4 11.2 16.7

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A 10-year CVD risk of >30% is defined according to age, sex, blood pressure, smoking status (current smokers or those who quit smoking less than one year before the assessment), total cholesterol, and diabetes (previously diagnosed or a fasting plasma glucose concentration of >7.0 mmol/l or 126 mg/dl). The percentage of respondents aged 40–69 years with a 10-year cardiovascular disease (CVD) risk of >30% or with existing CVD was 1.8%. The percentage among urban women was 1.5 percentage points higher than among rural women (3.3% v. 1.8%) (Figure 18.2, Annex 1, Table 12.4). Figure 18.2: Percentage of respondents in age group 40–69 years with a 10-year CVD risk >30% or with existing CVD 5

4 3.2 Percentage 3 3.3 3.3

Men

Women

Both sexes

2.2 2 1.1 1 1.8 1.4 1.5 1.8

0 Urban Rural Total

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19. Discussions and recommendations Bhutan is undergoing an epidemiological transition whereby the proportion of population aged 65 years and above as well as the older age groups will nearly double by 2025. Noncommunicable diseases have become the biggest health challenge in Bhutan in terms of the number of life years lost due to ill health, disability and early death (DALYs). The major NCDs in Bhutan are cardiovascular diseases (CVD), mental health (neuropsychiatric) conditions, injuries, respiratory diseases, cancer and diabetes. National hospital-based cancer and diabetes surveillance is in place in Bhutan. Cervical cancer screening is part of the National Reproductive Health Strategy 2012. The cost of health care due to NCDs in Bhutan is rapidly increasing. This first nationwide STEPs survey to evaluate the prevalence of NCDs and NCD risk factors in Bhutan was a comprehensive study incorporating all three STEPs, as recommend by the World Health Organization. It is the first survey in Bhutan to measure population salt intake through spot urinary sodium testing. Modules on mental health (focusing on suicide) and cervical cancer were also included. This survey – also including urban and rural comparisons – provides crucial risk factor data for focusing and prioritizing national efforts to reduce the NCD burden and setting and monitoring national targets on NCDs. Bhutan has robust tobacco control policies in place. Bhutan adopted the WHO Framework Convention on Tobacco Control in 2004. The National Tobacco Control Act was promulgated in 2010 and several rules were developed in subsequent years for its implementation. Tobacco control in Bhutan is unique in the sense that it bans production, distribution and sale of tobacco products across the country. In addition it also has other components such as a ban on smoking in public places and a ban on all kinds of tobacco. In spite of these rules nearly a quarter of the adult population uses tobacco and is exposed to second-hand smoke in public places. This shows that enforcement of the existing policy needs to be further strengthened. Among current smokers, 69.0% have tried to stop smoking during the preceding 12 months of the survey. Bhutan is trying to get its health professionals trained in tobacco cessation and to establish smoking cessation guidelines. However, the challenges to establishing tobacco cessation at the community level are still considerable. While any degree of alcohol consumption is harmful for health, hazardous drinking such as in excess of the recommended daily limit is damaging to health. Alcohol drinking is also common in Bhutan. Nearly half of all men and a third of women consume alcohol on a regular basis. Binge drinking is a serious problem in Bhutan (22.4%). Apart from increasing risks for CVDs, the harmful use of alcohol will also increase the number road traffic injuries. Intake of fruits and vegetables plays a protective role in the prevention of cancers, heart diseases and many other diseases. WHO recommends a minimum of five daily servings of fruits and/or vegetables. The survey reveals a huge gap in consumption of fruits and/or vegetables in the population with more than two thirds not consuming the recommended number of five servings per day. This is not only a health literacy issue but is also determined by the underlying social and economic factors such as pricing and affordability. This should be changed through

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broad and supportive public and economic policy reforms. Awareness at the national level is needed through regular campaigns to increase health literacy. It may be included in the school curriculum too. The benefits of physical activity include prevention of heart diseases and diabetes, reduction in obesity, blood pressure and cholesterol, and improved mental health conditions. However, only 6.4% (men 3.8%, women 9.6%) of the population did not attain the WHO recommended level of physical activity (>150 minutes of moderate intensity physical activity per week or equivalent). Strategic national health promotion activities should encourage sports and other recreational opportunities. Taking the stairs at home and in public places instead of the elevators, observance of car-free days and regular use of bicycles are other good examples of ways to increase the level of physical activity among the general population. Rural populations showed better performance than urban with regard to physical activity. Median minutes of physical activity among rural population were 390 minutes as compared with 180 minutes for the urban population. Such disparities call for greater urban health promotion, such as regular health activities, the conduct of marathon races and the availability of more fitness centres. The metabolic risk factors for NCDs are raised blood pressure, obesity, and raised cholesterol and blood sugar levels. These will lead to a growing burden of NCDs. Nearly half the population above 18 years has raised blood pressure, and 10.7% have impaired fasting glycaemia. Those living with metabolic abnormalities or already suffering from NCDs do not receive the required treatment. Health-seeking behaviour for NCD management is low: nearly nine out of 10 persons have never had their blood sugar (85%) and blood cholesterol (96%) measured. As many as 97.3% of people with raised blood pressure were not receiving treatment. Even among those diagnosed with hypertension or raised cholesterol, or diabetes, the majority are not receiving treatment. This survey also shows that mean intake of salt among Bhutanese adults is nine grams per day. This is due to cultural factors that calls for salted preservatives for food and adding salt to food. Processed foods are consumed more frequently in urban areas (18.8%) than rural (7.5%). Health systems should be made more responsive to address treatment issues and healthseeking behaviours. Both private and public health systems should be involved in integrating NCD services to promote health as well as manage NCD patients. Access to cervical cancer is poor for the rural population. Cervical cancer screening coverage was reported to be lower for women aged 30–49 years in rural areas (59.5%) as compared to urban area ( 73.2% ) . The degree of public health initiatives taken by health-care providers is poor in Bhutan. Less than half of all health-care providers have advised patients to quit using tobacco or not start using, or to reduce salt in diet, or to start or do more physical activity, maintain a healthy body weight or lose weight. The prevalence of combined risk factors such as current daily smoking, less than five servings of fruits and vegetables per day, insufficient physical activity, overweight and raised blood pressure also need to be taken into account. Nearly three fourths of the population is exposed to 1–2 risk factors and nearly one in 10 are exposed to three or more of the risk factors. Those in the higher age group (45–69 years) are more exposed (18.9%) than those in the younger age group (18–44 years) (10.7%). Females had a higher prevalence (16.7%) of three or more risk factors

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than males (11.2%). Exposure to a single risk factor as well as a combination of more risk factors substantially increases the risk of developing NCDs. One out of 10 individuals in Bhutan is already exposed to three or more NCD risk factors. NCDs will potentially emerge as the biggest public health challenge in Bhutan due to the high prevalence of NCD risk factors and the existing gap between prevalence and treatment. Best buys to control NCDs in Bhutan are the formulation of the correct policies and effective implementation with the help of several sectors. Sustainable health literacy programmes also need to be increased. Bhutan adopted a National Policy and Strategy Framework on the Prevention and Control of NCDs in December 2009. Bhutan has a set of time-bound national targets for NCD indicators (11th Five Year Plan). Bhutan has a national NCD policy, strategy or action plan which integrates several NCDs and their risk factors (National Policy and Strategic Framework on Prevention and Control of NCDs). The National NCD Action Plan 2015–2020 and the National Policy and Strategy to Control Harmful Effects of Alcohol are at different stages of development. National Food-Based Dietary Guidelines serve as a roadmap for reducing unhealthy diets related to NCDs and for promoting in tandem healthy diets. A national public awareness programme on healthy food has been launched through national television and the medium of posters. Bhutan`s Health Promotion Plan 2013–2023 addresses several NCD risk factors including increased physical exercise. Bhutan is gradually integrating NCDs prevention and treatment into its primary care system. Treatment of several NCDs is still referred, and the country has not yet developed a sustainable strategy to enhance skills of health professionals in NCDs. Basic health units that deliver primary health care consist of a health assistant, an assistant nurse-midwife and a basic health worker. NCD training is not included in the Village Health Worker programme. In general, there is a conspicuous lack of health-care professionals in adequate numbers in the country, especially for NCDs. In the past few health care professionals on NCD control. Currently neither in-country training facilities for NCDs nor institutionalized international exchange programmes are available to address the training gap that exists among Bhutanese health-care professionals. The Ministry of Health of the Royal Government of Bhutan through its Department of Public Health initiated the implementation of PEN interventions in two pilot districts (Paro and Bunthang) in 2009. A performance assessment study of the PEN pilot was conducted by the MoH over a three-month period during 2012. Changes in the behavioural and biological risk factors could be assessed as patient data were recorded during each clinic visit in individual case records. Comparisons of the characteristics of patients revealed a significant improvement with regard to reduced CVD risk due to better control of hypertension and diabetes through the regular intake of medications, and the reduction in alcohol and tobacco use.

Recommendations The following recommendations were made on the basis of findings from this survey in the following areas:

Strengthening health services delivery tt

Bhutan should assign greater priority to the development of NCD-related skills among its health workforce. Both the number of workers and the type of skill sets available with them need to be expanded.

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tt

There should be a framework for monitoring accessibility (e.g. drugs), action plans and their evaluation, and the like. Facilities need to be equipped with basic diagnostic and management infrastructure. Essential NCD drugs could be made more available and accessible, especially for the poor. Bhutan should use regional education and training capacities to improve staffing and skill levels. Health system delivery should reach people at the grassroot level.

tt

tt tt

Strengthening enforcement of obacco control legislation and legislation regulating use of alcohol tt

While the tobacco ban and alcohol-related restrictions are commendable, the government should place greater emphasis on their enforcement. Health risk literacy regarding tobacco and more broadly on all NCD risk factors is needed urgently.

tt

Strengthening implementation of new NCD plans tt

The government and major stakeholders should work jointly for implementation of the national NCD policy.

Evaluating programmes and policies tt

An objective evaluation of the tobacco policy and NCD policies would provide an evidence base for future efforts. A health technology assessment institution should be established to improve the comparative effectiveness of interventions for NCDs and other conditions.

tt

Developing national NCD surveillance tt

This is the first national NCD risk factor survey. Bhutan should integrate periodic risk factor surveys in their national programme. Notwithstanding the initial efforts, much needs to be done to strengthen the national health system. Vital registration systems for mortality should go beyond hospitals (population based). Surveillance of morbidity and risk factors should be institutionalized and recorded. Public and private institutions have to be included to build up a surveillance system.

tt

tt tt

Developing and strengthening policies to address all risk factors tt

Standardizing and mandating food labelling through a policy to improve knowledge and awareness of food composition needs to be implemented. Collaboration on group purchase of essential medications to increase access and affordability is recommended. Mulisectoral high level committee should be made for effective implementation of the existing NCD policies and time to time modification of the programmes based on the mod term evaluation and lessons learnt.

tt

tt

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Bibliography Word Health Organization. Disease and injury country estimates: burden of disease. Geneva: WHO. http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html - accessed 22 December 2015. World Health Organization, Regional Office for South-East Asia. Approaches to establishing country-level, multisectoral coordination mechanisms for the prevention and control of noncommunicable diseases. New Delhi: WHO-SEARO, 2015. The World Bank, South Asia Human Development, Health Nutrition, and Population. NCDs policy brief: Bhutan. 2011. http://siteresources.worldbank.org/SOUTHASIAEXT/Resources/223546-1296680097256/77074371296680114157/NCD_BH_Policy_Feb_2011.pdf - accessed 22 December 2015. Royal Government of Bhutan, Ministry of Health, Department of Medical Service. Managing diabetes mellitus: guide for health workers. Thimphu, 2007. Royal Government of Bhutan, Ministry of Health, Department of public health. Package of essential NCD (PEN) interventions for hospitals. Thimphu, 2015. Wangchuk D, Virdi NK, Garg R, Mendis S, Nair N, Kumar R. Package of essential noncommunicable disease (PEN) interventions in primary health-care settings of Bhutan: a performance assessment study. WHO South-East Asia J Public Health. 2014;3(2): 154-160. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO, 2011. World Health Organization. The WHO STEP-wise approach to surveillance of noncommunicable diseases (STEPS). Geneva: WHO, 2003. http://www.who.int/ncd_surveillance/en/stepsinstrumentcore_exp_v1.4.pdf - accessed 22 December 2015. Royal Government of Bhutan, Ministry of Health. Annual health bulletin. Thimphu: Policy and Planning Department, 2012. Royal Government of Bhutan, Ministry of Health. Report on 2007 STEPS survey for risk factors and prevalence of non-communicable diseases in Thimphu. Thimphu, 2009. http://www.who.int/chp/ steps/2007NCDreport.pdf - accessed 22 December 2015. World Health Organization. Package of essential noncommunicable (PEN): disease interventions for primary health care in low-resource settings. Geneva: WHO, 2010. Royal Government of Bhutan, Ministry of Health. Package of essential NCD (PEN) interventions for basic health units. Thimphu, 2011. World Health Organization. Noncommunicable disease progress monitor 2015. Geneva: WHO, 2015. World Health Organization. Preventing chronic diseases: a vital investment. Geneva: WHO, 2005.

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Annex 1: Data tables Background characteristics

*Table 3.1: Age group and sex of respondents Men n Age Group (years) 18–39 40–69 Total Residence Rural Urban Total 775 299 1074 39.7 34.4 38.1 1177 571 1748 60.3 65.6 61.9 1952 870 2822 69.2 30.8 100 500 574 1074 34.0 42.4 38.1 969 779 1748 66.0 57.6 61.9 1469 1353 2822 52.1 47.9 100 % n Women % n Both Sexes %

Table 3.2: Mean number of years of education Age Group (years) 18–39 40–69 Total Men n 492 553 1045 Mean 5.5 2.2 3.8 n 938 732 1670 Women Mean 4.3 0.9 2.8 n 1430 1285 2715 Both Sexes Mean 4.8 1.4 3.2

Table 3.3: Highest level of education by sex and age Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total 969 777 1746 52.3 88.2 68.3 14.0 5.5 10.3 11.2 4.6 8.3 10.5` 1.0 6.3 8.7 0.4 5.0 2.2 0.3 1.3 1.0 0.0 0.6 500 573 1073 36.6 68.2 53.5 20.2 17.6 18.8 14.4 5.9 9.9 9.8 4.0 6.7 11.6 1.0 6.0 5.2 1.7 3.4 2.2 1.4 1.8 % No formal schooling % Less than primary school %Primary school completed %Secondary school completed %High school completed %College/ University completed % Post graduate degree completed

n

* First digit of table number are matching with chapter numbers for ease of understanding. National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014 55

Age Group (years) Both Sexes 18–39 40–69 Total

n

% No formal schooling

% Less than primary school 16.1 10.7 13.5

%Primary school completed

%Secondary school completed

%High school completed

%College/ University completed

% Post graduate degree completed 1.4 0.6 1.0

1469 1350 2819

47.0 79.7 62.6

12.3 5.2 8.9

10.3 2.3 6.5

9.7 0.7 5.4

3.2 0.9 2.1

Table 3.4: Marital status of respondents by sex and age Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1469 1351 2820 13.1 2.4 8.0 81.3 80.0 80.7 1.0 1.6 1.3 3.5 5.0 4.2 1.0 11.0 5.7 0.1 0.0 0.1 969 778 1747 10.4 2.6 6.9 82.7 73.3 78.5 1.3 1.8 1.5 4.4 7.2 5.7 1.1 15.2 7.4 – – – 500 573 1073 18.4 2.1 9.7 78.8 89.2 84.3 0.2 1.4 0.8 1.6 2.1 1.9 0.6 5.2 3.1 0.4 0.0 0.2 n % Never married % Currently married % Separated % Divorced % Widowed % Cohabiting

Table 3.5: Employment status of respondents by sex and age Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total 969 778 1747 7.0 2.1 4.8 5.5 1.9 3.9 47.7 63.0 54.5 39.8 33.0 36.8 500 573 1073 31.0 16.1 23.0 9.8 5.6 7.5 45.2 66.3 56.5 14.0 12.0 13.0 n % Government employee % Nongovernment employee % Selfemployed % Unpaid

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Age Group (years) Both Sexes 18–39 40–69 Total

n

% Government employee

% Nongovernment employee 6.9 3.5 5.3

% Selfemployed

% Unpaid

1469 1351 2820

15.2 8.0 11.7

46.8 64.4 55.2

31.0 24.1 27.7

Table 3.6: Proportion unpaid work and unemployed among respondents by age and sex Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 456 326 782 1.3 2.8 1.9 12.9 0.0 7.5 71.7 71.2 71.5 0.0 5.2 2.2 12.7 19.0 15.3 1.3 1.8 1.5 386 257 643 0.8 1.2 0.9 9.1 0.0 5.4 81.9 84.4 82.9 – – – 7.3 13.6 9.8 1.0 0.8 0.9 70 69 139 4.3 8.7 6.5 34.3 0.0 17.3 15.7 21.7 18.7 0.0 24.6 12.2 42.9 39.1 41.0 2.9 5.8 4.3 n % Nonpaid % Student %Homemaker Unemployed % Retired % Able to work % Not able to work

Table 3.7: Per capita annual income Mean annual per capita income n 2739 Mean 67622.70

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Tobacco use Table 4.1: Percentage of current smokers by sex, age and residence of respondents Age Group (years) Men n 500 573 775 298 1073 % 14.5 3.8 8.3 16.7 10.8 95% CI 10.8–18.3 1.9–5.8 5.3–11.4 11.1–22.2 8.1–13.6 n 969 778 1176 571 1747 Women % 3.1 3.1 2.3 4.7 3.1 95% CI 1.7–4.5 1.2–5.1 1.2–3.4 2.3–7.1 2.0–4.2 n 1469 1351 1951 869 2820 Both Sexes % 9.5 3.5 5.8 11.0 7.4 95% CI 7.3–11.7 2.2–4.8 3.9–7.6 8.1–14.0 5.8–9.0

Age Group (Years) 18–39 40–69 Residence Rural Urban Total

Table 4.2: Smoking status Age Group (years) Men 18–39 40–69 Residence Rural Urban Total Women 18–39 40–69 Residence Rural Urban Total Both Sexes 18–39 40–69 Residence Rural Urban Total 1951 869 2820 2.7 7.9 4.3 1.7–3.7 5.7–10.1 3.2–5.4 3.1 3.2 3.1 1.6–4.6 1.4–5.0 1.9–4.3 19.2 20.5 19.6 16.2–22.1 16.4–24.5 17.2–21.9 75.1 68.5 73.0 71.2–79.0 64.1–72.8 69.9–76.1 1469 1351 5.7 1.7 4.2–7.2 0.9–2.6 3.8 1.8 2.1–5.5 0.8–2.8 16.9 24.6 13.9–19.8 21.2–28.0 73.6 71.8 69.8–77.5 68.1–75.5 1176 571 1747 1.3 3.7 2.1 0.6–2.0 1.8–5.7 1.3–3.0 1.0 1.0 1.0 0.3–1.7 0.2–1.7 0.4–1.5 10.7 10.0 10.4 7.8–13.5 6.3–13.6 8.2–12.7 87.0 85.3 86.4 83.7–90.3 80.9–89.8 83.8–89.1 969 778 2.3 1.9 1.1–3.4 0.7–3.0 0.8 1.3 0.2–1.4 0.1–2.5 7.5 15.9 5.3–9.8 12.1–19.7 89.4 80.9 86.6–92.2 76.4–85.4 775 298 1073 3.7 11.5 6.0 2.1–5.3 7.5–15.5 4.2–7.8 4.7 5.1 4.8 2.1–7.2 1.7–8.6 2.7–6.9 25.4 29.8 26.7 21.3–29.6 23.1–36.4 23.2–30.3 66.2 53.6 62.5 60.8–71.6 46.7–60.5 58.0–66.9 500 573 8.4 1.6 5.8–10.9 0.4–2.8 6.2 2.2 3.2–9.1 0.7–3.8 24.2 31.5 19.6–28.8 26.2–36.7 61.3 64.7 55.5–67.0 59.3–70.1 Current smoker n % Daily 95% CI % Nondaily 95% CI % Former smoker Non-smokers 95% CI % Never smoker 95% CI

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Table 4.3: Current daily smokers among smokers Age Group (years) 18–39 40–69 Total Men n 76 25 101 % Daily smokers 57.5 41.9 55.6 95% CI 43.2–71.9 17.3–66.5 43.0–68.2 n 32 23 55 Women % Daily smokers 73.2 59.2 68.3 95% CI 58.0–88.5 36.1–82.3 55.3–81.3 n 108 48 156 Both Sexes % Daily smokers 59.8 48.7 57.9 95% CI 47.2–72.4 30.6–66.7 47.4–68.5

Table 4.4: Mean age started smoking and mean duration of smoking among current daily smokers Age Group (years) 18–69 18–69 Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Mean age started smoking 57 57 19.0 11.9 17.3–20.8 9.6–14.2 * * * * * * 93 93 18.9 13.0 17.5–20.3 10.8–15.2 Mean duration of smoking * Less than 50 respondents.

Table 4.5: Manufactured cigarette smokers among daily smokers Age Group (years) 18–69 Men n 56 % 90.1 95% CI 82.2–98.0 n * Women % * 95% CI * n 93 Both Sexes % 84.1 95% CI 76.3–92.0

* Less than 50 respondents.

Table 4.6: Manufactured cigarette smokers among current smokers Age Group (years) Rural Urban Total Men n 57 * 98 % 71.5 * 81.5 95% CI 57.1–85.9 * 71.4–91.6 n * * 54 Women % * * 61.2 95% CI * * 43.4–79.1 n 88 64 152 Both Sexes % 65.0 91.1 77.6 95% CI 52.6–77.5 83.3–98.9 68.5–86.7

* Less than 50 respondents.

Table 4.7: Mean amount of tobacco used by daily smokers by type Age Group (years) n Mean # of manufac­ tured cig. 95% CI n Mean # of handrolled cig. 95% CI n Mean # 95% CI of bidi n Mean # of cigars, cheerots, cigarillos 95% CI n Mean # of other type of tobacco 95% CI

Men 18–69 55 3.7 2.6–4.8 56 0.4 0.0–0.8 57 1.3 0.2–2.4 57 0.1 0.0–0.4 57 0.2 0.0–0.5

Both Sexes 18–69 89 3.5 2.6–4.3 93 0.6 0.1–1.0 92 1.2 0.3–2.1 92 0.2 0.0–0.4 93 0.3 0.0–0.7

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Table 4.8: Percentage of current smokers smoking by products, sex and age Age Group (years) n % Manuf. cigs. 95% CI % Handrolled cigs. 95% CI % bidi 95% CI n % Cigars, cheroots, cigarillos 95% CI % Other 95% CI

Men 18–69 101 77.2 66.5–87.9 10.9 3.5–18.3 20.4 11.2–29.7 101 4.6 0.2–9.1 5.6 0.4–10.8

Women 18–69 55 60.8 44.7–76.9 22.1 8.1–36.2 11.9 2.8–21.1 55 9.8 0.2–19.3 8.3 0.0–18.5

Both Sexes Total 156 74.2 64.9–83.5 13.0 6.3–19.6 18.9 11.2–26.6 156 5.6 1.5–9.7 6.1 1.5–10.7

Table 4.9: Percentage of daily smokers smoking given quantities of manufactured or hand-rolled cigarettes per day: Both Sexes Age Group (years) 18–69 n 68 % <5 Cigs. 56.2 95% CI 40.9–71.5 % 5–9 Cigs. 27.4 95% CI 13.3–41.5 % 10–14 Cigs. 13.9 95% CI 3.6–24.2 % 15–24 Cigs. 2.4 95% CI 0.0–5.8

Table 4.10: Former daily smokers (who don’t smoke currently) among respondents Age Group (years) 18–39 40–69 Total Men n 500 573 1073 % 16.3 25.0 19.3 95% CI 12.6–20.0 20.8–29.2 16.5–22.2 n 969 778 1747 Women % 3.1 11.0 5.9 95% CI 1.6–4.7 7.6–14.4 4.2–7.5 n 1469 1351 2820 Both Sexes % 10.5 18.9 13.4 95% CI 8.1–12.9 16.1–21.6 11.6–15.3

Table 4.11: Former daily smokers (who don’t smoke currently) among ever daily smokers Age Group (years) 18–39 40–69 Total Men n 125 147 272 % 66.1 94.0 76.3 95% CI 57.6–74.6 89.8–98.1 70.7–81.9 n 53 95 148 Women % 58.1 85.5 73.4 95% CI 42.1–74.1 77.8–93.2 65.0–81.9 n 178 242 420 Both Sexes % 64.9 91.6 75.7 95% CI 57.3–72.5 87.9–95.4 71.0–80.5

Table 4.12: Mean years since cessation Age Group (years) 18–39 40–69 Total Men n 122 171 293 Mean 6.6 21.2 12.5 95% CI 5.3–7.9 18.5–23.8 10.8–14.2 n 77 110 187 Women Mean 6.9 19.7 13.6 95% CI 5.0–8.7 16.6–22.9 11.7–15.6 n 199 281 480 Both Sexes Mean 6.7 20.8 12.8 95% CI 5.5–7.8 18.6–22.9 11.4–14.2

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Table 4.13: Current smokers who have tried to stop smoking in the last 12 months Age Group (years) 18–69 Men n 101 % 66.0 95% CI 55.2–76.8 n 55 Women % 82.1 95% CI 68.6–95.7 n 156 Both Sexes % 69.0 95% CI 59.8–78.1

Table 4.14: Current smokers who have been advised by doctor to stop smoking Age Group (years) 18–69 Men n 80 % 33.2 95% CI 22.2–44.3 n * Women % * 95% CI * n 124 Both Sexes % 31.8 95% CI 22.6–41.0

* Less than 50 respondents.

Table 4.15: Percentage of current users of smokeless tobacco by sex, age and residence of respondents Age Group (years) 18–39 40–69 Residence Rural Urban Total 775 298 1073 27.4 24.4 26.5 21.7–33.1 17.9–30.9 22.1–31.0 1176 571 1747 13.5 6.1 11.0 10.0–17.0 3.9–8.2 8.6–13.5 1951 869 2820 21.5 15.8 19.7 17.2–25.8 12.1–19.5 16.5–22.9 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Age Group (years) 500 573 28.6 22.7 23.1–34.1 17.2–28.2 969 778 9.7 13.5 7.0–12.4 9.9–17.2 1469 1351 20.3 18.7 16.5–24.0 15.0–22.4

Table 4.16: Percentage of smokeless tobacco use history by sex and age Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1469 1351 2820 18.9 17.7 18.5 15.2–22.6 14.0–21.4 15.3–21.7 1.4 1.0 1.2 0.6–2.2 0.3–1.6 0.7–1.8 10.0 18.3 12.9 7.8–12.2 15.0–21.5 10.8–15.0 69.7 63.1 67.4 65.7–73.8 58.2–67.9 63.6–71.2 61

Current user n % Daily 95% CI % Nondaily 95% CI % Past user 11.4 18.8 13.9 8.3 17.6 11.5

Non user 95% CI % Never used 60.1 58.5 59.5 82.0 68.9 77.4 95% CI

500 573 1073 969 778 1747

27.0 21.8 25.2 8.6 12.5 9.9

21.5–32.5 16.3–27.2 20.7–29.7 5.9–11.2 8.9–16.2 7.5–12.4

1.5 1.0 1.3 1.1 1.0 1.1

0.3–2.8 0.0–2.0 0.5–2.2 0.2–2.0 0.3–1.7 0.5–1.7

7.8–14.9 14.3–23.3 10.8–17.0 6.1–10.6 14.0–21.2 9.6–13.5

54.1–66.0 52.1–64.9 54.3–64.7 78.4–85.6 63.9–73.8 74.2–80.6

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Table 4.17: Former daily smokeless tobacco users (who don’t use tobacco currently) among all respondents Age Group (years) 18–39 40–69 Total Men n 500 573 1073 % 9.9 17.1 12.4 95% CI 6.6–13.3 12.8–21.5 9.6–15.2 n 969 778 1747 Women % 7.4 15.8 10.4 95% CI 5.2–9.7 12.6–19.1 8.5–12.2 n 1469 1351 2820 Both Sexes % 8.8 16.6 11.5 95% CI 6.8–10.9 13.5–19.6 9.6–13.4

Table 4.18: Former daily smokeless tobacco users (who don’t use tobacco currently) among ever daily users Age Group (years) 18–39 40–69 Total Men n 180 217 397 % 26.9 44.1 33.1 95% CI 18.7–35.1 34.3–53.8 26.6–39.5 n 142 205 347 Women % 46.5 55.8 51.0 95% CI 35.6–57.4 46.7–64.9 43.7–58.4 n 322 422 744 Both Sexes % 31.9 48.3 38.4 95% CI 24.8–38.9 41.2–55.4 32.8–44.0

Table 4.19: Mean times per day smokeless tobacco used by daily smokeless tobacco users by type Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 203 196 399 13.2 10.8 12.4 10.9–15.6 9.1–12.5 10.6–14.2 212 205 417 0.3 0.1 0.3 0.0–0.7 0.0–0.3 0.0–0.5 211 204 415 0.2 1.3 0.6 0.0–0.4 0.5–2.1 0.2–0.9 211 206 417 0.1 0.2 0.1 0.0–0.2 0.0–0.4 0.0–0.2 77 80 157 11.2 11.5 11.3 8.9–13.5 9.0–14.0 9.5–13.2 79 83 162 0.0 0.4 0.2 0.0–0.0 0.0–1.0 0.0–0.4 79 82 161 0.5 2.0 1.2 0.0–1.3 0.2–3.7 0.3–2.0 79 84 163 0.2 0.1 0.2 0.0–0.4 0.0–0.2 0.0–0.3 126 116 242 13.8 10.5 12.8 11.0–16.5 8.5–12.6 10.6–14.9 133 122 255 0.4 0.0 0.3 0.0–0.9 0.0–0.1 0.0–0.7 132 122 254 0.1 1.0 0.4 0.0–0.3 0.2–1.8 0.1–0.7 132 122 254 0.1 0.2 0.1 0.0–0.2 0.0–0.5 0.0–0.2 n Chewing tobacco/ Snuff by mouth 95% CI n Snuff by nose 95% CI n Betel quid 95% CI n Other 95% CI

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Table 4.20: Percentage of current users of smokeless tobacco using each of the following products Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total 18–39 40–69 Total Both Sexes 227 222 449 96.7 92.9 95.5 94.2–99.3 88.7–97.1 93.2–97.8 4.5 1.9 3.7 0.0–9.3 0.2–3.7 0.3–7.0 3.0 12.5 6.1 0.8–5.2 6.2–18.7 3.3–8.9 3.7 2.4 3.3 1.1–6.3 0.0–4.8 1.2–5.3 86 94 180 93.5 91.5 92.7 87.5–99.6 85.6–97.4 87.9–97.4 3.5 4.1 3.7 0.0–8.5 0.3–7.9 0.0–7.7 6.7 16.5 10.9 1.2–12.2 5.0–28.0 5.1–16.7 8.7 2.3 5.9 2.3–15.1 0.0–4.9 1.8–10.1 141 128 269 97.6 93.6 96.4 94.7–100.0 87.8–99.3 93.8–99.0 4.8 0.9 3.6 0.0–10.8 0.0–2.8 0.0–8.0 2.0 10.6 4.6 0.0–4.3 4.0–17.1 1.8–7.3 2.4 2.4 2.4 0.0–5.2 0.0–5.8 0.2–4.6 %Chewing tobacco/ Snuff by mouth % Snuff by nose % Betel quid

n

95% CI

95% CI

95% CI

% Other

95% CI

Table 4.21: Percentage of current tobacco users by sex, age and residence of respondents Age Group (years) 18–39 40–69 Residence Rural Urban Total 775 298 1073 32.8 35.6 33.6 26.4–39.1 29.0–42.3 28.8–38.5 1176 571 1747 15.3 10.3 13.6 11.6–19.1 6.9–13.6 10.9–16.4 1951 869 2820 25.3 23.7 24.8 20.6–30.0 19.8–27.7 21.4–28.3 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Age Group (Years) 500 573 38.1 25.2 32.4–43.9 19.6–30.7 969 778 12.4 16.0 9.4–15.5 11.8–20.1 1469 1351 26.8 21.1 22.8–30.8 17.3–25.0

Table 4.22: Daily tobacco users Age Group (years) 18–39 40–69 Residence Rural Urban Total 775 298 1073 30.0 30.0 30.0 24.1–35.9 23.4–36.6 25.4–34.6 1176 571 1747 13.5 8.4 11.8 9.9–17.1 5.6–11.2 9.2–14.4 1951 869 2820 23.0 19.8 22.0 18.4–27.5 16.3–23.4 18.7–25.3 Men n 500 573 % 33.9 22.7 95% CI 28.4–39.4 17.2–28.3 n 969 778 Women % 10.6 13.9 95% CI 7.8–13.5 10.1–17.8 n 1469 1351 Both Sexes % 23.6 18.9 95% CI 19.9–27.4 15.0–22.7

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Table 4.23: Exposed to second-hand smoke in home and workplace during the past 30 days Age Group (years) Home 18–39 40–69 Total Workplace 18–39 40–69 Total 434 479 913 33.6 19.8 29.0 28.0–39.3 14.7–24.9 24.6–33.4 838 676 1514 22.1 13.6 19.1 18.0–26.2 9.6–17.5 15.9–22.3 1272 1155 2427 28.6 17.0 24.6 24.6–32.6 13.4–20.6 21.5–27.7 500 573 1073 23.3 15.8 20.7 18.6–28.0 11.6–20.0 17.0–24.4 969 778 1747 23.7 15.0 20.7 20.0–27.5 11.4–18.6 17.8–23.6 1469 1351 2820 23.5 15.4 20.7 20.2–26.8 12.3–18.6 18.0–23.4 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Table 4.24: Percentage of all respondents who noticed information in media about the dangers of smoking or that encourages quitting during the past 30 days. Age Group (years) 18–39 40–69 Total Television 18–39 40–69 Total Radio 18–39 40–69 Total 477 536 1013 44.2 48.0 45.5 37.6–50.9 41.3–54.7 40.1–50.9 895 729 1624 43.5 42.3 43.0 38.4–48.5 36.9–47.6 38.8–47.3 1372 1265 2637 43.9 45.5 44.4 39.0–48.8 40.6–50.3 40.3–48.6 487 547 1034 65.2 62.6 64.3 58.7–71.8 56.4–68.9 59.1–69.6 934 745 1679 67.1 58.9 64.3 61.0–73.2 52.4–65.4 59.1–69.4 1421 1292 2713 66.1 61.0 64.3 60.9–71.2 55.7–66.3 59.8–68.8 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Newspapers or magazines 460 498 958 27.9 19.7 25.2 22.5–33.3 15.5–24.0 21.2–29.2 852 651 1503 19.6 6.9 15.4 15.6–23.6 4.2–9.6 12.5–18.2 1312 1149 2461 24.3 14.3 21.0 20.6–28.1 11.4–17.1 18.2–23.7

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Table 4.25: Percentage of current smokers who noticed health warnings on cigarette packages during the past 30 days. Age Group (years) 18–69 Men n 97 % 68.7 95% CI 55.7–81.8 n * Women % * 95% CI * n 145 Both Sexes % 69.8 95% CI 58.3–81.2

*Less than 50 respondents

Table 4.26: Percentage of current smokers who noticed health warnings on cigarette packages during the past 30 days that thought about quitting due to the health warnings they saw. Age Group (years) 18–69 Men n 66 % 83.1 95% CI 73.1–93.1 n * Women % * 95% CI * n 99 Both Sexes % 84.3 95% CI 76.1–92.6

*Less than 50 respondents

Table 4.27: Average price paid for 20 manufactured cigarettes, based on the last manufactured cigarette purchase (in Ngultrum). Age Group (years) 18–69 Men n 76 Mean 252.4 95% CI 137.5–367.2 n * Women Mean * 95% CI * n 111 Both Sexes Mean 269.3 95% CI 162.9–375.7

*Less than 50 respondents

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Alcohol consumption Table 5.1: Alcohol consumption status by sex and age Age Group (years) Men 18–39 40–69 500 572 48.3 53.3 42.0–54.6 47.5–59.0 9.1 4.1 5.9–12.3 2.0–6.2 11.7 12.8 7.7–15.6 9.3–16.3 30.9 29.8 24.9–36.9 25.0–34.7 % Current drinker (past 30 days) % Drank in past 12 months, not current % Past 12 months abstainer % Lifetime abstainer

n

95% CI

95% CI

95% CI

95% CI

Residence Rural Urban Total Women 18–39 40–69 969 778 30.8 36.5 27.4–34.2 31.3–41.7 9.3 6.1 6.9–11.7 4.0–8.2 8.8 10.2 5.6–11.9 7.4–13.0 51.2 47.2 46.5–55.9 41.9–52.5

775 297 1072

51.4 46.7 50.0

45.9–56.9 39.2–54.2 45.5–54.5

5.9 10.7 7.4

3.5–8.4 5.4–16.0 5.0–9.7

10.8 15.1 12.1

7.9–13.7 8.7–21.5 9.2–14.9

31.9 27.5 30.6

26.7–37.0 19.3–35.7 26.2–35.0

Residence Rural Urban Total Both Sexes 18–39 40–69 1469 1350 40.6 45.9 36.8–44.4 41.7–50.1 9.2 5.0 7.0–11.4 3.5–6.5 10.4 11.7 7.8–13.0 9.1–14.3 39.8 37.5 35.6–44.1 33.8–41.2

1176 571 1747

33.9 30.6 32.8

29.5–38.2 26.2–35.0 29.5–36.0

6.9 10.7 8.2

4.8–9.0 7.5–14.0 6.4–10.0

8.9 10.1 9.3

5.8–11.9 6.8–13.4 7.0–11.6

50.4 48.6 49.8

45.3–55.5 42.9–54.3 45.9–53.7

Residence Rural Urban Total

1951 868 2819

43.9 39.2 42.4

39.9–47.9 34.7–43.6 39.3–45.5

6.3 10.7 7.7

4.6–8.1 7.3–14.2 6.1–9.4

10.0 12.7 10.8

7.7–12.2 8.9–16.6 8.8–12.8

39.8 37.4 39.0

35.8–43.8 31.7–43.0 35.7–42.3

Table 5.2: Stop drinking due to health reasons Age Group (years) 18–39 40–69 Total Men n 61 76 137 % 47.8 75.9 58.1 95% CI 31.3–64.3 64.3–87.5 45.9–70.4 n 76 96 172 Women % 46.2 75.7 57.5 95% CI 34.6–57.9 66.1–85.4 49.3–65.7 n 137 172 309 Both Sexes % 47.2 75.8 57.9 95% CI 36.0–58.4 67.1–84.6 49.4–66.4

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Table 5.3: Frequency of alcohol consumption in the past 12 months Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 703 653 1356 11.8 26.2 16.9 7.8–15.9 20.8–31.6 13.1–20.7 4.6 7.9 5.8 2.2–7.1 5.0–10.7 3.9–7.7 9.8 14.7 11.5 7.1–12.6 11.1–18.2 9.3–13.8 30.9 21.0 27.4 25.2–36.6 17.4–24.6 23.5–31.3 16.7 12.4 15.2 13.0–20.4 8.6–16.2 12.4–17.9 26.2 17.8 23.2 20.9–31.4 13.9–21.7 19.3–27.1 420 320 740 7.3 16.6 10.7 4.1–10.5 11.1–22.1 7.7–13.6 2.1 7.8 4.2 0.5–3.7 3.7–11.8 2.1–6.2 8.9 13.0 10.4 5.4–12.4 8.5–17.5 7.3–13.4 24.9 22.4 24.0 18.7–31.1 17.0–27.8 19.7–28.3 18.1 12.5 16.1 13.0–23.3 7.8–17.1 12.3–19.9 38.7 27.8 34.7 31.7–45.7 21.3–34.3 29.3–40.2 283 333 616 14.3 31.8 20.4 8.7–19.9 24.7–38.9 15.3–25.6 6.0 7.9 6.7 2.2–9.9 4.3–11.5 3.9–9.5 10.3 15.6 12.2 6.6–14.0 11.2–20.1 9.4–15.0 34.2 20.3 29.3 27.5–40.9 15.2–25.4 24.5–34.1 15.9 12.3 14.7 10.7–21.1 7.7–16.9 10.8–18.5 19.2 12.0 16.7 13.4–25.0 7.8–16.3 12.5–20.9 N % Daily 95% CI % 5–6 days/ week 95% CI % 3–4 days/ week 95% CI % 1–2 days/ week 95% CI % 1–3 days/ mon 95% CI % < once a month 95% CI

Table 5.4: Mean number of drinking occasions in the past 30 days among current (past 30 days) drinkers Age Group (years) 18–39 40–69 Total Men n 233 290 523 Mean 8.1 12.0 9.5 95% CI 6.5–9.6 10.2–13.8 8.2–10.8 n 302 259 561 Women Mean 5.3 8.9 6.7 95% CI 4.2–6.3 6.9–10.9 5.5–7.8 n 535 549 1084 Both Sexes Mean 7.2 10.9 8.5 95% CI 6.0–8.3 9.5–12.3 7.5–9.6

Table 5.5: Mean number of standard drinks per drinking occasion among current (past 30 days) drinkers Age Group (years) 18–39 40–69 Total Men n 238 299 537 Mean 7.1 6.8 7.0 95% CI 5.3–8.9 5.6–8.0 5.7–8.2 n 306 262 568 Women Mean 4.6 5.6 5.0 95% CI 3.6–5.5 4.7–6.5 4.2–5.7 n 544 561 1105 Both Sexes Mean 6.3 6.4 6.3 95% CI 5.0–7.5 5.5–7.3 5.4–7.2

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Table 5.6: Percentage of respondents drinking at high-end, intermediate and lower-end level among all respondents of pure alcohol on average per occasion by sex and age Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both sexes 18–39 40–69 Total 1444 1312 2756 3.9 6.1 4.7 2.4–5.3 4.1–8.2 3.3–6.0 1.9 2.8 2.2 1.0–2.8 1.6–3.9 1.5–2.9 33.8 35.1 34.3 29.9–37.7 31.2–39.0 31.2–37.3 951 759 1710 493 553 1046 n % highend (≥60g) 5.3 6.7 5.8 (≥40g) 2.0 5.5 3.2 0.8–3.3 3.1–7.8 1.9–4.5 3.0–7.6 3.9–9.4 3.9–7.7 95% CI % inter­ mediate (40–59.9g) 2.0 3.6 2.5 (20–39.9g) 1.8 1.7 1.8 0.9–2.7 0.7–2.8 1.1–2.5 0.6–3.4 1.8–5.4 1.4–3.6 95% CI % lowerend (<40g) 40.2 41.3 40.6 (<20g) 25.7 27.2 26.2 22.6–28.7 22.5–32.0 23.4–29.0 33.8–46.6 35.6–47.1 36.0–45.2 95% CI

Table 5.7: Percentage of current (past 30 days) drinkers with different drinking levels. Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both sexes 18–39 40–69 Total 531 543 1074 9.8 13.9 11.3 6.1–13.5 9.6–18.3 8.2–14.5 4.9 6.3 5.4 2.6–7.1 3.8–8.7 3.6–7.1 85.3 79.8 83.3 80.6–90.1 74.8–84.8 79.4–87.2 299 254 553 232 289 521 n % highend (≥60g) 11.2 12.9 11.8 (≥40g) 6.9 15.9 10.3 2.8–11.1 9.3–22.5 6.4–14.2 6.3–16.1 7.7–18.1 7.9–15.7 95% CI % inter­ mediate (40–59.9g) 4.2 6.9 5.2 (20–39.9g) 6.2 5.0 5.7 3.3–9.1 2.1–7.8 3.6–7.8 1.4–7.0 3.5–10.4 3.0–7.4 95% CI % lowerend (<40g) 84.6 80.1 83.0 (<20g) 86.9 79.2 83.9 81.5–92.2 72.2–86.1 79.1–88.8 78.4–90.8 73.9–86.4 78.2–87.8 95% CI

Table 5.8: Mean maximum number of standard drinks consumed on one occasion in the past 30 days Age Group (years) 18–39 40–69 Total Men n 233 283 516 Mean 9.1 9.3 9.2 95% CI 7.7–10.6 7.7–10.9 8.0–10.4 n 290 251 541 Women Mean 5.3 7.3 6.1 95% CI 4.4–6.3 6.0–8.6 5.2–7.0 n 523 534 1057 Both Sexes Mean 7.9 8.6 8.2 95% CI 6.9–9.0 7.3–9.9 7.3–9.1

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Table 5.9: Six or more drinks on a single occasion at least once during the past 30 days among total population Age Group (years) 18–39 40–69 Residence Rural Urban Total 775 297 1072 30.0 26.6 29.0 24.6–35.3 21.1–32.1 24.9–33.1 1176 571 1747 16.2 9.8 14.1 12.6–19.8 5.6–14.0 11.3–16.9 1951 868 2819 24.1 18.7 22.4 20.3–27.9 14.7–22.7 19.5–25.3 Men n 500 572 % 28.2 30.3 95% CI 22.9–33.6 25.3–35.4 n 969 778 Women % 11.0 19.8 95% CI 8.3–13.7 15.2–24.4 n 1469 1350 Both Sexes % 20.7 25.7 95% CI 17.3–24.0 21.8–29.6

Table 5.10: Mean number of times with six or more drinks during a single occasion in the past 30 days among current drinkers Age Group (years) 18–39 40–69 Total Men n 225 284 509 Mean 4.1 4.6 4.3 95% CI 2.7–5.5 3.4–5.7 3.2–5.3 n 291 242 533 Women Mean 2.0 3.6 2.6 95% CI 1.2–2.7 2.6–4.7 1.9–3.3 n 516 526 1042 Both Sexes Mean 3.4 4.3 3.7 95% CI 2.4–4.4 3.3–5.2 2.9–4.5

Table 5.11: Frequency of alcohol consumption in the past 7 days Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 494 492 986 13.3 31.8 19.9 8.5–18.0 26.1–37.4 15.7–24.1 5.9 12.6 8.3 3.4–8.4 8.4–16.7 6.0–10.6 16.5 14.3 15.7 12.5–20.5 10.8–17.8 12.9–18.6 47.6 29.6 41.1 42.4–52.9 23.7–35.5 36.7–45.6 16.7 11.8 14.9 12.7–20.7 7.8–15.7 11.8–18.0 276 221 497 6.5 20.9 11.8 2.4–10.6 14.2–27.7 7.9–15.7 6.1 9.9 7.5 2.7–9.5 4.8–14.9 4.4–10.5 10.8 19.8 14.1 6.3–15.2 13.5–26.2 10.3–17.9 54.5 32.0 46.1 46.7–62.2 24.5–39.5 39.7–52.6 22.3 17.4 20.5 16.0–28.6 10.4–24.5 15.5–25.5 218 271 489 16.5 37.3 23.9 9.7–23.3 30.3–44.4 18.2–29.7 5.8 13.9 8.7 2.6–9.1 8.6–19.2 5.8–11.6 19.3 11.5 16.5 13.6–25.1 7.8–15.2 12.5–20.5 44.4 28.4 38.7 37.1–51.6 21.0–35.8 33.1–44.3 14.0 8.9 12.2 8.7–19.2 4.6–13.1 8.3–16.0 n % Daily 95% CI % 5–6 days 95% CI % 3–4 days 95% CI % 1–2 days 95% CI %0 days 95% CI

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Table 5.12: Mean number of standard drinks and unrecorded alcohol consumed on average per day in the past 7 days among current drinkers Age Group (years) Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Standard drinks consumed 18–39 40–69 Total 18–39 40–69 Total 218 271 489 99 154 253 2.2 3.8 2.8 1.5 1.6 1.5 1.5–2.8 2.8–4.9 2.1–3.4 1.1–1.8 1.3–1.9 1.3–1.8 276 221 497 125 135 260 1.1 2.7 1.7 1.0 1.6 1.3 0.8–1.4 1.9–3.5 1.3–2.1 0.7–1.3 1.2–2.0 1.0–1.5 494 492 986 224 289 513 1.8 3.4 2.4 1.3 1.6 1.4 1.3–2.3 2.6–4.3 1.9–2.9 1.0–1.6 1.4–1.9 1.2–1.6

standard drinks of unrecorded alcohol

Table 5.13: Consumption of unrecorded alcohol by sex, age and residence of respondents* Age Group (years) 18–39 40–69 Residence Rural Urban Total 405 136 541 64.6 42.6 58.4 58.4-70.7 33.1-52.2 53.0-63.9 404 175 579 63.5 42.1 56.8 55.9-71.2 31.6-52.6 50.4-63.2 809 311 1120 64.2 42.4 57.9 59.1-69.4 35.2-49.7 53.4-62.3 Men n 236 305 % 57.8 59.5 95% CI 50.6–65.0 52.5–66.5 n 310 269 Women % 53.5 62.0 95% CI 45.6–61.3 53.9–70.2 n 546 574 Both Sexes % 56.4 60.4 95% CI 50.8–61.9 54.7–66.0

*Percentage of respondents that consumed unrecorded alcohol (homebrewed alcohol, alcohol brought over the border, not intended for drinking or other untaxed alcohol) during the past 7 days among current (past 30 days) drinkers.

Table 5.14: Percentage of unrecorded alcohol from all alcohol consumed during past 7 days Age Group (years) 18–39 40–69 Total Men n 150 204 354 % 48.6 36.6 41.7 n 169 143 312 Women % 57.3 50.8 54.3 n 319 347 666 Both Sexes % 53.2 42.5 47.6

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Table 5.15: Unrecorded alcohol consumption during the past 7 days by type* Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 184 233 417 44 54.9 50.1 50.5 38.6 43.9 4.3 6.0 5.3 1.1 0.4 0.7 98 100 198 48.6 48 48.5 43 39.3 40.9 7.1 12.4 9.6 1.3 0.3 0.5 86 133 219 38.5 59.8 51.6 59.3 38 46.6 1.0 1.5 1.4 1.2 0.7 0.9 n % homebrewed spirits % homebrewed beer/ wine % brought over border % other

*Percentage of each type of unrecorded alcohol of all unrecorded alcohol consumed in the past 7 days among current (past 30 days) drinkers.

Table 5.16: Frequency of not being able to stop drinking once started during the past 12 months among past 12 month drinkers Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 706 654 1360 21.7 27.6 23.8 17.2–26.1 23.0–32.1 20.1–27.5 13.3 15.9 14.2 9.2–17.5 12.3–19.5 11.1–17.4 65.0 56.5 62.0 59.4–70.5 51.1–62.0 57.5–66.5 421 321 742 14.6 22.4 17.4 10.5–18.6 17.2–27.6 14.1–20.7 9.7 17.3 12.4 6.1–13.4 12.2–22.4 9.3–15.6 75.7 60.3 70.1 70.4–81.1 53.6–67.0 65.7–74.6 285 333 618 25.6 30.6 27.3 19.5–31.7 24.9–36.4 22.4–32.2 15.3 15.1 15.2 9.9–20.8 10.7–19.5 11.2–19.3 59.1 54.3 57.4 51.9–66.3 47.2–61.3 51.7–63.1 n % monthly or more frequently 95% CI % less than monthly 95% CI % never 95% CI

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Table 5.17: Frequency of failing to do what was normally expected from you during the past 12 months among past 12 month drinkers Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 706 654 1360 5.3 5.8 5.5 3.1–7.6 3.5–8.0 3.8–7.2 9.5 11.5 10.2 6.3–12.7 8.4–14.6 7.8–12.6 85.2 82.7 84.3 81.3–89.1 78.8–86.6 81.3–87.3 421 321 742 2.9 5.3 3.8 1.1–4.6 2.5–8.1 2.2–5.3 7.4 7.7 7.5 4.3–10.6 4.2–11.2 5.2–9.9 89.7 87.0 88.7 86.1–93.3 82.4–91.6 85.8–91.6 285 333 618 6.7 6.1 6.5 3.2–10.1 3.1–9.1 4.0–9.0 10.6 13.7 11.7 5.9–15.3 9.3–18.2 8.2–15.2 82.7 80.2 81.9 76.9–88.6 75.0–85.4 77.5–86.2 n % monthly or more frequently 95% CI % less than monthly 95% CI % never 95% CI

Table 5.18: Frequency of needing a first drink in the morning to get going during the past 12 months among past 12 month drinkers Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 706 654 1360 4.9 10.2 6.7 2.5–7.3 7.2–13.1 4.6–8.8 5.0 5.8 5.3 2.9–7.1 3.2–8.5 3.6–7.0 90.1 84.0 87.9 87.1–93.2 80.1–87.9 85.3–90.6 421 321 742 2.8 4.7 3.5 0.2–5.5 2.3–7.0 1.3–5.7 4.5 5.0 4.7 1.4–7.5 1.7–8.4 2.4–6.9 92.7 90.3 91.8 88.9–96.5 85.7–95.0 88.8–94.9 285 333 618 6.0 13.4 8.6 2.6–9.3 9.1–17.8 5.6–11.5 5.3 6.3 5.7 2.5–8.2 3.0–9.6 3.5–7.8 88.7 80.3 85.8 84.4–93.0 75.0–85.6 82.3–89.3 n % monthly or more frequently 95% CI % less than monthly 95% CI % never 95% CI

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Table 5.19: Frequency of family/partner problems due to someone else’s drinking during the past 12 months among all respondents Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1469 1350 2819 0.9 0.4 0.7 0.3–1.4 0.1–0.7 0.3–1.1 6.4 5.4 6.0 4.4–8.3 3.8–7.1 4.5–7.6 92.8 94.2 93.3 90.7–94.9 92.5–95.9 91.6–94.9 969 778 1747 1.2 0.8 1.0 0.4–2.1 0.1–1.4 0.5–1.6 7.1 3.9 6.0 4.0–10.1 1.9–5.9 3.8–8.1 91.7 95.4 93.0 88.6–94.8 93.3–97.4 90.7–95.2 500 572 1072 0.6 0.1 0.4 0.0–1.3 0.0–0.3 0.0–0.9 5.8 6.6 6.1 3.6–8.1 4.0–9.2 4.5–7.7 93.6 93.3 93.5 91.2–96.0 90.6–95.9 91.7–95.2 n % monthly or more frequently 95% CI % less than monthly 95% CI % never 95% CI

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Dietary habits Table 6.1: Mean number of days fruit and vegetables consumed in a typical week Age Group (years) Fruit 18–39 40–69 Residence Rural Urban Total Vegetables 18–39 40–69 Residence Rural Urban Total 774 297 1071 5.6 5.9 5.6 5.3–5.8 5.5–6.2 5.5–5.8 1174 571 1745 5.3 5.9 5.5 5.1–5.5 5.6–6.2 5.3–5.7 1948 868 2816 5.4 5.9 5.6 5.3–5.6 5.6–6.2 5.4–5.7 500 571 5.7 5.6 5.4–5.9 5.4–5.8 969 776 5.5 5.5 5.3–5.7 5.3–5.7 1469 1347 5.6 5.6 5.4–5.8 5.4–5.7 735 296 1031 1.2 2.4 1.6 1.0–1.5 2.0–2.9 1.4–1.8 1117 570 1687 1.6 2.6 1.9 1.3–1.8 2.3–2.9 1.7–2.1 1852 866 2718 1.4 2.5 1.7 1.2–1.6 2.2–2.8 1.5–1.9 487 544 1.7 1.4 1.4–2.0 1.2–1.6 942 745 2.0 1.7 1.8–2.3 1.4–2.0 1429 1289 1.8 1.5 1.6–2.0 1.3–1.7 Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Table 6.2: Mean number of servings of fruit and/or vegetables on average per day by sex, age and residence of respondents Age Group (years) Fruit 18–39 40–69 Residence Rural Urban Total Vegetables 18–39 40–69 774 297 4.2 3.4 3.7–4.8 2.9–4.0 1173 571 3.3 3.7 2.9–3.7 3.1–4.4 1947 868 3.9 3.6 3.4–4.3 3.0–4.1 735 296 1031 0.5 1.0 0.7 0.4–0.7 0.7–1.3 0.5–0.8 1114 569 1683 0.6 1.1 0.8 0.5–0.8 0.8–1.3 0.7–0.9 1849 865 2714 0.6 1.0 0.7 0.4–0.7 0.8–1.2 0.6–0.8 487 544 0.7 0.6 0.5–0.9 0.4–0.7 940 743 0.8 0.7 0.7–1.0 0.5–0.9 1427 1287 0.8 0.6 0.6–0.9 0.5–0.8 Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

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Age Group (years) Residence Rural Urban Total 18–39 40–69 Total Rural Urban Total

Men n Mean 95% CI n

Women Mean 95% CI n

Both Sexes Mean 95% CI

774 297 1071 500 571 1071 774 297 1071

4.2 3.4 4.0 4.6 4.7 4.6 4.7 4.4 4.6

3.7–4.8 2.9–4.0 3.5–4.4 4.0–5.1 4.2–5.3 4.1–5.1 4.1–5.3 3.7–5.1 4.1–5.1

1173 571 1744 969 777 1746 1175 571 1746

3.3 3.7 3.5 4.3 4.1 4.2 4.0 4.8 4.2

2.9–3.7 3.1–4.4 3.1–3.8 3.9–4.7 3.6–4.5 3.8–4.6 3.5–4.4 4.0–5.5 3.8–4.6

1947 868 2815 1469 1348 2817 1949 868 2817

3.9 3.6 3.8 4.5 4.4 4.5 4.4 4.6 4.5

3.4–4.3 3.0–4.1 3.4–4.1 4.0–4.9 4.0–4.9 4.1–4.8 3.9–4.9 4.0–5.2 4.1–4.8

Fruit and/or vegetables

Residence – Fruit and/or vegetables

Table 6.3: Number of servings of fruit and/or vegetables on average per day Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total 18–39 40–69 Total Both Sexes 1469 1348 2817 6.6 7.9 7.1 4.7–8.6 5.6–10.2 5.3–8.9 28.1 32.1 29.5 23.1–33.1 27.2–37.0 25.0–34.0 32.0 27.2 30.3 27.9–36.1 23.7–30.7 26.8–33.8 33.3 32.8 33.1 27.6–39.0 27.3–38.3 28.0–38.3 969 777 1746 5.9 10.7 7.6 3.6–8.3 7.3–14.1 5.4–9.7 30.9 34.4 32.1 25.7–36.1 29.3–39.5 27.8–36.5 32.0 25.8 29.9 28.0–36.0 22.1–29.6 26.5–33.2 31.2 29.1 30.4 25.3–37.1 23.5–34.7 25.3–35.6 500 571 1071 7.2 5.7 6.7 4.2–10.2 3.4–8.0 4.4–8.9 25.9 30.3 27.4 19.4–32.4 24.2–36.5 21.8–33.1 32.0 28.2 30.7 25.4–38.5 23.2–33.3 25.4–35.9 35.0 35.7 35.2 27.7–42.3 28.9–42.6 28.8–41.7 % no fruit and/or vegetables % 1–2 servings % 3–4 servings % ≥5 servings

n

95% CI

95% CI

95% CI

95% CI

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Table 6.4: Less than five servings of fruit and/or vegetables on average per day Age Group (years) 18–39 40–69 Residence Rural Urban Total 774 297 1071 63.1 68.8 64.8 54.8–71.3 59.8–77.7 58.3–71.2 1175 571 1746 71.3 66.1 69.6 65.3–77.3 56.6–75.7 64.4–74.7 1949 868 2817 66.6 67.5 66.9 59.9–73.2 59.8–75.3 61.7–72.0 Men n 500 571 % 65.0 64.3 95% CI 57.7–72.3 57.4–71.1 n 969 777 Women % 68.8 70.9 95% CI 62.9–74.7 65.3–76.5 n 1469 1348 Both Sexes % 66.7 67.2 95% CI 61.0–72.4 61.7–72.7

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Dietary salt Table 7.1: Salt consumption habits Age Group (years) 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Total 18–39 40–69 Rural Urban Total 769 297 1066 499 566 1065 497 567 769 295 1064 8.2 5.5 7.4 40.8 43.8 41.8 12.5 8.1 7.2 20.1 11.0 4.2–12.2 1.9–9.1 4.4–10.5 34.6–47.0 37.0–50.5 36.6–47.1 9.0–16.0 5.4–10.9 4.7-9.6 14.2-26.0 8.4-13.6 1169 570 1739 965 774 1739 961 771 1161 571 1732 7.8 9.2 8.3 43.9 36.6 41.4 15.0 4.1 8.0 17.4 11.2 5.2–10.4 5.7–12.7 6.2–10.4 38.1–49.8 31.4–41.8 36.6–46.2 12.2–17.7 2.0–6.2 5.4-10.7 14.1-20.7 9.1-13.3 1938 867 2805 1464 1340 2804 1458 1338 1930 866 2796 8.0 7.2 7.8 42.2 40.6 41.6 13.6 6.4 7.5 18.8 11.1 4.9–11.2 4.2–10.3 5.4–10.2 37.1–47.2 35.6–45.6 37.2–46.1 11.2–16.0 4.6–8.1 5.6-9.5 15.1-22.6 9.3-12.9 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Add salt always or often before eating or when eating 499 567 7.9 6.6 3.3–12.4 4.0–9.2 967 7h72 9.0 6.9 6.3–11.7 4.5–9.3 1466 1339 8.4 6.7 4.9–11.8 4.8–8.7

Add salt always or often when cooking or preparing food at home

Always or often consume processed food high in salt

Always or often consume processed food high in salt by Residence

Table 7.2: Percentage of people who think they consume far too much or too much salt Age Group (years) 18–39 40–69 Total Men n 496 565 1061 % 16.8 17.6 17.1 95% CI 13.5–20.2 13.6–21.5 14.5–19.7 n 956 764 1720 Women % 19.0 10.9 16.2 95% CI 15.7–22.2 7.9–13.9 13.8–18.5 n 1452 1329 2781 Both Sexes % 17.8 14.6 16.7 95% CI 15.4–20.1 12.0–17.3 14.9–18.5

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Table 7.3: Self-reported quantity of salt consumed Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1452 1329 2781 0.7 0.6 0.7 0.3–1.2 0.0–1.1 0.3–1.0 17.1 14.1 16.0 14.7–19.4 11.5–16.6 14.2–17.8 70.8 68.2 69.9 67.6–74.0 64.3–72.0 67.4–72.3 10.9 16.3 12.8 8.6–13.2 13.6–18.9 11.0–14.5 0.5 1.0 0.7 0.2–0.9 0.3–1.6 0.3–1.0 956 764 1720 0.8 0.4 0.7 0.3–1.4 0.0–1.1 0.2–1.1 18.2 10.4 15.5 15.0–21.4 7.7–13.2 13.2–17.8 69.4 69.4 69.4 65.1–73.7 64.8–73.9 66.1–72.6 10.9 18.6 13.6 8.6–13.2 14.9–22.3 11.5–15.7 0.8 1.2 0.9 0.2–1.3 0.3–2.2 0.4–1.4 496 565 1061 0.6 0.6 0.6 0.0–1.3 0.0–1.4 0.1–1.1 16.2 16.9 16.4 12.8–19.6 13.1–20.7 13.9–19.0 71.9 67.2 70.3 67.6–76.2 61.8–72.7 66.9–73.7 10.9 14.5 12.1 7.6–14.2 11.0–17.9 9.7–14.6 0.4 0.8 0.5 0.0–0.9 0.0–1.5 0.1–0.9 n % Far too much 95% CI % Too much 95% CI % Just the right amount 95% CI % Too little 95% CI % Far too little 95% CI

Table 7.4: Percentage of respondents who agree with the importance of lowering salt in diet Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1344 1226 2570 65.8 62.9 64.8 62.0–69.6 58.1–67.6 61.4–68.2 30.1 33.0 31.1 26.5–33.7 28.5–37.5 27.8–34.4 4.1 4.2 4.1 2.8–5.3 2.4–5.9 3.2–5.1 881 710 1591 63.0 62.7 62.9 58.5–67.5 56.9–68.4 59.0–66.8 32.3 33.2 32.6 28.1–36.5 28.1–38.4 29.1–36.2 4.7 4.1 4.5 2.9–6.4 2.1–6.1 3.1–5.8 463 516 979 67.9 63.0 66.2 62.7–73.1 57.0–69.0 61.7–70.8 28.5 32.8 29.9 23.6–33.4 26.7–38.9 25.4–34.5 3.6 4.2 3.8 1.8–5.5 1.8–6.7 2.4–5.3 n % Very important 95% CI % Somewhat important 95% CI % Not at all important 95% CI

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Table 7.5: Percentage of respondents who think that consuming too much salt could cause serious health problems Age Group (years) 18–39 40–69 Total Men n 455 506 961 % 91.6 92.5 91.9 95% CI 88.5–94.7 89.3–95.6 89.6–94.2 n 890 710 1600 Women % 93.6 89.7 92.3 95% CI 91.3–95.9 86.6–92.8 90.4–94.1 n 1345 1216 2561 Both Sexes % 92.5 91.2 92.1 95% CI 90.4–94.5 88.8–93.7 90.4–93.7

Table 7.6: Mean salt intake (g/day) by age, sex and residence Age Group (years) 18–39 40–69 Residence Rural Urban Total 736 282 1018 9.6 9.8 9.6 9.3-9.8 9.5-10.1 9.4-9.8 1084 516 1600 8.0 8.2 8.0 7.8-8.1 8.0-8.3 7.9-8.2 1820 798 2618 8.9 9.0 9.0 8.7-9.1 8.8-9.3 8.8-9.1 Men n 472 546 Mean 9.5 9.9 95% CI 9.2–9.8 9.7– 10.1 n 857 743 Women Mean 8.3 7.6 95% CI 8.1–8.4 7.4–7.8 n 1329 1289 Both Sexes Mean 9.0 8.9 95% CI 8.8–9.2 8.7–9.1

Table 7.7: Techniques used on a regular basis to reduce salt intake Age Group (years) 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Limit consumption of processed foods 500 572 1072 500 572 1072 500 572 1072 40.4 39.9 40.2 12.5 9.2 11.3 8.1 5.3 7.1 34.7–46.1 34.6–45.1 35.6–44.8 8.5–16.4 6.0–12.3 8.2–14.4 4.4–11.8 3.1–7.4 4.4–9.8 969 778 1747 969 778 1747 969 778 1747 39.6 41.9 40.4 9.0 3.8 7.2 8.4 6.3 7.7 35.3–43.9 36.4–47.4 36.6–44.2 6.6–11.4 2.2–5.3 5.5–8.9 5.7–11.2 3.8–8.9 5.6–9.8 1469 1350 2819 1469 1350 2819 1469 1350 2819 40.1 40.8 40.3 11.0 6.8 9.5 8.3 5.7 7.4 36.1–44.0 36.6–44.9 36.9–43.7 8.4–13.5 4.7–8.8 7.5–11.5 5.8–10.7 3.9–7.6 5.4–9.4

Look at the salt or sodium content on food labels

Buy low salt/sodium alternatives

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Age Group (years) 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total

Men n % 95% CI n

Women % 95% CI n

Both Sexes % 95% CI

Use spices other than salt when cooking 500 572 1072 500 572 1072 500 572 1072 13.2 10.9 12.4 28.0 26.2 27.4 8.9 12.7 10.3 8.8–17.7 7.4–14.4 8.9–16.0 22.2–33.9 21.8–30.7 23.0–31.8 5.1–12.8 8.7–16.8 7.1–13.4 969 778 1747 969 778 1747 969 778 1747 14.2 9.5 12.6 30.4 26.4 29.0 9.6 10.5 9.9 10.7–17.7 6.5–12.5 9.8–15.3 25.8–35.0 22.0–30.8 25.1–32.9 6.6–12.5 7.5–13.6 7.6–12.2 1469 1350 2819 1469 1350 2819 1469 1350 2819 13.6 10.3 12.5 29.1 26.3 28.1 9.2 11.7 10.1 10.1–17.2 7.6–13.0 9.6–15.3 24.9–33.3 22.8–29.9 24.7–31.6 6.5–12.0 8.8–14.6 7.7–12.5

Avoid eating foods prepared outside of a home

Do other things specifically to control your salt intake

Table 7.8: Type of oil or fat most often used for meal preparation in household n (households) 2819 % Vege­ table oil 97.1 95% CI 95.9–98.3 % Lard 0.0 95% CI 0.0–0.1 % Butter 2.3 95% CI 1.2–3.4 % Other 0.1 95% CI 0.0–0.3 % none in parti­ cular 0.4 95% CI 0.0–0.9

Table 7.9: Mean number of meals eaten outside a home Age Group (years) 18–39 40–69 Total Men n 494 555 1049 mean 1.0 1.0 1.0 95% CI 0.9–1.2 0.7–1.2 0.9–1.1 n 950 752 1702 Women mean 0.6 0.7 0.7 95% CI 0.5–0.8 0.5–0.9 0.5–0.8 n 1444 1307 2751 Both Sexes mean 0.9 0.8 0.9 95% CI 0.8–1.0 0.7–1.0 0.8–1.0

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Physical inactivity Table 8.1: Metabolic equivalent (MET) Domain Work Transport Recreation MET value Moderate MET value = 4.0 Vigorous MET value = 8.0 Cycling and walking MET value = 4.0 Moderate MET value = 4.0 Vigorous MET value = 8.0

Table 8.2: Not meeting WHO recommendations on physical activity for health Men n Age Group (years) 18–39 40–69 Residence Rural Urban Total 737 287 1024 1.9 8.4 3.8 0.9-2.9 5.0-11.8 2.5-5.0 1127 561 1688 4.9 18.6 9.6 2.8-7.0 12.4-24.8 6.8-12.4 1864 848 2712 3.2 13.2 6.4 2.2-4.2 9.0-17.4 4.7-8.0 486 538 3.5 4.5 2.0–5.0 2.6–6.5 938 750 10.1 8.7 7.0–13.1 5.4–11.9 1424 1288 6.4 6.4 4.6–8.1 4.4–8.3 % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Table 8.3: Level of total physical activity according to former recommendations Age Group (years) Men 18–39 40–69 Residence Rural Urban Total Women 18–39 40–69 Residence Rural Urban Total 1127 561 1688 12.8 24.1 16.6 9.8–15.8 17.2–31.0 13.4–19.9 9.9 17.3 12.4 7.5–12.4 13.3–21.4 10.2–14.7 77.3 58.6 70.9 72.9–81.7 50.0–67.1 66.5–75.4 938 750 16.8 16.3 13.1–20.5 12.4–20.1 13.9 9.7 11.0–16.8 7.0–12.5 69.3 74.0 64.3–74.3 68.8–79.1 737 287 1024 5.5 13.1 7.7 3.1–7.8 8.0–18.1 5.4–10.0 5.6 17.1 9.0 3.6–7.6 11.7–22.5 6.7–11.4 89.0 69.8 83.2 85.5–92.4 62.4–77.3 79.6–86.8 486 538 7.3 8.7 4.5–10.0 5.7–11.6 7.6 11.8 4.9–10.4 8.3–15.4 85.1 79.5 81.3–88.9 74.5–84.5 n % Low 95% CI % Moderate 95% CI % High 95% CI

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Age Group (years) Both Sexes 18–39 40–69 Residence Rural Urban Total

n

% Low

95% CI

% Moderate 10.4 10.9 7.4 17.2 10.5

95% CI

% High

95% CI

1424 1288 1864 848 2712

11.5 12.1 8.6 18.3 11.7

8.9–14.0 9.6–14.5 6.5–10.7 13.1–23.4 9.4–13.9

8.2–12.5 8.5–13.3 5.9–9.0 13.2–21.2 8.7–12.4

78.2 77.0 84.0 64.5 77.8

74.9–81.5 73.1–81.0 81.0–87.0 57.7–71.3 74.5–81.1

Table 8.4: Mean and median minutes of total physical activity on average per day Age Group (years) Men 18–39 40–69 Residence Rural Urban Total Women 18–39 40–69 Residence Rural Urban Total Both Sexes 18–39 40–69 Residence Rural Urban Total 1864 848 2712 – – 350.5 – – 330.0–371.0 390 180 330.0 344.3 312.9 377.1 1424 1288 346.9 357.5 322.0–371.8 335.5–379.4 312.9 351.4 377.1 374.3 1127 561 1688 – – 308.3 – – 283.9–332.8 347 180 274.3 360 325.7 377.1 938 750 294.4 334.8 265.9–323.0 306.0–363.6 250.7 317.1 360 361.4 737 287 1024 – – 383.7 – – 357.3–410.2 445.7 197.1 367.1 327.1 307.9 362.1 486 538 387.8 375.8 355.0–420.6 346.2–405.3 368.6 360.0 360.0 378.6 n Mean 95% CI Median Inter-quartile range (P25-P75)

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Table 8.5: Mean minutes spent in work-, transport- and recreation-related physical activity on average per day. Age Group (years) Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Work-related 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total 486 538 1024 486 538 1024 486 538 1024 287.7 304.6 293.4 63.1 59.4 61.8 37.1 11.7 28.5 255.1–320.2 275.2–334.1 266.7–320.1 51.2–74.9 41.8–77.0 49.9–73.7 29.6–44.5 7.7–15.7 22.9–34.1 938 750 1688 938 750 1688 938 750 1688 237.4 275.6 250.6 48.4 54.7 50.6 8.7 4.5 7.2 214.1–260.7 1424 251.4–299.7 1288 230.4–270.7 2712 37.3–59.4 42.9–66.5 41.1–60.0 5.5–11.9 1.8–7.3 5.0–9.5 1424 1288 2712 1424 1288 2712 265.7 291.7 274.5 56.6 57.3 56.9 24.6 8.5 19.1 242.1–289.2 270.5–312.8 255.0–294.1 47.4–65.8 45.2–69.4 47.8–65.9 20.0–29.2 5.7–11.3 15.6–22.7

Transport-related

Recreation-related

Table 8.6: Median minutes spent on average per day in work-, transport- and recreation-related physical activity Men Age Group (years) n Median Interquartile range (P25-P75) 394.3 394.3 411.4 85.7 68.6 77.1 51.4 0.0 39.3 n Women Median Interquartile range (P25-P75) 347.1 347.1 351.4 60.0 64.3 60.0 0.0 0.0 0.0 n Both Sexes Median Interquartile range (P25-P75) 368.6 394.3 385.7 60.0 64.3 60.0 25.7 0.0 8.6

Work-related 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total 486 538 1024 486 538 1024 486 538 1024 257.1 300.0 274.3 25.7 20.0 25.7 0.0 0.0 0.0 938 750 1688 938 750 1688 938 750 1688 180.0 257.1 210 17.1 17.1 17.1 0.0 0.0 0.0 1424 1288 2712 1424 1288 2712 1424 1288 2712 231.4 278.6 240.0 20.0 17.1 20.0 0.0 0.0 0.0

Transport-related

Recreation-related

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Table 8.7: Percentage of respondents classified as doing no work-, transport- or recreational-related physical activity. Age Group (years) Men n 486 538 1024 486 538 1024 486 538 1024 % 12.4 11.4 12.1 35.7 38.6 36.6 52.7 78.7 61.5 95% CI 8.5–16.3 7.1–15.6 9.0–15.2 28.6–42.7 31.8–45.3 30.5–42.7 45.2–60.2 73.0–84.4 55.1–67.8 n 938 750 1688 938 750 1688 938 750 1688 Women % 16.9 14.5 16.0 39.8 41.2 40.3 86.3 94.1 89.0 95% CI 12.9–20.8 10.4–18.5 12.7–19.4 33.9–45.7 35.1–47.4 35.2–45.4 82.9–89.7 91.8–96.4 86.5–91.5 n 1424 1288 2712 1424 1288 2712 1424 1288 2712 Both Sexes % 14.4 12.7 13.8 37.5 39.8 38.3 67.4 85.6 73.6 95% CI 11.6–17.1 9.7–15.8 11.5–16.1 31.9–43.1 34.1–45.4 33.2–43.4 62.6–72.3 81.9–89.2 69.5–77.7

No work-related physical activity 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total

No transport-related physical activity

No recreation-related physical activity

Table 8.8: Percentage of work, transport and recreational activity contributing to total activity. Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1355 1231 2586 68.4 75.5 70.8 64.7–72.1 71.9–79.2 67.6–74.1 20.7 19.6 20.3 17.8–23.6 16.5–22.7 17.9–22.8 10.9 4.9 8.9 8.5–13.3 3.3–6.5 6.9–10.8 877 710 1587 72.8 77.3 74.3 68.7–76.8 73.8–80.7 71.1–77.6 23.2 21.3 22.5 19.3–27.1 17.8–24.7 19.4–25.6 4.1 1.4 3.2 2.8–5.3 0.6–2.3 2.3–4.0 478 521 999 65.2 74.2 68.2 60.5–69.9 69.2–79.2 63.9–72.5 18.9 18.3 18.7 15.6–22.1 14.3–22.3 15.7–21.6 16.0 7.5 13.1 12.3–19.7 4.9–10.1 10.1–16.2 % Activity from work % Activity for transport % Activity during leisure time

n

95% CI

95% CI

95% CI

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Table 8.9: Percentage of respondents not engaging in vigorous physical activity. Age Group (years) 18–39 40–69 Residence Rural Urban Total 737 287 1024 27.9 52.4 35.2 22.4–33.4 44.6–60.3 30.3–40.2 1127 561 1688 54.5 88.5 66.0 49.0–60.1 84.0–92.9 61.2–70.9 1864 848 2712 39.2 69.4 48.8 34.8–43.7 63.2–75.6 44.6–53.1 Men n 486 538 % 31.2 43.3 95% CI 25.8–36.6 36.8–49.8 n 938 750 Women % 68.1 62.0 95% CI 63.3–73.0 56.7–67.3 n 1424 1288 Both Sexes % 47.4 51.6 95% CI 42.9–51.9 46.9–56.3

Table 8.10: Minutes spent in sedentary activities on average per day Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1469 1350 2819 153.9 136.9 148.0 142.8–165.0 128.9–144.8 139.3–156.6 120.0 120.0 120.0 120.0 120.0 120.0 969 778 1747 173.5 140.0 161.9 158.2–188.9 130.8–149.3 150.3–173.5 120.0 120.0 120.0 140.0 120.0 120.0 500 572 1072 138.4 134.4 137.0 127.0–149.9 123.4–145.4 127.8–146.3 120.0 120.0 120.0 120.0 120.0 120.0 n Mean minutes 95% CI Median minutes Inter-quartile range (P25-P75)

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Blood pressure Table 9.1: Blood pressure measurement and diagnosis % measu­ red, not diag­ nosed 51.8 45.9 49.7 61.6 43.5 55.3 56.1 44.9 52.2 % diag­ nosed, but not within past 12 months 2.5 6.6 3.9 5.6 7.0 6.1 3.9 6.8 4.9 % diag­ nosed within past 12 months

Age Group (years)

n

% Never measured

95% CI

95% CI

95% CI

95% CI

Men 18–39 40–69 Total Women 18–39 40–69 Total Both sexes 18–39 40–69 Total 1469 1350 2819 32.8 28.5 31.3 28.2–37.3 24.4–32.5 27.7–34.8 51.7–60.4 40.9–48.8 48.6–55.7 2.8–5.0 4.7–8.8 3.8–6.0 7.3 19.9 11.7 5.6–9.0 16.9–22.9 10.1–13.3 969 778 1747 23.7 23.7 23.7 19.6–27.9 19.2–28.3 20.6–26.9 57.3–65.8 38.8–48.2 51.8–58.8 4.0–7.3 3.9–10.1 4.6–7.6 9.1 25.8 14.9 6.7–11.4 21.5–30.0 12.7–17.1 500 572 1072 39.9 32.2 37.2 33.3–46.5 26.7–37.6 32.0–42.4 45.1–58.4 40.4–51.5 44.5–55.0 1.0–4.1 3.9–9.3 2.4–5.5 5.9 15.3 9.1 3.4–8.4 11.5–19.1 7.1–11.2

Table 9.2: Currently taking drugs (medication) for raised blood pressure prescribed by doctor or health worker among those diagnosed Age Group (years) 18–39 40–69 Total Men n 52 122 174 % 13.5 38.0 27.8 95% CI 2.1–24.9 26.7–49.3 18.8–36.8 n 152 240 392 Women % 8.8 46.5 29.3 95% CI 4.4–13.3 38.0–55.0 23.7–34.9 n 204 362 566 Both Sexes % 10.8 42.6 28.6 95% CI 5.3–16.2 35.5–49.7 23.5–33.8

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Table 9.3: Percentage of previously diagnosed hypertensive respondents who have visited or received treatment from a traditional healer Age Group (years) 18–39 40–69 Total 18–39 40–69 Total Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Seen a traditional healer 52 122 174 52 122 174 2.5 12.9 8.6 0.3 8.6 5.1 0.0–6.0 6.1–19.7 4.3–12.8 0.0–1.0 1.8–15.4 1.0–9.3 152 240 392 152 240 392 3.6 15.4 10.0 1.3 4.8 3.2 0.4–6.8 7.3–23.5 5.2–14.9 0.0–3.3 1.4–8.2 1.1–5.3 204 362 566 204 362 566 3.2 14.3 9.4 0.9 6.5 4.1 0.9–5.5 9.1–19.4 6.3–12.5 0.0–2.1 2.6–10.4 1.7–6.4

Currently taking herbal or traditional remedy for raised blood pressure

Physical Measurements Table 9.4: Mean blood pressure among all respondents, including those currently on medication for raised blood pressure. Age Group (years) 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total 774 297 1071 84.8 84.2 84.6 83.3–86.3 82.0–86.3 83.4–85.9 1176 569 1745 86.3 83.7 85.4 85.1–87.4 82.3–85.1 84.5–86.3 1950 866 2816 85.4 84.0 85.0 84.2–86.6 82.7–85.2 84.0–85.9 774 297 1071 499 572 128.1 127.7 128.0 82.5 88.7 126.5–129.8 125.0–130.3 126.6–129.4 81.1–83.9 87.2–90.2 1176 569 1745 968 777 125.5 120.6 123.8 82.3 91.2 123.8–127.1 118.6–122.5 122.5–125.1 81.4–83.2 89.8–92.5 1950 866 2816 1467 1349 127.0 124.3 126.2 82.4 89.8 125.6–128.4 122.9–125.8 125.1–127.2 81.5–83.4 88.6–90.9 Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Mean systolic blood pressure (mmHg) 499 572 125.1 133.4 123.7–126.5 131.1–135.6 968 777 117.9 135.0 116.8–118.9 132.8–137.2 1467 1349 121.9 134.1 120.9–122.9 132.4–135.8

Mean diastolic blood pressure (mmHg)

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Table 9.5: Percentage of respondents with raised blood pressure. Age Group (years) 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total 774 297 1071 13.7 12.3 13.3 10.1–17.3 7.7–16.8 10.4–16.2 1176 569 1745 16.8 13.8 15.8 13.8–19.7 9.7–17.8 13.4–18.2 1950 866 2816 15.0 13.0 14.4 12.3–17.8 10.1–15.8 12.3–16.5 747 286 1033 499 572 11.2 9.4 10.6 7.9 23.4 7.9–14.4 5.0–13.7 8.0–13.3 4.6–11.2 19.2–27.5 1096 531 1627 968 777 11.8 8.0 10.5 6.9 32.3 9.2–14.4 5.1–10.9 8.5–12.5 5.2–8.7 27.7–37.0 1843 817 2660 1467 1349 11.4 8.7 10.6 7.5 27.3 9.0–13.8 6.1–11.4 8.7–12.4 5.4–9.6 24.1–30.5 774 297 1071 494 539 33.5 40.4 35.5 7.2 17.5 29.0–37.9 32.0–48.9 31.5–39.6 4.0–10.3 13.6–21.5 1176 569 1745 952 675 39.1 29.7 35.9 5.8 20.8 34.5–43.6 25.2–34.2 32.5–39.4 4.2–7.4 16.7–24.9 1950 866 2816 1446 1214 35.9 35.4 35.7 6.6 18.9 32.2–39.5 30.7–40.0 32.8–38.6 4.6–8.6 15.9–21.9 747 286 1033 499 572 31.5 38.4 33.6 28.8 48.1 27.0–35.9 29.9–47.0 29.5–37.6 24.1–33.6 43.1–53.2 1096 531 1627 968 777 35.4 25.0 32.0 23.2 59.8 31.0–39.9 20.7–29.2 28.6–35.4 19.5–26.8 55.1–64.5 1843 817 2660 1467 1349 33.1 32.2 32.9 26.3 53.3 29.6–36.7 27.2–37.3 30.0–35.8 23.0–29.7 49.6–56.9 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

SBP >140 and/or DBP > 90 mmHg, excluding those on medication for raised blood pressure 494 539 28.3 44.2 23.5–33.0 39.0–49.4 952 675 22.3 53.0 18.7–25.9 47.9–58.1 1446 1214 25.6 47.9 22.3–29.0 44.0–51.7

SBP >140 and/or DBP > 90 mmHg or currently on medication for raised blood pressure

SBP >160 and/or DBP > 100 mmHg, excluding those on medication for raised blood pressure

SBP >160 and/or DBP > 100 mmHg or currently on medication for raised blood pressure

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Table 9.6: Percentage of respondents with treated and/or controlled of raised blood pressure among those with raised blood pressure(SBP >140 and/or DBP > 90 mmHg) or currently on medication for raised blood pressure. % On medication and SBP<140 and DBP<90 % On medication and SBP>140 and/or DBP>90 % Not on medication and SBP>140 and/or DBP>90 97.2 85.3 91.6 94.9 75.6 83.7 96.3 80.5 88.1

Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total

n

95% CI

95% CI

95% CI

147 276 423 234 444 678 381 720 1101

1.5 3.3 2.3 0.5 4.8 3.0 1.1 4.0 2.6

0.0–3.5 1.2–5.4 0.9–3.8 0.0–1.3 2.3–7.3 1.5–4.5 0.0–2.4 2.5–5.6 1.6–3.7

1.3 11.4 6.1 4.5 19.6 13.3 2.5 15.5 9.2

0.0–3.0 6.5–16.4 3.5–8.6 1.8–7.2 14.9–24.3 10.2–16.3 1.1–4.0 12.1–18.8 7.4–11.1

94.6–99.9 79.9–90.7 88.7–94.5 92.2–97.7 69.8–81.4 80.0–87.5 94.4–98.3 76.6–84.4 85.9–90.4

Table 9.7: Mean heart rate (beats per minute) of respondents by sex and age Age Group (years) 18–39 40–69 Total Men n 499 572 1071 mean 71.4 72.5 71.8 95% CI 70.1–72.6 71.3–73.8 70.8–72.7 n 968 777 1745 Women mean 76.8 75.4 76.4 95% CI 75.9–77.8 74.2–76.6 75.5–77.2 n 1467 1349 2816 Both Sexes mean 73.8 73.8 73.8 95% CI 72.9–74.6 72.8–74.8 73.1–74.5

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Blood glucose Table 10.1: Blood sugar measurement and diagnosis Age Group (years) Men 18–39 40–69 500 572 89.3 80.5 86.1–92.4 76.8–84.2 10.4 16.0 7.3–13.5 12.6–19.4 0.0 0.9 0.0–0.0 0.1–1.6 0.3 2.6 0.0–1.0 1.1–4.2 n % Never measured 95% CI % measured, not diagnosed 95% CI % diagnosed, but not within past 12 months 95% CI % diagnosed within past 12 months 95% CI

Total Women 18–39 40–69

1072 969 778

86.2 85.6 76.6

83.7–88.8 82.5–88.6 72.2–81.0

12.3 13.7 19.1

9.8–14.9 10.7–16.8 15.2–22.9

0.3 0.1 1.1

0.0–0.6 0.0–0.4 0.0–2.3

1.1 0.6 3.2

0.4–1.8 0.0–1.2 1.5–4.9

Total 18–39 40–69

1747 1469 1350

82.4 87.6 78.8

79.9–85.0 85.5–89.8 75.7–81.8

15.6 11.9 17.4

13.1–18.1 9.7–14.0 14.7–20.0

0.5 0.1 1.0

0.0–0.9 0.0–0.2 0.3–1.6

1.5 0.4 2.9

0.8–2.2 0.0–0.9 1.7–4.0

Both sexes

Total

2819

84.6

82.7–86.4

13.8

12.0–15.6

0.4

0.1–0.6

1.3

0.8–1.8

Table 10.2: Percentage of respondents currently taking oral medication and insulin prescribed for diabetes among those previously diagnosed: Both Sexes Age Group (years) Taking oral drugs 18–69 Taking insulin 18–69 59 4.8 0.0–10.4 59 35.0 18.6–51.5 Both Sexes n % 95% CI

Table 10.3: Percentage of respondents who have sought advise or treatment from a traditional healer for diabetes among those previously diagnosed: Both Sexes Age Group (years) 18–69 Both Sexes n 59 % seen trad. healer 11.5 95% CI 0.6–22.5 % taking trad. meds 2.4 95% CI 0.0–7.2

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Table 10.4: Mean fasting blood glucose results including those currently on medication for diabetes (non–fasting recipients excluded) by sex, age and residence Age Group (years) 18–39 40–69 Total 18–39 40–69 Rural Urban Total Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Mean fasting blood glucose (mmol/L) 484 553 1037 484 553 752 285 1037 4.8 5.1 4.9 86.7 92.5 88.4 89.3 88.7 4.7–4.9 5.0–5.3 4.8–5.0 84.5–88.8 89.6–95.4 86.2-90.6 86.4-92.2 86.9-90.5 935 752 1687 935 752 1135 552 1687 4.8 5.1 4.9 87.0 92.5 88.7 89.2 88.9 4.7–4.9 5.0–5.3 4.9–5.0 85.4–88.5 90.0–95.0 87.1-90.4 86.1-92.3 87.4-90.4 1419 1305 2724 1419 1305 1887 837 2724 4.8 5.1 4.9 86.8 92.5 88.6 89.3 88.8 4.7–4.9 5.0–5.3 4.9–5.0 85.3–88.3 90.3–94.7 86.8-90.3 86.7-91.8 87.4-90.2

Mean fasting blood glucose (mg/dl)

Mean fasting blood glucose (mg/dl), by residence 

Table 10.5: Categorization of respondents into blood glucose level categories and percentage of respondents currently on medication for raised blood glucose (non–fasting recipients excluded) by sex and age Age Group (years) Men n 484 553 752 285 1037 484 553 752 285 1037 % 10.2 13.5 11.3 11.4 11.4 4.9 9.6 5.3 9.5 6.5 95% CI 6.7–13.7 9.3–17.8 7.4–15.3 6.4–16.4 8.2–14.5 2.5–7.3 6.2–13.0 3.1–7.6 5.7–13.3 4.6–8.5 n 935 752 1135 552 1687 935 752 1135 552 1687 Women % 8.5 12.7 9.7 10.5 10.0 3.4 11.7 5.7 7.5 6.3 95% CI 6.1–10.8 9.7–15.8 7.3–12.1 6.7–14.4 7.9–12.0 2.0–4.8 8.1–15.4 4.0–7.4 4.1–11.0 4.7–7.9 n 1419 1305 1887 837 2724 1419 1305 1887 837 2724 Both Sexes % 9.4 13.2 10.6 11.0 10.7 4.3 10.5 5.5 8.5 6.4 95% CI 7.1–11.8 10.3–16.1 8.0–13.3 7.7–14.3 8.6–12.9 2.7–5.8 7.9–13.1 3.9–7.1 5.8–11.3 5.0–7.8

Impaired Fasting Glycaemia* 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total

Raised blood glucose or currently on medication for diabetes**

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Age Group (years)

Men n 500 574 775 299 1074 % 0.0 1.1 0.1 0.9 0.4 95% CI 0.0–0.0 0.0–2.2 0.0–0.4 0.0–2.2 0.0–0.8 n 969 779 1177 571 1748

Women % 0.1 2.3 0.5 1.7 0.9 95% CI 0.0–0.2 1.0–3.7 0.0–0.9 0.4–2.9 0.4–1.3 n 1469 1353 1952 870 2822

Both Sexes % 0.0 1.6 0.3 1.3 0.6 95% CI 0.0–0.1 0.7–2.5 0.0–0.5 0.4–2.2 0.3–0.9

Currently on medication for diabetes 18–39 40–69 Residence Rural Urban Total

* Impaired fasting glycaemia is defined as either • plasma venous value: =6.1mmol/L (110mg/dl) and <7.0mmol/L (126mg/dl) • capillary whole blood value: =5.6mmol/L (100mg/dl) and <6.1mmol/L (110mg/dl) • plasma venous value: = 7.0 mmol/L (126 mg/dl) • capillary whole blood value: = 6.1 mmol/L (110 mg/dl)

** Raised blood glucose is defined as either

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Abnormal lipids Table 11.1: Mean total cholesterol among respondents including those currently on medication for raised cholesterol Age Group (years) Men n 489 560 1049 489 560 762 287 1049 Mean 3.6 3.9 3.7 139.8 152.2 143.8 144.9 144.1 95% CI 3.5–3.7 3.8–4.1 3.6–3.8 135.3–144.2 147.8–156.7 139.3–148.2 137.8–152.1 140.3–147.9 n 945 767 1712 945 767 1153 559 1712 Women Mean 3.7 4.2 3.8 142.1 161.0 147.8 150.5 148.7 95% CI 3.6–3.8 4.1–4.3 3.8–3.9 138.6–145.6 157.3–164.8 144.5–151.2 146.1–154.8 146.0–151.4 n 1434 1327 2761 1434 1327 1915 846 2761 Both Sexes Mean 3.6 4.0 3.8 140.8 156.1 145.5 147.6 146.1 95% CI 3.6–3.7 4.0–4.1 3.7–3.8 137.6–144.0 152.9–159.4 142.1–148.9 143.2–151.9 143.4–148.9

Mean total cholesterol (mmol/L) 18–39 40–69 Total 18–39 40–69 Residence Rural Urban Total

Mean total cholesterol (mg/dl)

Table 11.2: Percentage of respondents with raised total cholesterol or on medication for raised cholesterol by sex and age Age Group (years) Men N 489 560 762 287 1049 489 560 762 287 1049 % 9.2 16.9 11.8 12.0 11.9 0.9 2.6 1.3 1.9 1.5 95% CI 6.0–12.4 13.2–20.6 8.5–15.1 6.9–17.2 9.1–14.7 0.1–1.7 0.9–4.3 0.5–2.1 0.1–3.7 0.7–2.3 n 945 767 1153 559 1712 945 767 1153 559 1712 Women % 9.0 21.2 13.2 13.5 13.3 2.3 3.6 2.5 3.2 2.8 95% CI 6.8–11.3 17.4–25.0 10.7–15.7 10.3–16.7 11.3–15.3 0.9–3.7 1.9–5.3 1.1–3.9 1.7–4.8 1.7–3.8 n 1434 1327 1915 846 2761 1434 1327 1915 846 2761 Both Sexes % 9.1 18.8 12.4 12.7 12.5 1.5 3.0 1.8 2.5 2.0 95% CI 6.9–11.3 16.0–21.6 10.0–14.8 9.6–15.9 10.6–14.4 0.8–2.3 1.8–4.2 1.0–2.6 1.4–3.7 1.4–2.7

Total cholesterol > 5.0 mmol/L or > 190 mg/dl or currently on medication for raised cholesterol 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total

Total cholesterol > 6.2 mmol/L or > 240 mg/dl or currently on medication

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Table 11.3: Total cholesterol measurement and diagnosis among respondents in last 12 month by sex and age. Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both sexes 18–39 40–69 Total 1469 1350 2819 97.1 96.3 96.8 95.7–98.5 95.0–97.7 95.8–97.8 2.7 2.1 2.5 1.3–4.1 1.2–3.0 1.5–3.5 0.0 0.4 0.2 0.0–0.1 0.0–0.9 0.0–0.3 0.2 1.2 0.5 0.0–0.4 0.5–1.9 0.3–0.8 969 778 1747 98.0 96.2 97.4 96.9–99.1 94.6–97.9 96.5–98.3 1.6 2.1 1.8 0.6–2.7 0.9–3.2 1.0–2.6 0.1 0.6 0.2 0.0–0.2 0.0–1.5 0.0–0.6 0.3 1.1 0.6 0.0–0.7 0.1–2.1 0.1–1.0 500 572 1072 96.3 96.4 96.3 93.9–98.7 94.8–98.0 94.7–98.0 3.5 2.2 3.1 1.2–5.9 0.9–3.4 1.5–4.7 0.0 0.2 0.1 0.0–0.0 0.0–0.7 0.0–0.3 0.1 1.2 0.5 0.0–0.4 0.2–2.2 0.1–0.9 % Never measured % measured, not diagnosed % diagnosed, but not within past 12 months % diagnosed within past 12 months

n

95% CI

95% CI

95% CI

95% CI

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Combined risk factors and cardiovascular disease risk prediction

Table 12.1: Summary of Combined Risk Factors Age Group (years) Men 18–39 40–69 Residence Rural Urban Total Women 18–39 40–69 Residence Rural Urban Total Both Sexes 18–39 40–69 Residence Rural Urban Total 1819 815 2634 14.2 9.6 12.7 10.8–17.5 6.8–12.4 10.2–15.2 76.4 68.0 73.7 73.2–79.5 64.6–71.4 71.3–76.1 9.5 22.4 13.5 7.7–11.2 18.9–25.8 11.8–15.3 1358 1276 14.6 9.1 11.4–17.9 6.9–11.3 74.7 72.0 71.2–78.1 68.8–75.1 10.7 18.9 8.6–12.8 15.7–22.2 1086 529 1615 8.8 10.3 9.3 6.3–11.3 7.1–13.5 7.3–11.3 77.5 67.0 74.0 74.3–80.8 61.7–72.4 71.0–77.0 13.7 22.7 16.7 11.0–16.4 17.9–27.5 14.1–19.2 874 741 11.9 4.6 9.1–14.7 2.5–6.7 75.8 70.8 72.1–79.5 66.0–75.6 12.3 24.6 9.6–15.0 19.9–29.3 733 286 1019 18.0 9.0 15.3 13.0–23.0 4.7–13.3 11.4–19.2 75.5 68.8 73.5 70.9–80.2 63.6–74.1 69.9–77.1 6.5 22.2 11.2 4.2–8.7 17.6–26.7 8.6–13.7 484 535 16.6 12.7 11.5–21.8 9.4–15.9 73.8 72.9 68.7–79.0 69.0–76.8 9.5 14.4 6.6–12.5 10.7–18.1 n % with 0 risk factors 95% CI % with 1–2 risk factors 95% CI % with 3–5 risk factors 95% CI

Table 12.2: Percentage of respondents having ever had a heart attack or chest pain from heart disease or a stroke, by age and sex Age Group (years) 18–39 40–69 Total Men n 500 572 1072 % 0.8 0.8 0.8 95% CI 0.0–2.2 0.0–1.7 0.0–1.8 n 969 778 1747 Women % 0.9 0.8 0.9 95% CI 0.0–1.9 0.0–1.7 0.2–1.6 n 1469 1350 2819 Both Sexes % 0.8 0.8 0.8 95% CI 0.0–1.8 0.2–1.4 0.2–1.5

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Table 12.3: Percentage of respondents currently taking asprin/statins regularly to prevent or treat heart disease Age Group (years) Taking aspirin 18–39 40–69 Total Taking statins 18–39 40–69 Total 500 572 1072 0.0 0.1 0.0 0.0–0.0 0.0–0.3 0.0–0.1 778 1747 1742 0.0 0.5 0.2 0.0–0.0 0.0–1.0 0.0–0.4 1469 1350 2819 0.0 0.3 0.1 0.0–0.0 0.0–0.5 0.0–0.2 500 572 1072 0.0 0.4 0.1 0.0–0.0 0.0–0.9 0.0–0.3 969 778 1747 0.0 0.1 0.0 0.0–0.0 0.0–0.2 0.0–0.1 1469 1350 2819 0.0 0.2 0.1 0.0–0.0 0.0–0.6 0.0–0.2 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Table 12.4: Percentage of respondents aged 40–69 years with a 10–year cardiovascular disease (CVD) risk >30% or with existing CVD Age Group (years) 40–54 55–69 Residence Rural Urban Total 438 113 551 1.1 3.2 1.5 0.0–2.2 0.0–6.7 0.4–2.7 580 169 749 1.8 3.3 2.2 0.5–3.1 0.6–6.1 1.0–3.4 1018 282 1300 1.4 3.3 1.8 0.6–2.2 1.1–5.5 1.0–2.6 Men n 354 197 % 0.6 3.2 95% CI 0.0–1.5 0.4–6.0 n 509 240 Women % 1.6 3.1 95% CI 0.2–3.1 0.9–5.3 n 863 437 Both Sexes % 1.1 3.2 95% CI 0.2–1.9 1.4–5.0

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Lifestyle advice by health care provider Table 13.1: Percentage of respondents who received lifestyle advice from a doctor or health worker during the past three months among all respondents. Age Group (years) Men n % advised 95% CI n Women % advised 95% CI n Both Sexes % advised 95% CI

Advised by doctor or health worker to quit using tobacco or don’t start 18–39 40–69 Total 500 572 1072 42.9 49.8 45.3 37.0–48.7 43.5–56.1 40.2–50.3 969 778 1747 34.8 44.0 38.0 30.3–39.3 39.3–48.8 34.3–41.8 1469 1350 2819 39.3 47.3 42.1 35.2–43.4 42.9–51.7 38.5–45.6

Advised by doctor or health worker to reduce salt in the diet 18–39 40–69 Total 500 572 1072 43.1 59.1 48.7 37.3–49.0 53.5–64.8 44.0–53.4 969 778 1747 46.5 60.3 51.3 42.1–51.0 54.6–66.0 47.4–55.3 1469 1350 2819 44.6 59.6 49.8 40.4–48.9 55.2–64.0 46.4–53.3

Advised by doctor or health worker to eat at least five servings of fruit and/or vegetables each day 18–39 40–69 Total 500 572 1072 52.4 61.8 55.6 45.7–59.0 56.1–67.4 50.1–61.2 969 778 1747 57.7 55.3 56.9 53.0–62.4 50.3–60.3 53.0–60.7 1469 1350 2819 54.7 58.9 56.2 49.7–59.7 54.7–63.2 52.0–60.4

Advised by doctor or health worker to reduce fat in the diet 18–39 40–69 Total 500 572 1072 48.8 61.5 53.2 42.8–54.8 55.7–67.3 48.0–58.4 969 778 1747 49.0 58.9 52.5 44.4–53.7 53.6–64.2 48.5–56.4 1469 1350 2819 48.9 60.3 52.9 44.4–53.5 55.8–64.9 48.9–56.8

Advised by doctor or health worker to start or do more physical activity 18–39 40–69 Total 500 572 1072 43.8 46.3 44.7 36.9–50.7 40.3–52.4 38.9–50.5 969 778 1747 36.1 38.3 36.9 31.7–40.6 33.4–43.2 33.3–40.5 1469 1350 2819 40.4 42.8 41.3 35.5–45.3 38.3–47.3 37.1–45.4

Advised by doctor or health worker to maintain a healthy body weight or to lose weight 18–39 40–69 Total 500 572 1072 32.9 35.2 33.7 25.7–40.2 29.3–41.1 27.7–39.8 969 778 1747 27.6 30.7 28.7 23.9–31.3 25.8–35.5 25.4–32.0 1469 1350 2819 30.6 33.2 31.5 25.8–35.4 29.0–37.4 27.5–35.6

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Table 13.2: Percentage of female respondents who have ever had a screening test for cervical cancer among all female respondents. Age Group (years) 18–39 40–69 Residence Rural Urban Total Residence (30–49) Rural Urban Total 602 291 893 59.5 73.2 64.1 52.8–66.2 65.6–80.7 59.0–69.2 1146 567 1713 48.3 55.4 50.7 43.8–52.9 49.3–61.5 47.0–54.4 Women n 956 757 % ever tested 51.5 49.2 95% CI 47.0–56.0 43.5–54.8

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Mental health Table 14.1: Percentage of respondents who seriously considered attempting suicide in the last 12 months among all respondents. Age Group (years) 18–39 40–69 Total Men n 500 571 1071 % 1.0 0.9 0.9 95% CI 0.1–1.9 0.0–1.9 0.3–1.6 n 968 778 1746 Women % 5.0 2.7 4.2 95% CI 2.5–7.5 1.3–4.1 2.5–5.9 n 1468 1349 2817 Both Sexes % 2.7 1.7 2.4 95% CI 1.5–4.0 0.9–2.5 1.5–3.2

Table 14.2: Percentage of respondents who sought professional help among those who considered attempting suicide in the past 12 months. Age Group (years) 18–39 40–69 Total Men n 6 4 10 % 35.7 0.0 24.0 95% CI 0.0–96.9 0.0–0.0 0.0–69.0 n 35 18 53 Women % 21.4 2.9 17.5 95% CI 0.0–44.1 0.0–8.8 0.0–36.6 n 41 22 63 Both Sexes % 24.3 2.0 18.9 95% CI 4.5–44.0 0.0–6.1 2.7–35.1

Table 14.3: Percentage of respondents who made a plan about how to attempt suicide in the past 12 months. Age Group (years) 18–39 40–69 Total Men n 500 571 1071 % 0.2 0.1 0.2 95% CI 0.0–0.6 0.0–0.4 0.0–0.4 n 968 777 1745 Women % 3.5 1.1 2.7 95% CI 1.2–5.9 0.2–1.9 1.1–4.2 n 1468 1348 2816 Both Sexes % 1.7 0.5 1.3 95% CI 0.6–2.8 0.1–0.9 0.6–2.0

Table 14.4: Percentage of respondents who have ever attempted suicide among all respondents. Age Group (years) 18–39 40–69 Total Men n 499 571 1070 % 0.0 0.0 0.0 95% CI 0.0–0.0 0.0–0.0 0.0–0.0 n 968 778 1746 Women % 2.1 0.0 1.4 95% CI 0.9–3.3 0.0–0.0 0.6–2.2 n 1467 1349 2816 Both Sexes % 0.9 0.0 0.6 95% CI 0.4–1.5 0.0–0.0 0.3–1.0

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Table 14.5: Percentage of respondents who have attempted suicide in the past 12 months among those who have ever attempted suicide. Age Group (years) 18–29 60–69 Total Men n – – – % – – – 95% CI – – – n 22 – 22 Women % 37.7 – 37.7 95% CI 10.2–65.2 – 10.2–65.2 n 22 – 22 Both Sexes % 37.7 – 37.7 95% CI 10.2–65.2 – 10.2–65.2

Table 14.6: Percentage of different methods used the last time suicide was attempted among those respondents who have ever attempted suicide:Women. Age Group (years) 18–39 40–69 Total n % razor, knife or other sharp instrument 9.1 – 9.1 95% CI % overdose of medication 27.3 – 27.3 95% CI % poisoning with pesticides 28.1 – 28.1 95% CI % other poisoning 5.9 – 5.9 95% CI % other 29.7 – 29.7 95% CI

21 – 21

0.0–19.9 – 0.0–19.9

4.4–50.2 – 4.4–50.2

0.0–58.6 – 0.0–58.6

0.0–17.1 – 0.0–17.1

3.5–56.0 – 3.5–56.0

Table 14.7: Percentage of respondents who sought medical care the last time they attempted suicide among those who have ever attempted suicide. Age Group (years) 18–39 40–69 Total Men n – – – % – – – 95% CI – – – n 22 – 22 Women % 26.7 – 26.7 95% CI 1.5–51.9 – 1.5–51.9 n 22 – 22 Both Sexes % 26.7 – 26.7 95% CI 1.5–51.9 – 1.5–51.9

Table 14.8: Percentage of respondents who were admitted to the hospital due to the last time they attempted suicide among those who sought medical care for having ever attempted suicide. Age Group (years) 18–39 40–69 Total Men n – – – % – – – 95% CI – – – n 4 – 4 Women % 91.4 – 91.4 95% CI 76.7–100.0 – 76.7–100.0 n 4 – 4 Both Sexes % 91.4 – 91.4 95% CI 76.7–100.0 – 76.7–100.0

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Table 14.9: Percentage of respondents who have ever had anyone in their close family attempt suicide. Age Group (years) 18–39 40–69 Total Men n 500 571 1071 % 1.3 0.7 1.1 95% CI 0.2–2.4 0.0–1.5 0.3–1.8 n 968 778 1746 Women % 2.3 1.4 2.0 95% CI 1.2–3.3 0.4–2.4 1.2–2.7 n 1468 1349 2817 Both Sexes % 1.7 1.0 1.5 95% CI 1.0–2.5 0.4–1.6 1.0–2.0

Table 14.10: Percentage of respondents who have ever had anyone in their close family die from suicide. Age Group (years) 18–39 40–69 Total Men n 500 571 1071 % 1.2 1.6 1.4 95% CI 0.1–2.4 0.4–2.9 0.5–2.2 n 968 778 1746 Women % 2.7 1.6 2.3 95% CI 1.2–4.2 0.3–2.8 1.2–3.4 n 1468 1349 2817 Both Sexes % 1.9 1.6 1.8 95% CI 1.0–2.8 0.7–2.5 1.1–2.5

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Family history of chronic disease conditions Table 15.1: Percentage with a family member who has been diagnosed with a chronic disease condition Age Group (years) 18–39 40–69 Total 18–39 40–69 Total Stroke 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total 500 572 1072 500 572 1072 500 572 1072 500 572 1072 2.4 2.9 2.6 3.8 4.3 4.0 2.8 2.1 2.5 1.0 1.4 1.1 1.0–3.7 1.1–4.8 1.5–3.6 1.8–5.9 2.6–6.1 2.5–5.5 1.2–4.4 0.6–3.6 1.4–3.7 0.1–1.8 0.1–2.7 0.4–1.8 969 778 1747 969 778 1747 969 778 1747 969 778 1747 2.3 3.3 2.7 5.6 4.2 5.1 2.1 0.9 1.7 1.1 1.9 1.4 1.3–3.3 1.6–4.9 1.8–3.5 3.8–7.4 2.8–5.7 3.8–6.4 1.0–3.3 0.3–1.6 1.0–2.5 0.3–1.9 0.7–3.1 0.7–2.0 1469 1350 2819 1469 1350 2819 1469 1350 2819 1469 1350 2819 2.4 3.1 2.6 4.6 4.3 4.5 2.5 1.6 2.2 1.0 1.6 1.2 1.4–3.3 1.8–4.4 1.9–3.3 3.2–6.0 3.1–5.5 3.5–5.5 1.5–3.5 0.7–2.5 1.5–2.9 0.4–1.6 0.6–2.6 0.7–1.7 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Diabetes or high blood sugar 500 572 1072 500 572 1072 11.6 10.9 11.3 37.6 26.3 33.7 8.0–15.1 7.7–14.2 8.7–14.0 32.2–43.0 21.4–31.3 29.3–38.1 969 778 1747 969 778 1747 13.6 11.1 12.7 36.0 32.8 34.9 10.9–16.2 8.1–14.0 10.6–14.8 32.3–39.8 28.5–37.2 31.8–38.1 1469 1350 2819 1469 1350 2819 12.4 11.0 11.9 36.9 29.2 34.2 10.1–14.8 8.6–13.4 10.1–13.7 33.4–40.5 25.6–32.8 31.2–37.2

Raised blood pressure

Cancer or malignant tumor

Raised cholesterol

Early myocardial infarction

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Overweight and obesity Table 16.1: Mean height (cm) of respondents by sex and age Age Group (years) 18–39 40–69 Total Men n 499 572 1071 Mean 164.6 162.5 163.9 95% CI 163.8–165.4 161.4–163.6 163.1–164.6 n 906 772 1678 Women Mean 153.2 153.1 153.2 95% CI 152.6–153.9 152.1–154.1 152.6–153.8

Table 16.2: Mean weight (kg) of respondents by sex and age Age Group (years) 18–39 40–69 Total Men n 498 572 1070 Mean 62.9 63.6 63.2 95% CI 61.7–64.2 62.4–64.9 62.1–64.2 n 906 772 1678 Women Mean 56.9 58.3 57.4 95% CI 56.1–57.6 57.0–59.6 56.6–58.1

Table 16.3: Mean BMI (kg/m2) of respondents by sex and age Age Group (years) 18–39 40–69 Residence Rural Urban Total 771 296 1067 23.1 24.5 23.5 22.7–23.5 24.0–25.0 23.2–23.9 1134 538 1672 24.1 25.3 24.5 23.7–24.5 24.9–25.7 24.2–24.8 1905 834 2739 23.5 24.9 24.0 23.2–23.9 24.6–25.2 23.7–24.2 Men n 497 570 Mean 23.2 24.2 95% CI 22.8–23.5 23.7–24.7 n 903 769 Women Mean 24.3 25.0 95% CI 24.0–24.6 24.5–25.5 n 1400 1339 Both Sexes Mean 23.6 24.6 95% CI 23.4–23.9 24.2–24.9

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Table 16.4: BMI classifications of respondents by sex and age* Age Group (years) Men 18–39 40–69 Residence Rural Urban Total Women 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total 1905 834 2739 3.7 2.8 3.4 2.2–5.1 1.2–4.4 2.3–4.5 68.8 52.2 63.6 65.1–72.6 48.0–56.4 60.5–66.8 22.7 35.7 26.7 19.3–26.1 31.3–40.2 23.8–29.6 4.8 9.3 6.2 3.5–6.2 7.4–11.2 5.1–7.4 1134 538 1672 1400 1339 2.9 2.6 2.8 3.7 2.9 1.6–4.2 0.7–4.5 1.7–3.9 2.1–5.3 1.5–4.2 61.8 46.6 56.8 67.2 57.1 57.3–66.3 41.6–51.6 53.1–60.4 63.5–70.9 52.9–61.2 28.6 38.6 31.9 24.5 30.9 24.1–33.1 33.6–43.6 28.4–35.5 21.2–27.8 27.2–34.6 6.7 12.2 8.5 4.6 9.2 4.8–8.6 8.9–15.4 6.8–10.2 3.2–6.0 7.0–11.3 903 769 3.6 1.4 2.0–5.1 0.5–2.3 59.0 52.8 54.7–63.3 47.4–58.2 30.9 33.7 26.5–35.3 28.7–38.8 6.5 12.1 4.9–8.1 8.7–15.4 771 296 1067 4.2 3.0 3.9 2.0–6.5 0.5–5.4 2.1–5.6 73.9 56.8 68.8 69.1–78.6 49.7–63.9 64.5–73.1 18.4 33.3 22.8 14.4–22.4 26.0–40.6 19.0–26.7 3.5 6.9 4.5 1.6–5.3 4.2–9.6 2.9–6.0 497 570 3.8 4.0 1.3–6.3 1.9–6.1 73.3 60.4 68.3–78.2 54.5–66.3 19.7 28.7 15.5–23.9 23.5–33.9 3.2 6.9 1.1–5.3 4.2–9.6 % Under– weight (<18.5) % Normal weight (18.5– 24.9) % Overweight (25.0– 29.9) % Obese (>30.0)

n

95% CI

95% CI

95% CI

95% CI

Both Sexes

*excluding pregnant women

Table 16.5: Percentage of respondents (excluding pregnant women) classified as overweight (BMI>25). Age Group (years) 18–39 40–69 Residence Rural Urban Total 771 296 1067 21.9 40.2 27.3 17.4–26.4 32.7–47.7 23.1–31.6 1134 538 1672 35.3 50.8 40.4 30.5–40.1 45.6–56.0 36.6–44.3 1905 834 2739 27.5 45.1 33.0 23.7–31.2 40.7–49.4 29.7–36.2 Men n 497 570 % 22.9 35.6 95% CI 18.3–27.5 29.9–41.3 n 903 769 Women % 37.4 45.8 95% CI 33.0–41.8 40.2–51.3 n 1400 1339 Both Sexes % 29.1 40.1 95% CI 25.6–32.6 35.8–44.3

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Table 16.6: Mean waist circumference (cm) of respondents by sex and age Age Group (years) 18–39 40–69 Residence Rural Urban Total 774 297 1071 80.8 84.6 81.9 79.8–81.9 82.9–86.2 81.0–82.9 1140 538 1678 78.5 81.7 79.5 77.3–79.6 80.7–82.8 78.7–80.4 Men n 499 572 Mean 80.5 84.6 95% CI 79.5–81.6 83.3–85.9 n 906 772 Women Mean 78.3 81.8 95% CI 77.3–79.2 80.4–83.1

Table 16.7: Mean Hip circumference (cm) of respondents by sex and age* Age Group (years) 18–39 40–69 Total *excluding pregnant women.

Men n 499 572 1071 Mean 92.0 93.5 92.5 95% CI 91.3–92.7 92.7–94.4 91.9–93.1 n 906 772 1678

Women Mean 93.1 95.7 94.0 95% CI 92.3–93.8 94.6–96.7 93.4–94.7

Table 16.8: Mean waist / hip ratio among respondents by age and sex Age Group (years) 18–39 40–69 Total Men n 499 572 1071 Mean 0.9 0.9 0.9 95% CI 0.9–0.9 0.9–0.9 0.9–0.9 n 906 772 1678 Women Mean 0.8 0.9 0.8 95% CI 0.8–0.8 0.8–0.9 0.8–0.9

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Annex 2: Survey instruments Survey Information Location and Date Gewog/EA ID Gewog/EA name Interviewer ID Date of completion of the survey Consent, Interview Language and Name Consent has been read and obtained Response └─┴─┴─┴─┴─┴─┘ Code I1 I2 I3 I4 Code 1 2 1 2 3 4 I7 I8 I9 I6 If NO, END I5

└─┴─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ dd mm year Response Yes No English

Interview Language [Insert language]

Dzongkha Tshanglakha Lhotshamkha

Time of interview (24 hour clock) Family Surname First Name Step 1 Demographic Information Demographic Information Question Sex (Record Male / Female as observed) What is your date of birth? Don't Know 77 77 7777 How old are you? In total, how many years have you spent at school and in full-time study (excluding pre-school)?

└─┴─┘: └─┴─┘ hrs mins

Response Male Female 1 2 If known, Go to C4

Code C1

└─┴─┘ └─┴─┘ └─┴─┴─┴─┘ dd mm year Years Years

C2 C3 C4

└─┴─┘ └─┴─┘

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No formal schooling Less than primary school Primary school completed What is the highest level of education you have completed? Class 10 completed Class 12 completed College/University completed Post graduate degree Refused Never married Currently married Separated What is your marital status? Divorced Widowed Cohabitating Refused Government employee Non-government employee Which of the following best describes your main work status over the past 12 months? Self-employed Non-paid Student Homemaker Retired (USE SHOWCARD) Unemployed (able to work) Unemployed (unable to work) Refused How many people older than 18 years, including yourself, live in your household? Taking the past year, can you tell me what the average earnings of the household have been? (RECORD ONLY ONE, NOT ALL 3) Step 1 Behavioural Measurements Number of people Per week OR per month OR per year Refused

1 2 3 4 5 6 7 88 1 2 3 4 5 6 88 1 2 3 4 5 6 7 8 9 88 └─┴─┘ └─┴─┴─┴─┴─┴─┴─┘ Go to T1 └─┴─┴─┴─┴─┴─┴─┘ Go to T1 └─┴─┴─┴─┴─┴─┴─┘ Go to T1 88 C9 C10a C10b C10c C10d C8 C7 C5

Tobacco Use Now I am going to ask you some questions about tobacco use. Question Do you currently smoke any tobacco products, such as cigarettes, cigars or bidis? (USE SHOWCARD) Do you currently smoke tobacco products daily? How old were you when you first started smoking? Response Yes No Yes No Age (years) Don’t know 77 └─┴─┘ If Known, go to T5a/T5aw 1 2 1 2 If No, go to T8 T2 T3 Code T1

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Do you remember how long ago it was? (RECORD ONLY 1, NOT ALL 3) Don’t know 77

In Years OR OR in Months in Weeks

└─┴─┘ If Known, go to T5a/T5aw └─┴─┘ If Known, go to T5a/T5aw └─┴─┘ DAILY↓ WEEKLY↓

T4a T4b T4c

Manufactured cigarettes On average, how many of the following products do you smoke each day/week? (IF LESS THAN DAILY, RECORD WEEKLY) (RECORD FOR EACH TYPE, USE SHOWCARD) Don’t Know 7777 Bidis Cigar, cheroots, cigarillos Other Other (please specify): During the past 12 months, have you tried to stop smoking? Yes No Yes During any visit to a doctor or other health worker in the past 12 months, were you advised to quit smoking tobacco? No No visit during the past 12 months In the past, did you eversmoke any tobacco products? (USE SHOWCARD) Yes No Yes In the past, did you ever smoke daily? No Age (years) Don’t Know 77 Years ago OR OR Yes No Yes No Months ago Weeks ago

└─┴─┴─┴─┘└─┴─┴─┴─┘

T5a/T5aw T5b/T5bw T5c/T5cw T5d/T5dw T5f/T5fw T5other/

Hand-rolled cigarette └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ If Other, go to T5other, else go to T6 └─┴─┴─┴─┴─┴─┘ 1 2 1 If T2=Yes, go to T12; if T2=No, go to T9 2 If T2=Yes, go to T12; if T2=No, go to T9 3 If T2=Yes, go to T12; if T2=No, go to T9 1 2 If No, go to T12 1 If T1=Yes, go to T12, else go to T10 2 If T1=Yes, go to T12, else go to T10

T5otherw T6

T7

T8

T9

How old were you when you stopped smoking? How long ago did you stop smoking? RECORD ONLY 1, NOT ALL 3) Don’t Know 77 Do you currently use any smokeless tobacco products such as snuff, chewing tobacco, betel? (USE SHOWCARD) Do you currently use smokeless tobacco products daily?

└─┴─┘ If Known, go to T12 └─┴─┘ If Known, go to T12 └─┴─┘ If Known, go to T12 └─┴─┘ 1 2 1 2 If No, go to T14aw If No, go to T15

T10 T11a T11b T11c T12

T13

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DAILY↓ Snuff, by mouth On average, how many times a day/week do you use …. (IF LESS THAN DAILY, RECORD WEEKLY) (RECORD FOR EACH TYPE, USE SHOWCARD) Don’t Know 7777 Chewing tobacco Snuff, by nose Chewing tobacco Betel, quid

WEEKLY↓ T14a/T14aw T14b/T14bw T14c/T14cw T14d/T14dw T14e/T14ew T14other/ T14otherw T15

└─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ If other, go to T14 other, if T13=No, go to T16, else go to T17 └─┴─┴─┴─┴─┴─┘ If T13=No, go to T16, else go to T17 1 2 1 2 1 2 1 2 3 If No, go to T17

Other (please specify): In the past, did you ever use smokeless tobacco products such as snuff, chewing tobacco, or betel? In the past, did you ever use smokeless tobacco products such snuff, chewing tobacco, or betel daily? During the past 30 days, did someone smoke in your home? During the past 30 days, did someone smoke in closed areas in your workplace (in the building, in a work area or a specific office)? Yes No Yes No Yes No Yes No Don't work in a closed area

T16

T17

T18

The next questions ask about tobacco control policies. They include questions on your exposure to the media and advertisements, health warnings and cigarette purchase. During the past 30 days, have you noticed information about the dangers of smoking cigarettes or that encourages quitting through the following media? (RECORD FOR EACH) Yes Newspapers or magazines No Don't know Yes Television No Don't know Yes Radio No Don't know Yes Posters or Banners No Don't know 1 2 77 1 2 77 1 2 77 1 2 77 TP1d TP1c TP1b TP1a

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The next questions TP4 - TP7 are administered to current smokers only. Yes During the past 30 days, did you notice any health warnings on cigarette packages? No Did not see any cigarette packages Don't know Yes During the past 30 days, have warning labels on cigarette packages led you to think about quitting? No Don't know Number of cigarettes The last time you bought manufactured cigarettes for yourself, how many cigarettes did you buy in total? Don't know or Don't smoke or purchase manuf. cigarettes 7777 Amount Don't know Refused Alcohol Consumption The next questions ask about the consumption of alcohol. Have you ever consumed any alcohol such as beer, wine, hard drinks, ara, changkoe, or Bangchang? (USE SHOWCARD OR SHOW EXAMPLES) Have you consumed any alcohol within the past 12 months? Have you stopped drinking due to health reasons, such as a negative impact on your health or on the advice of your doctor or other health worker? Yes No Yes No Yes No Daily During the past 12 months, how frequently have you had at least one standard alcoholic drink? (READ RESPONSES, USE SHOWCARD) 5-6 days per week 3-4 days per week 1-2 days per week 1-3 days per month Less than once a month Have you consumed any alcohol within the past 30 days? During the past 30 days, on how many occasions did you have at least one standard alcoholic drink? Yes No Number Don't know 77 └─┴─┘ 1 2 If No, go to A16 1 If Yes, go to A4 2 1 If Yes, go to A16 2 If No, go to A16 1 2 3 4 5 6 1 2 If No, go to A13 A5 A4 A1 1 2 If no, go to TP6 3 If "did not see any cigarette packages", go to TP6 77 If Don't know, go to TP6 1 2 77 └─┴─┴─┴─┘ If "Don't know or don't smoke or purchase manuf. cig.", go to A1 └─┴─┴─┴─┘ 7777 8888 TP7 TP6 TP5 TP4

In total, how much money did you pay for this purchase? (DIGITS TO BE ADAPTED TO COUNTRY NEEDS)

A2

A3

A6

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During the past 30 days, when you drank alcohol, how many standard drinks on average did you have during one drinking occasion? (USE SHOWCARD) During the past 30 days, what was the largest number of standard drinks you had on a single occasion, counting all types of alcoholic drinks together? During the past 30 days, how many times did you have six or more standard drinks in a single drinking occasion?

Number Don't know 77 Largest number Don't Know 77 Number of times Don't Know 77 Monday Tuesday └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘

A7

A8

A9 A10a A10b A10c A10d A10e A10f A10g

During each of the past 7 days, how many standard drinks did you have each day? (USE SHOWCARD) Don't Know 77

Wednesday Thursday Friday Saturday Sunday

I have just asked you about your consumption of alcohol during the past 7 days. The questions were about alcohol in general, while the next questions refer to your consumption of homebrewed alcohol, alcohol brought over the border/from another country, any alcohol not intended for drinking or other untaxed alcohol. Please only think about these types of alcohol when answering the next questions. During the past 7 days, did you consume any Yes homebrewed alcohol, any alcohol brought over the border/from another country, any alcohol not intended for drinking or other untaxed alcohol? [AMEND ACCORDING TO LOCAL CONTEXT] (USE SHOWCARD) Homebrewed spirits, e.g. ara On average, how many standard drinks of the following did you consume during the past 7 days? [INSERT COUNTRY-SPECIFIC EXAMPLES] (USE SHOWCARD) Don't Know 77 Homebrewed beer or wine, e.g. beer, palm or fruit wine Alcohol brought over the border/from another country Alcohol not intended for drinking, e.g. alcohol-based medicines, perfumes, after shaves Other untaxed alcohol in the country Daily or almost daily During the past 12 months, how often have you found that you were not able to stop drinking once you had started? Weekly Monthly Less than monthly Never └─┴─┘ └─┴─┘ └─┴─┘ A12a A12b A12c A12d └─┴─┘ └─┴─┘ 1 2 3 4 5 A13 A12e No 1 A11 2 If No, go to A13

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Daily or almost daily During the past 12 months, how often have you failed to do what was normally expected from you because of drinking? Weekly Monthly Less than monthly Never Daily or almost daily During the past 12 months, how often have you needed a first drink in the morning to get yourself going after a heavy drinking session? Weekly Monthly Less than monthly Never Yes, more than monthly During the past 12 months, have you had family problems or problems with your partner due to someone else’s drinking? Yes, monthly Yes, several times but less than monthly Yes, once or twice No Diet

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 A16 A15 A14

The next questions ask about the fruits and vegetables that you usually eat. I have a nutrition card here that shows you some examples of local fruits and vegetables. Each picture represents the size of a serving. As you answer these questions please think of a typical week in the last year. Question In a typical week, on how many days do you eat fruit? (USE SHOWCARD) How many servings of fruit do you eat on one of those days? (USE SHOWCARD) In a typical week, on how many days do you eat vegetables? (USE SHOWCARD) How many servings of vegetables do you eat on one of those days? (USE SHOWCARD) Dietary salt With the next questions, we would like to learn more about salt in your diet. Dietary salt includes ordinary table salt, unrefined salt such as sea salt, iodized salt, salty stock cubes and powders, and salty sauces such as soya sauce or fish sauce (see showcard). The following questions are on adding salt to the food right before you eat it, on how food is prepared in your home, on eating processed foods and other foods that are high in salt such as Ezay and questions on controlling your salt intake. Please answer the questions even if you consider yourself to eat a diet low on salt. How often do you add salt or a salty sauce such as soya sauce to your food right before you eat it or as you are eating it? (SELECT ONLY ONE) (USE SHOWCARD) Always Often Sometimes Rarely Never Don't know 1 2 3 4 5 77 D5 Response Number of days Don't Know 77 Number of servings Don't Know 77 Number of days Don't Know 77 Number of servings Don’t know 77 └─┴─┘ └─┴─┘ If Zero days, go to D5 └─┴─┘ D3 └─┴─┘ If Zero days, go to D3 Code D1

D2

D4

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Always Often How often is salt, salty seasoning or a salty sauce added in Sometimes cooking or preparing foods in your household? Rarely Never Don't know How often do you eat processed food high in salt? By processed food high in salt, I mean foods that have been altered from their natural state, such as packaged salty snacks, canned salty food including pickles and preserves, salty foods prepared at a fast food restaurant, cheese, bacon and processed meat and dried fish. Other foods high in salt include Ezay, potato chips, [INSERT EXAMPLES] (USE SHOWCARD) Always Often How often do you drink Suja? Sometimes Rarely Never Don't know Far too much Too much How much salt or salty sauce do you think you consume? Just the right amount Too little Far too little Don't know Very important How important to you is lowering the salt in your diet? Somewhat important Not at all important Don't know Yes Do you think that too much salt or salty sauce in your diet could cause a health problem? No Don't know Do you do anything of the following on a regular basis to control your salt intake? (RECORD FOR EACH) Limit consumption of processed foods and other salty foods Look at the salt or sodium content on food labels Buy low salt/sodium alternatives Use spices other than salt when cooking Yes No Yes No Yes No Yes No Always Often Sometimes Rarely Never Don't know

1 2 3 4 5 77 1 2 3 4 5 77 1 2 3 4 5 77 1 2 3 4 5 77 1 2 3 77 1 2 77 D8 D10 D9 X1 D7 D6

1 2 1 2 1 2 1 2

D11a D11b D11c D11d

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Avoid eating foods prepared outside of a home Do other things specifically to control your salt intake Other (please specify)

Yes No Yes No └─┴─┴─┴─┴─┴─┴─┘

1 2 1 If Yes, go to D11other 2

D11e D11f D11other

The next questions ask about the oil or fat that is most often used for meal preparation in your household, and about meals that you eat outside a home. Vegetable oil Lard or suet What type of oil or fat is most often used for meal preparation in your household? Butter or ghee Margarine Other None in particular (USE SHOWCARD) (SELECT ONLY ONE) None used Don’t know Other On average, how many meals per week do you eat that were not prepared at a home? By meal, I mean breakfast, lunch and dinner. Physical Activity Next I am going to ask you about the time you spend doing different types of physical activity in a typical week. Please answer these questions even if you do not consider yourself to be a physically active person. Think first about the time you spend doing work. Think of work as the things that you have to do such as paid or unpaid work, study/training, household chores, harvesting food/crops, fishing or hunting for food, seeking employment. [Insert other examples if needed]. In answering the following questions '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. Work Does your work involve vigorous-intensity activity that causes large increases in breathing or heart rate like carrying or lifting heavy loads, digging or construction work for at least 10 minutes continuously? (USE SHOWCARD) Yes No 1 2 If No, go to P 4 P2 P3 (a-b) P1 Number Don’t know 77 └─┴─┘ 1 2 3 4 5 6 7 77 └─┴─┴─┴─┴─┴─┴─┘ D12other If Other, go to D12 other D12

D13

In a typical week, on how many days do you do vigorous-intensity Number of days activities as part of your work? How much time do you spend doing vigorous-intensity activities at work on a typical day? Does your work involve moderate-intensity activity, that causes small increases in breathing or heart rate such as brisk walking, [or carrying light loads] for at least 10 minutes continuously? [INSERT EXAMPLES] (USE SHOWCARD) In a typical week, on how many days do you do moderateintensity activities as part of your work? How much time do you spend doing moderate-intensity activities at work on a typical day? Hours : minutes

└─┘ └─┴─┘: └─┴─┘ hrs mins 1 2 If No, go to P 7

Yes No Number of days

P4

└─┘ └─┴─┘: └─┴─┘ hrs mins

P5 P6 (a-b)

Hours : minutes

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Travel to and from places The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way you travel to and from places. For example to work, for shopping, to market, to place of worship. [Insert other examples if needed] Do you walk or use a bicycle (pedal cycle) for at least 10 minutes continuously to get to and from places? In a typical week, on how many days do you walk or bicycle for at least 10 minutes continuously to get to and from places? How much time do you spend walking or bicycling for travel on a typical day? Recreational activities The next questions exclude the work and transport activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities (leisure), [Insert relevant terms]. Do you do any vigorous-intensity sports, fitness or recreational Yes (leisure) activities that cause large increases in breathing or heart rate like running or football, martial arts, badminton, basketball for No at least 10 minutes continuously? (USE SHOWCARD) In a typical week, on how many days do you do vigorous-intensity Number of days sports, fitness or recreational (leisure) activities? How much time do you spend doing vigorous-intensity sports, fitness or recreational activities on a typical day? Do you do any moderate-intensity sports, fitness or recreational activities that cause a small increase in breathing or heart rate such as dancing, brisk walking, cycling, swimming, khuru, or degor or archery for at least 10 minutes continuously? (USE SHOWCARD) In a typical week, on how many days do you do moderateintensity sports, fitness or recreational (leisure) activities? 1 P10 2 If No, go to P 13 P11 └─┘ P12 └─┴─┘: └─┴─┘ hrs mins 1 P13 No 2 If No, go to P16 (a-b) Yes No Number of days 1 2 If No, go to P 10 P7

└─┘ └─┴─┘: └─┴─┘ hrs mins

P8 P9 (a-b)

Hours : minutes

Hours : minutes

Yes

Number of days └─┘ Hours : minutes └─┴─┘: └─┴─┘ hrs mins

P14

How much time do you spend doing moderate-intensity sports, fitness or recreational (leisure) activities on a typical day? Sedentary Behaviour

P15 (a-b)

The following question is about sitting or reclining at work, at home, getting to and from places, or with friends including time spent sitting at a desk, sitting with friends, traveling in bus, reading, playing cards or watching television, but do not include time spent sleeping. (USE SHOWCARD) How much time do you usually spend sitting or reclining on a typical day? Hours : minutes P16 └─┴─┘: └─┴─┘ hrs mins (a-b)

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History of Raised Blood Pressure Have you ever had your blood pressure measured by a doctor or other health worker? Have you ever been told by a doctor or other health worker that you have raised blood pressure or hypertension? Have you been told in the past 12 months? In the past two weeks, have you taken any drugs (medication) for raised blood pressure prescribed by a doctor or other health worker? Have you ever seen a local healer, drungdsho or sMenpa for raised blood pressure or hypertension? Are you currently taking any herbal or traditional remedy for your raised blood pressure? History of Diabetes Have you ever had your blood sugar measured by a doctor or other health worker? Have you ever been told by a doctor or other health worker that you have raised blood sugar or diabetes? Have you been told in the past 12 months? In the past two weeks, have you taken any drugs (medication) for diabetes prescribed by a doctor or other health worker? Are you currently taking insulin for diabetes prescribed by a doctor or other health worker? Have you ever seen a local healer, drungdsho or sMenpa for diabetes or raised blood sugar? Are you currently taking any herbal or traditional remedy for your diabetes? History of Raised Total Cholesterol Have you ever had your cholesterol (fat levels in your blood) measured by a doctor or other health worker? Have you ever been told by a doctor or other health worker that you have raised cholesterol? Have you been told in the past 12 months? Yes No Yes No Yes No 1 2 1 2 If No, go to H17 1 2 If No, go to H17 H12 Yes No Yes No Yes No Yes No Yes No Yes No Yes No 1 2 1 2 1 2 1 2 1 2 1 2 1 2 If No, go to H12 If No, go to H12 H6 Yes No Yes No Yes No Yes No Yes No Yes No 1 2 1 2 1 2 1 2 1 2 1 2 If No, go to H6 If No, go to H6 H1

H2a

H2b

H3

H4

H5

H7a

H7b

H8

H9

H10

H11

H13a

H13b

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In the past two weeks, have you taken any oral treatment (medication) for raised total cholesterol prescribed by a doctor or other health worker? Have you ever seen a local healer, drungsho, or sMenpa for raised cholesterol? Are you currently taking any herbal or traditional remedy for your raised cholesterol? History of Cardiovascular Diseases Have you ever had a heart attack or chest pain from heart disease (angina) or a stroke (cerebrovascular accident or incident)? Are you currently taking aspirin regularly to prevent or treat heart disease? Are you currently taking statins (Atorvastatin) or fibrates (Fenofibrate) regularly to prevent or treat heart disease? (if D/K, interviewer to check medication) Lifestyle Advice

Yes No Yes No Yes No Yes No Yes No Yes No

1 2 1 2 1 2 1 2 1 2 1 2

H14

H15

H16

H17

H18

H19

During the past three years, has a doctor or other health worker advised you to do any of the following? (RECORD FOR EACH) Quit using tobacco or don’t start Reduce salt in your diet Eat at least five servings of fruit and/or vegetables each day Yes No Yes No Yes No Yes No Yes No Yes No 1 2 1 2 1 2 1 2 1 2 1 2 If C1=1 go to M1 H20a H20b H20c

Reduce fat in your diet

H20d

Start or do more physical activity

H20e

Maintain a healthy body weight or lose weight Cervical Cancer Screening (for women only):

H20f

The next question asks about cervical cancer prevention. A screening test for cervical cancer prevention is done by a doctor or nurse taking a swab to wipe from inside your vagina. This is sent to a laboratory where they check for abnormal cell changes. Yes Have you ever had a pap smear screening test for cervical cancer? No Don’t know 1 2 77 CX1

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Family history Have any of your blood family members (sibling, parent, grandparent, aunt or uncle) been diagnosed with the following diseases? Diabetes or raised blood sugar Raised Blood pressure Stroke Cancer or malignant tumor Raised Cholesterol Early Heart attack (below age 50 for men and below age 55 for women) Asthma or chronic lung disease (COPD) Kidney disease Mental health / Suicide The next questions ask about thoughts, plans, and attempts of suicide. Please answer the questions even if no one usually talks about these issues. During the past 12 months, have you seriously considered attempting suicide? Did you seek professional help for these thoughts? During the past 12 months, have you made a plan about how you would attempt suicide? Yes No Refused Yes No Refused Yes No Refused Yes Have you ever attempted suicide? No Refused During the past 12 months, have you attempted suicide? Yes No Refused Razor, knife or other sharp instrument Overdose of medication (e. g. prescribed, over-the-counter) Overdose of other substance (e.g. heroin, crack, alcohol) What was the main method you used the last time you attempted suicide? (SELECT ONLY ONE) Poisoning with pesticides (e.g. rat poison, insecticide, weed-killer) Other poisoning (e.g. plant/seed, household product) Poisonous gases from charcoal Other Refused Other (specify) 1 2 88 1 2 88 1 2 88 1 2 88 1 2 88 1 2 3 4 5 6 7 If Other, go to MH6other 88 └─┴─┴─┴─┴─┴─┴─┘ MH6 other MH6 MH5 If No, go to MH9 MH4 MH3 MH2 If No, go to MH3 MH1 Yes No Yes No Yes No Yes No Yes No Yes 1 2 1 2 1 2 1 2 1 2 1 F1a F1b F1c F1d F1e F1f X2 If C1=1 go to M1 If C1=1 go to M1 X3

No 2 Yes 1 No Yes No 2 1 2

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Yes Did you seek medical care for this attempt? No Refused Were you admitted to hospital overnight because of this attempt? Has anyone in your close family (mother, father, brother, sister or children) ever attempted suicide? Has anyone in your close family (mother, father, brother, sister or children) ever died from suicide? Yes No Refused Yes No Refused Yes No

1 2 88 1 2 88 1 2 88 1 2 MH10 MH9 MH8 If No, go to MH9 MH7

Step 2

Physical Measurements

Blood Pressure and Heart Rate Interviewer ID Device ID for blood pressure Reading 1 Systolic ( mmHg) Diastolic (mmHg) Systolic ( mmHg) Diastolic (mmHg) Systolic ( mmHg) Diastolic (mmHg) └─┴─┴─┘ └─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ 1 2 1 If Yes, go to M 16 2 └─┴─┴─┘ Height Weight in Centimetres (cm) in Kilograms (kg) └─┴─┘ └─┴─┘ └─┴─┴─┘. └─┘ M1 M2 M4a M4b M5a M5b M6a M6b M7

Reading 2

Reading 3

During the past two weeks, have you been treated for Yes raised blood pressure with drugs (medication) prescribed No by a doctor or other health worker? Height and Weight For women: Are you pregnant? Interviewer ID Device IDs for height and weight Height Weight If too large for scale 666.6 Yes No

M8 M9 M10a M10b M11 M12

└─┴─┴─┘.└─┘

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Waist and hip circumference Device ID for waist Waist circumference Hip circumference Heart rate Reading 1 Reading 2 Reading 3 Beats per minute Beats per minute Beats per minute └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ M16a M16b M16c in Centimetres (cm) in Centimetres (cm) └─┴─┘ └─┴─┴─┘.└─┘ └─┴─┴─┘.└─┘ M13 M14 M15

Step 3

Biochemical Measurements

Blood Glucose and Total Cholesterol During the past 10 hours have you had anything to eat or Yes drink, other than water? No Technician ID Device ID Time of day blood specimen taken (24 hour clock) Fasting blood glucose Hours : minutes mg/dl 1 2 └─┴─┴─┘ └─┴─┘ └─┴─┘: └─┴─┘ hrs mins └─┴─┘. └─┴─┘ 1 2 └─┴─┘. └─┴─┘ 1 2 B1 B2 B3 B4 B5 B6 B8 B9

Today, have you taken insulin or other drugs (medication) Yes that have been prescribed by a doctor or other health No worker for raised blood glucose? Total cholesterol During the past two weeks, have you been treated for raised cholesterol with drugs (medication) prescribed by a doctor or other health worker? Urinary sodium and creatinine Had you been fasting prior to the urine collection? Technician ID Time of day urine sample taken (24 hour clock) Urinary sodium Urinary creatinine mg/dl Yes No

Yes No

1 2 └─┴─┴─┘

B10 B11 B13 B14 B15

Hours : minutes mmol/l mmol/l

└─┴─┘: └─┴─┘ hrs mins └─┴─┴─┘.└─┘ └─┴─┘. └─┴─┘

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Annex 3: Fact sheet – Risk factors The STEPS survey of non-communicable disease (NCD) risk factors in Bhutan was carried out from April-June 2014. Bhutan carried out Step 1, Step 2 and Step 3. Socio demographic and behavioral information was collected in Step 1. Physical measurements such as height, weight and blood pressure were collected in Step 2. Biochemical measurements were collected to assess salt intake, blood glucose and cholesterol levels in Step 3.The survey was a population-based survey of adults aged 18-69. A multi-stage stratified cluster sampling design was used to produce representative data for that age range in Bhutan. Total of 2822 adults participated in the survey. The overall response rate was 96%. Results for adults aged 18-69 years (incl. 95% CI) Step 1: Tobacco Use Percentage who currently smoke tobacco Percentage who currently smoke tobacco daily For those who smoke tobacco daily Average age started smoking (years) Percentage of daily smokers smoking manufactured cigarettes Smokeless tobacco user Percentage who currently use smokeless tobacco Percentage who currently use smokeless tobacco daily For those who use smokeless tobacco daily Percentage of daily smokeless tobacco users using chewing tobacco/snuff by mouth Mean times per day chewing tobacco/snuff by mouth (by user of chewing tobacco/snuff by mouth) Step 1: Alcohol Consumption Percentage who are lifetime abstainers Percentage who are past 12 month abstainers Percentage who currently drink (drank alcohol in the past 30 days) Percentage who engage in heavy episodic drinking (6 or more drinks on any occasion in the past 30 days) Step 1: Diet Mean number of days fruit consumed in a typical week Mean number of servings of fruit consumed on average per day Mean number of days vegetables consumed in a typical week Mean number of servings of vegetables consumed on average per day Percentage who ate less than 5 servings of fruit and/or vegetables on average per day Percentage who always or often add salt or salty sauce to their food before eating or as they are eating Percentage who always or often eat processed foods high in salt Step 1: Physical Activity Percentage with insufficient physical activity (defined as < 150 minutes of moderate-intensity activity per week, or equivalent)* Median time spent in physical activity on average per day (minutes) (presented with inter-quartile range) Percentage not engaging in vigorous activity 39.0% (35.7–42.3) 10.8% (8.8–12.8) 42.4% (39.3–45.5) 22.4% (19.5–25.3) 1.7 (1.5–1.9) 0.7 (0.6–0.8) 5.6 (5.4–5.7) 3.8 (3.4–4.1) 66.9% (61.7–72.0) 7.8% (5.4–10.2) 11.1% (9.3–12.9) 6.4% (4.7–8.0) 330 (377.1) 48.8% (44.6–53.1) 30.6% (26.2–35.0) 12.1% (9.2–14.9) 50.0% (45.5–54.5) 29.0% (24.9–33.1)) 1.6 (1.4–1.8) 0.7 (0.5–0.8) 5.6 (5.5–5.8) 4.0 (3.5–4.4) 64.8% (58.3–71.2) 7.4% (4.4–10.5) 11.0% (8.4–13.6) 3.8% (2.5–5.0) 367.1 (362.1) 35.2% (30.3–40.2) 49.8% (45.9–53.7) 9.3% (7.0–11.6) 32.8% (29.5–36.0) 14.1% (11.3–16.9) 1.9 (1.7–2.1) 0.8 (0.7–0.9) 5.5 (5.3–5.7) 3.5 (3.1–3.8) 69.6% (64.4–74.7) 8.3% (6.2–10.4) 11.2% (9.1–13.3) 9.6% (6.8–12.4) 274.3 (377.1) 66.0% (61.2–70.9) 19.7% (16.5–22.9) 18.5% (15.3–21.7) 95.5% (93.2–97.8) 12.4 (10.6–14.2) 26.5% (22.1–31.0) 25.2% (20.7–29.7) 96.4% (93.8–99.0) 12.8 (10.6–14.9) 11.0 % (8.6–13.5) 9.9% (7.5–12.4) 92.7% (87.9–97.4) 11.3 (9.5–13.2) 18.9 (17.5–20.3) 84.1% (76.3–92.0) 19.0 (17.3–20.8) 90.1% (82.2–98.0) # # Both Sexes 7.4% (5.8–9.0) 4.3% (3.2–5.4) Men 10.8% (8.1–13.6) 6.0% (4.3–7.7) Women 3.1% (2.0–4.2) 2.1% (1.3–3.0)

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Results for adults aged 18-69 years (incl. 95% CI) Step 1: Cervical Cancer Screening Percentage of women aged 30-49 years who have ever had a screening test for cervical cancer Step 2: Physical Measurements Mean body mass index - BMI (kg/m2) Percentage who are overweight (BMI > 25 kg/m2) Percentage who are obese (BMI > 30 kg/m2) Average waist circumference (cm) Mean systolic blood pressure - SBP (mmHg), including those currently on medication for raised BP Mean diastolic blood pressure - DBP (mmHg), including those currently on medication for raised BP Percentage with raised BP (SBP > 140 and/or DBP > 90 mmHg or currently on medication for raised BP) Percentage with raised BP (SBP > 140 and/or DBP > 90 mmHg) who are not currently on medication for raised BP Step 3: Biochemical Measurement Mean fasting blood glucose, including those currently on medication for raised blood glucose (mg/dl) Percentage with impaired fasting glycaemia as defined below •• capillary whole blood value >5.6 mmol/L (100 mg/dl) and <6.1 mmol/L (110 mg/dl) Percentage with raised fasting blood glucose as defined below or currently on medication for raised blood glucose •• capillary whole blood value > 6.1 mmol/L (110 mg/dl) Mean total blood cholesterol, including those currently on medication for raised cholesterol (mg/dl) Percentage with raised total cholesterol (> 5.0 mmol/L or > 190 mg/dl or currently on medication for raised cholesterol) Mean intake of salt per day (in grams) Cardiovascular disease (CVD) risk Percentage aged 40-69 years with a 10-year CVD risk > 30%, or with existing CVD** Summary of combined risk factors •• current daily smokers •• less than 5 servings of fruits & vegetables per day •• insufficient physical activity Percentage with none of the above risk factors Percentage with three or more of the above risk factors, aged 18 to 39 years Percentage with three or more of the above risk factors, aged 40 to 69 years Percentage with three or more of the above risk factors, aged 18 to 69 years # The sample size “n” is less than 50

Both Sexes

Males

Females 64.1% (59.0–69.2)

24.0 (23.7–24.2) 26.7% (23.8–29.6) 6.2% (5.1–7.3)

23.5 (23.2–23.9) 22.8% (19.0–26.7) 4.5% (2.9–6.0) 81.9 (81.0–82.9)

24.5 (24.2–24.8) 31.9% (28.4–35.5) 8.5% (6.8–10.2) 79.5 (78.7–80.4) 123.8 (122.5–125.1) 85.4 (84.5–86.3) 35.9% (32.5–39.4) 32.0% (28.6–35.3) 88.9 (87.4–90.4) 10.0% (7.9–12.0) 6.3% (4.7–7.9) 148.7 (146.0–151.4) 13.3% (11.3–15.3) 8.0 (7.9–8.2) 2.2% (1.0–3.4)

126.2 (125.1–127.2) 85.0 (84.0–85.9) 35.7% (32.8–38.6) 32.9% (30.0–35.8) 88.8 (87.4–90.2) 10.7% (8.6–12.9) 6.4% (5.0–7.8) 146.1 (143.4–148.9) 12.5% (10.6–14.4) 9.0 (8.8–9.1) 1.8% (1.0–2.6)

128.0 (126.6–129.4) 84.6 (83.4–85.9) 35.5% (31.5–39.6) 33.6% (29.5–37.6) 88.7 (86.9–90.5) 11.4% (8.2–14.5) 6.5% (4.6–8.5) 144.1 (140.3–147.9) 11.9% (9.1–14.7) 9.6 (9.4–9.8) 1.5% (0.4–2.7)

•• overweight (BMI > 25 kg/m2) •• raised BP (SBP > 140 and/or DBP > 90 mmHg or currently on medication for raised BP) 12.7% (10.2–15.2) 10.7% (8.6–12.8) 18.9% (15.7–22.2) 13.5% (11.8–15.3) 15.3% (11.4–19.2) 9.5% (6.6–12.5) 14.4% (10.7–18.1) 11.2% (8.6–13.7) 9.3% (7.3–11.3) 12.3% (9.6–15.0) 24.6% (19.9–29.3) 16.7% (14.1–19.2)

* For complete definitions of insufficient physical activity, refer to the GPAQ Analysis Guide (http://www.who.int/chp/steps/GPAQ/en/ index.html) or to the WHO Global recommendations on physical activity for health (http://www.who.int/dietphysicalactivity/factsheet_ recommendations/en/index.html) ** A 10-year CVD risk of >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 >7.0 mmol/l (126 mg/dl).

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Annex 4: Fact sheet – Tobacco The WHO STEPwise approach to surveillance (STEPS) is a simple, standardized method for collecting, analysing and disseminating data on noncommunicable diseases (NCDs) and risk factors. Data are collected on the established risk factors and NCD conditions that determine the major NCD burden, including tobacco use, harmful use of alcohol, unhealthy diet, insufficient physical activity, overweight and obesity, raised blood pressure, raised blood glucose, and abnormal blood lipids. Data from STEPS surveys can be used by countries to help monitor progress in meeting the global voluntary targets related to specific risk factors such as tobacco, alcohol, diet and physical inactivity. The tobacco indicators from STEPS can be used to evaluate and monitor existing tobacco-control policies and programs. The STEPS survey on NCD risk factors in Bhutan was carried out from April–June 2014. It was a population-based survey of adults aged 18–69. A multi-stage stratified cluster sampling design was used to produce representative data for that age range in Bhutan. Survey information was collected electronically using handheld devices. The survey was implemented by the Ministry of Health, Bhutan. A total of 2822 adults participated in the Bhutan STEPS survey. The overall response rate was 96%.

Highlights Tobacco use ¤¤ Overall 24.8% of adults (33.6% of men and 13.6% of women) were current users of tobacco. ¤¤ Overall 7.4% of adults (10.8% of men and 3.1% of women) were current smokers of tobacco. ¤¤ Overall 19.7% of adults (26.5% of men and 11.0% of women) were current users of smokeless tobacco.

Cessation ¤¤ 7 in 10 current smokers tried to stop smoking in the last 12 months. ¤¤ 3 in 10 current smokers were advised by a health care provider to stop smoking in the last 12 months.

Secondhand smoke ¤¤ 1 in 4 adults were exposed to tobacco smoke at the workplace. ¤¤ 1 in 5 adults were exposed to tobacco smoke at home.

Media ¤¤ 3 in 5 adults noticed anti-cigarette smoking information on the television. ¤¤ 2 in 5 adults noticed anti-cigarette smoking information on the radio.

Economics ¤¤ Average amount spent on 20 manufactured cigarettes was 269.3 Bhutanese Ngultrum (Nu).

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Results for adults aged 18-69 years Tobacco Use Current tobacco users(smoked and/or smokeless)1 Current tobacco users Current daily tobacco users Current tobacco smokers Current tobacco smokers Current cigarette smokers2 (among current tobacco smokers) Current daily tobacco smokers Current daily cigarette smokers (among daily tobacco smokers) Average age started tobacco smoking (years) Average number of manufactured cigarettes smoked per day (among daily cigarette smokers) Current smokeless tobacco users3 Current smokeless tobacco users Current daily smokeless tobacco users Current tobacco non-users Former tobacco smokers4 Never Smokers Former smokeless users5 Never smokeless users Exposure to Second-hand smoke Adults exposed to second-hand smoke at home* Adults exposed to second-hand smoke in the closed areas in their workplace* Tobacco Cessation Current smokers who tried to stop smoking in past 12 months Current smokers advised by a health care provider to stop smoking in past 12 months6 Health Warnings Current smokers who thought about quitting because of a warning label* Adults who noticed anti-cigarette smoking information on the television* Adults who noticed anti-cigarette smoking information on the radio* Adults who noticed anti-cigarette smoking information in newspapers or magazines* Economics Average amount spent on 20 manufactured cigarettes

Overall %(95% CI)

Men %(95% CI)

Women %(95% CI)

24.8% (21.4–28.3) 22.0% (18.7–25.3) 7.4% (5.8–9.0) 77.6% (68.9–86.4) 4.3% (3.2–5.4) 84.1% (76.3–92.0) 18.9 (17.5–20.3) 3.5 (2.6–4.3) 19.7% (16.5–22.9) 18.5% (15.3–21.7) 19.6% (17.2–21.9) 73.0% (69.9–76.1) 12.9% (10.8–15.0) 67.4% (63.6–71.2) 20.7% (18.0–23.4) 24.6% (21.5–27.7) 69.0% (59.8–78.1) 31.8% (22.6–41.0)

33.6% (28.8–38.5) 30.0% (25.4–34.6) 10.8% (8.1–13.6) 81.5% (71.4–91.6) 6.0% (4.2–7.8) 90.1% (82.2–98.0) 19.0 (17.3–20.8) 3.7 (2.6–4.8) 26.5% (22.1–31.0) 25.2% (20.7–29.7) 26.7% (23.2–30.3) 62.5% (58.0–66.9) 13.9% (10.8–17.0) 59.5% (54.3–64.7) 20.7% (17.0–24.4) 29.0% (24.6–33.4) 66.0% (55.2–76.8) 33.2% (22.2–44.3)

13.6% (10.9–16.4) 11.8% (9.2–14.4) 3.1% (2.0–4.2) 61.2% (43.4–79.1) 2.1% (1.3–3.0) # # # 11.0% (8.6–13.5) 9.9% (7.5–12.4) 10.4% (8.2–12.7) 86.4% (83.8–89.1) 11.5% (9.6–13.5) 77.4% (74.2–80.6) 20.7% (17.8–23.6) 19.1% (15.9–22.3) 82.1% (68.6–95.7) #

84.3% (76.1–92.6) 64.3% (59.8–68.8) 44.4% (40.3–48.6) 21.0% (18.2–23.7)

83.1% (73.1–93.1) 64.3% (59.1–69.6) 45.5% (40.1–50.9) 25.2% (21.2–29.2)

# 64.3% (59.1–69.4) 43.0% (38.8–47.3) 15.4% (12.5–18.2)

Local Currency (Ngultrum) 269.3 (162.9–375.7)

1. Current use refers to daily and less than daily use. 2. Includes manufactured cigarettes and hand-rolled cigarettes. Adapted for other products as per country situation. 3. Current non-users. 4. Current non-smokers. 5. Current non smokeless users. 6. Among those who visited a health care provider in past 12 months. * During the past 30 days. # The sample size “n” is the less than 50.

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Findings from the Bhutan STEPs Noncommunicable Disease Risk Factor Survey 2014 provide information on several key indicators in a nationally representative sample age group of 18–69 years for the first time in the country. These indicators include tobacco use, alcohol consumption, dietary habits, physical inactivity, salt intake history, history of exposure to screening for cancer cervix, body mass index and blood pressure measurement, biochemical measurements of blood glucose and cholesterol. This survey provides Bhutan an opportunity to obtain baseline information on NCD risk factors as well as to compare with other countries. In addition, the findings will help improve understanding of the effect of interventions and the formulation of nationwide strategies for better NCD control. The rich data contained in this document will be useful to programme managers, researchers, NCD control advocates and other stakeholders. The data will generate credible evidence to promote NCD control and formulate strategies for NCD control in the country.

World Health House Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110002, India www.searo.who.int



National survey for noncommunicable disease risk factors and mental health using approach in Bhutan – 2014

WHO STEPS

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia. National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan, 2014. 1. Tobacco use - statistics and numerical data. 2. Alcohol Drinking – statistics and numerical data. 3. Diet - statistics and numerical data. 4. Cardiovascular diseases statistics and numerical data. 5. Uterine Cervical Neoplasms. 6. Suicide - statistics and numerical data. 7. Surveys and questionnaires. I. Bhutan. ISBN 978-92-9022-500-3 (NLM classification: WA 900)

Contributors: Tandin Dorji, Wangchuk Dukpa, Karma Doma, Dorji Pelzom, Mongal Sing Gurung, Lubna Bhatti, Dhirendra N Sinha, Renu Garg and Naveen Agarwal.

© World Health Organization 2015 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from SEARO Library, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: searolibrary@who.int). 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. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. 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. This publication does not necessarily represent the decisions or policies of the World Health Organization. Printed in India

Contents List of figures........................................................................................................................................... v List of tables..........................................................................................................................................viii Acronyms..............................................................................................................................................xiv Message ............................................................................................................................................... xv Foreword ............................................................................................................................................. xvii Acknowledgement................................................................................................................................xix Executive summary................................................................................................................................xxi 1. Introduction........................................................................................................................................1 2. Methods..............................................................................................................................................3 3. Background characteristics .................................................................................................................7 STEP 1: Behavioural measurements 4. Tobacco use........................................................................................................................................9 5: Alcohol consumption.........................................................................................................................15 6. Dietary habits....................................................................................................................................20 7. Dietary salt .......................................................................................................................................23 8. Physical inactivity...............................................................................................................................27 9. History of raised blood pressure.........................................................................................................31 10. History of raised blood glucose........................................................................................................33 11. History of raised total cholesterol.....................................................................................................34 12. History of cardiovascular diseases....................................................................................................35 13. Lifestyle advice................................................................................................................................36 14. Mental health..................................................................................................................................37 15. Family history of chronic disease conditions.....................................................................................41 STEP 2: Physical measurements 16. Physical measurements....................................................................................................................42 STEP 3: Biochemical measurements 17. Biochemical measurements..............................................................................................................45 18. Combined risk factors and cardiovascular diseases risk prediction....................................................48

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19. Discussions and recommendations...................................................................................................50 Bibliography..........................................................................................................................................54 Annexes 1. Data tables.....................................................................................................................................56 2. STEPS Instruments........................................................................................................................107 3. Fact sheet – Risk factors................................................................................................................122 4. Fact sheet – Tobacco....................................................................................................................125

List of figures Figure 3.1: Figure 4.1: Figure 4.2: Figure 4.3 Figure 4.4 Figure 4.5 Figure 4.6 Figure 4.7 Figure 4.8 Figure 4.9 Figure 5.1 Figure 5.2 Figure 5.3 Figure 5.4 Figure 5.5 Figure 5.6 Figure 5.7 Figure 5.8 Figure 6.1 Figure 6.2 Figure 6.3 Figure 6.4 Figure 6.5 Respondents by age, sex and residence ................................................................... 7 Percentage of current tobacco users by age groups, residence and sex.................... 9 Percentage of current tobacco smokers by age groups, residence and sex............. 10 Percentage of current smokers smoking by product and sex................................... 10 Proportion of never smokers, former smokers, non-daily and daily users of smoked tobacco products by sex............................................................................ 11 Percentage of current smokeless users by age groups, residence and sex............... 11 Proportion of never users, past users, non-daily and daily users of smokeless tobacco products classified by sex.......................................................... 12 Percentage of smokeless tobacco products using by current smokeless tobacco users ........................................................................................ 12 Percentage of respondents who reported being exposed to second-hand smoke at home or in the workplace classified by sex.......................... 13 Percentage of respondents who noticed information in the media about the dangers of smoking or that encourages quitting during past 30 days............... 14 Alcohol consumption status by sex......................................................................... 15 Having stopped drinking due to health reasons...................................................... 15 Frequency of alcohol consumption in the past 12 months...................................... 16 Frequency of alcohol consumption in the past 7 days among current (past 30 days) drinkers............................................................................... 16 Percentage of respondents drinking pure alcohol at different levels among all respondents on average per occasion classified by sex........................... 17 Percentage current (past 30 days) drinkers with different drinking levels classified by sex...................................................................................................... 17 Heavy episodic drinking on a single occasion at least once during the past 30 days.......................................................................................... 18 Consumption of unrecorded alcohol by sex, age and residence of respondents...... 19 Mean number of days fruits are consumed in a typical week by age, sex and residence....................................................................................... 20 Mean number of days vegetables are consumed in a typical week by age, sex and residence....................................................................................... 20 Mean number of servings of fruits consumed on average per day classified by sex, age and residence of respondents ............................................................. 21 Mean number of servings of vegetables consumed on average per day classified by sex and age of respondents............................................................................... 21 Mean number of servings of fruits and/or vegetables consumed on average per day by sex, age and residence of respondents................................ 22

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Figure 6.6 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7.4 Figure 7.5 Figure 7.6 Figure 7.7 Figure 8.1 Figure 8.2 Figure 8.3 Figure 8.4 Figure 8.5 Figure 8.6 Figure 8.7 Figure 9.1 Figure 9.2

Number of servings of fruit and/or vegetables on an average per day.................... 22 Percentage of adults who always or often add salt when cooking or preparing food at home classified by age and sex of respondents.......................... 23 Percentage of adults who always or often add salt before eating or when eating classified by age, sex and residence of respondents........................... 23 Percentage of adults who always or often consumed processed foods high in salt classified by age, sex and residence of respondents.............................. 24 Self-reported quantity of salt consumed................................................................. 24 Percentage of those who agreed with the importance of lowering salt in diet........ 25 Steps taken on a regular basis to reduce salt intake............................................... 25 Type of oil or fat most often used for meal preparation in households................... 26 Percentage not meeting WHO recommendations on physical activity for health..... 27 Level of total physical activity.................................................................................. 28 Mean minutes spent on physical activity on average per day ................................. 28 Percentage of respondents not doing any work-, transport-, or recreation-related physical activity........................................................................... 29 Contribution of work-, transport- and recreation-related physical activity to total activity....................................................................................................... 29 Percentage of respondents not engaging in vigorous physical activity.................... 30 Mean and median minutes spent on sedentary activity on a typical day................. 30 Blood pressure measurement and diagnosis among adults..................................... 31 Proportion of adults currently taking drugs (medication) for raised blood pressure prescribed by a doctor or health worker among those diagnosed, by sex and age................................................................ 31 Percentage of previously diagnosed hypertensive respondents who visited or received treatment from a traditional healer........................................................... 32

Figure 9.3

Figure 10.1 Blood sugar measurement and diagnosis................................................................ 33 Figure 11.1 Total cholesterol measurement and diagnosis......................................................... 34 Figure 12.1 Percentage of respondents having ever had a heart attack or chest pain from heart diseases or a stroke............................................................................... 35 Figure 12.2 Percentage of respondents currently taking aspirin/statins on a regular basis to prevent or treat heart disease............................................................................ 35 Figure 13.1 Lifestyle advice by doctor or health worker............................................................. 36 Figure 13.2 Percentage of female respondents who have ever had a screening test for cervical cancer among all female respondents........................................................ 36 Figure 14.1 Percentage of respondents who seriously considered attempting suicide in the preceding 12 months among all respondents......................................................... 37 Figure 14.2 Percentage of respondents who sought professional help among those who had considered attempting suicide in the preceding 12 months..................... 37

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Figure 14.3 Percentage of respondents who made a plan about how to attempt suicide in the preceding 12 months.................................................................................... 38 Figure 14.4 Percentage of respondents who have ever attempted suicide among all respondents....................................................................................................... 38 Figure 14.5 Percentage of respondents who have ever had anyone in their close family attempt suicide.................................................................................... 39 Figure 14.6 Percentage of respondents who have ever had anyone in their close family commit suicide.................................................................................... 39 Figure 14.7 Percentage of different methods used the last time suicide was attempted among those female respondents who have ever attempted suicide..... 40 Figure 15.1 Percentage of people with a family member who has been diagnosed with a chronic disease condition............................................................................. 41 Figure 16.1 BMI classifications of respondents by sex and age (excluding pregnant women) and residence........................................................... 42 Figure 16.2 Mean waist and hip circumference (cm) of respondents by sex ............................. 43 Figure 16.3 Mean blood pressure among all respondents, including those currently on medication for raised blood pressure, classified by age, sex and residence of respondents........................................................................... 43 Figure 16.4 Percentage of respondents with raised blood pressure by sex................................. 44 Figure 17.1 Mean fasting blood glucose (mg dl) classified by age, sex and residence................ 45 Figure 17.2 Percentage of respondents with raised blood glucose, including those on medication, classified by age, sex and residence..................................................... 46 Figure 17.3 Percentage of respondents with impaired fasting glycaemia, classified by sex, age and residence........................................................................ 46 Figure 17.4 Percentage of respondents with raised cholesterol, including those on medication, classified by sex, age and residence................................................ 47 Figure 17.5 Mean intake of salt classified by sex, age and residence ........................................ 47 Figure 18.1 Summary of risk factors.......................................................................................... 48 Figure 18.2 Percentage of respondents in age group 40–69 years with a 10-year CVD risk >30% or with existing CVD.............................................................................. 49

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List of tables Annex 1 Background characteristics Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Tobacco use Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 Table 4.9 Table 4.10 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 4.18 Percentage of current smokers by sex, age and residence of respondents.............. 58 Smoking status....................................................................................................... 58 Current daily smokers among smokers................................................................... 59 Mean age started smoking and mean duration of smoking among current daily smokers.................................................................................. 59 Manufactured cigarette smokers among daily smokers.......................................... 59 Manufactured cigarette smokers among current smokers...................................... 59 Mean amount of tobacco used by daily smokers by type........................................ 59 Percentage of current smokers smoking by products, sex and age......................... 60 Percentage of daily smokers smoking given quantities of manufactured or hand-rolled cigarettes per day................................................................................. 60 Former daily smokers (who don’t smoke currently) among respondents................. 60 Former daily smokers (who don’t smoke currently) among ever daily smokers....... 60 Mean years since cessation..................................................................................... 60 Current smokers who have tried to stop smoking in the last 12 months................. 61 Current smokers who have been advised by doctor to stop smoking...................... 61 Percentage of current users of smokeless tobacco by sex, age and residence of respondents........................................................................................ 61 Percentage of smokeless tobacco use history by sex and age................................. 61 Former daily smokeless tobacco users (who don’t use tobacco currently) among all respondents........................................................................................... 62 Former daily smokeless tobacco users (who don’t use tobacco currently) among ever daily users........................................................................................... 62 Age group and sex of respondents......................................................................... 55 Mean number of years of education....................................................................... 55 Highest level of education by sex and age.............................................................. 55 Marital status of respondents by sex and age......................................................... 56 Employment status of respondents by sex and age................................................ 56 Proportion unpaid work and unemployed among respondents by age and sex....... 57 Per capita annual income........................................................................................ 57

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Table 4.19 Table 4.20 Table 4.21 Table 4.22 Table 4.23 Table 4.24 Table 4.25 Table 4.26

Mean times per day smokeless tobacco used by daily smokeless tobacco users by type............................................................................................. 62 Percentage of current users of smokeless tobacco using each of the following products........................................................................................... 63 Percentage of current tobacco users by sex, age and residence of respondents...... 63 Daily tobacco users................................................................................................. 63 Exposed to second-hand smoke in home and workplace during the past 30 days.......................................................................................... 64 Percentage of all respondents who noticed information in media about the dangers of smoking or that encourages quitting during the past 30 days......... 64 Percentage of current smokers who noticed health warnings on cigarette packages during the past 30 days............................................................ 65 Percentage of current smokers who noticed health warnings on cigarette packages during the past 30 days that thought about quitting due to the health warnings they saw......................................................... 65 Average price paid for 20 manufactured cigarettes, based on the last manufactured cigarette purchase (in Ngultrum)............................................... 65

Table 4.27

Alcohol consumption Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Alcohol consumption status by sex and age........................................................... 66 Stop drinking due to health reasons....................................................................... 66 Frequency of alcohol consumption in the past 12 months...................................... 67 Mean number of drinking occasions in the past 30 days among current (past 30 days) drinkers........................................................................................... 67 Mean number of standard drinks per drinking occasion among current (past 30 days) drinkers........................................................................................... 67 Percentage of respondents drinking at high-end, intermediate and lower-end level among all respondents of pure alcohol on average per occasion by sex and age................................................................................... 68 Percentage of current (past 30 days) drinkers with different drinking levels............ 68 Mean maximum number of standard drinks consumed on one occasion in the past 30 days................................................................................................. 68 Six or more drinks on a single occasion at least once during the past 30 days among total population............................................................................. 69 Mean number of times with six or more drinks during a single occasion in the past 30 days among current drinkers............................................................ 69 Frequency of alcohol consumption in the past 7 days............................................. 69 Mean number of standard drinks and unrecorded alcohol consumed on average per day in the past 7 days among current drinkers.................................... 70 Consumption of unrecorded alcohol by sex, age and residence of respondents...... 70

Table 5.7 Table 5.8 Table 5.9 Table 5.10 Table 5.11 Table 5.12 Table 5.13

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Table 5.14 Table 5.15 Table 5.16 Table 5.17 Table 5.18 Table 5.19

Percentage of unrecorded alcohol from all alcohol consumed during past 7 days... 70 Unrecorded alcohol consumption during the past 7 days by type........................... 71 Frequency of not being able to stop drinking once started during the past 12 months among past 12 month drinkers............................................... 71 Frequency of failing to do what was normally expected from you during the past 12 months among past 12 month drinkers.................................... 72 Frequency of needing a first drink in the morning to get going during the past 12 months among past 12 month drinkers.................................... 72 Frequency of family/partner problems due to someone else’s drinking during the past 12 months among all respondents................................... 73

Dietary habits Table 6.1 Table 6.2 Table 6.3 Table 6.4 Dietary salt Table 7.1 Table 7.2 Table 7.3 Table 7.4 Table 7.5 Table 7.6 Table 7.7 Table 7.8 Table 7.9 Salt consumption habits......................................................................................... 77 Percentage of people who think they consume far too much or too much salt....... 77 Self-reported quantity of salt consumed................................................................. 78 Percentage of respondents who agree with the importance of lowering salt in diet................................................................................................ 78 Percentage of respondents who think that consuming too much salt could cause serious health problems....................................................................... 79 Mean salt intake (g/day) by age, sex and residence................................................ 79 Techniques used on a regular basis to reduce salt intake........................................ 79 Type of oil or fat most often used for meal preparation in household..................... 80 Mean number of meals eaten outside a home........................................................ 80 Mean number of days fruit and vegetables consumed in a typical week................. 74 Mean number of servings of fruit and/or vegetables on average per day by sex, age and residence of respondents.............................................................. 74 Number of servings of fruit and/or vegetables on average per day......................... 75 Less than five servings of fruit and/or vegetables on average per day.................... 76

Physical inactivity Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 8.5 Table 8.6 Metabolic equivalent (MET).................................................................................... 81 Not meeting WHO recommendations on physical activity for health....................... 81 Level of total physical activity according to former recommendations..................... 81 Mean and median minutes of total physical activity on average per day................. 82 Mean minutes spent in work-, transport- and recreation-related physical activity on average per day........................................................................ 83 Median minutes spent on average per day in work-, transport- and recreation-related physical activity........................................................................... 83

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Table 8.7 Table 8.8 Table 8.9 Table 8.10

Percentage of respondents classified as doing no work-, transport- or recreational-related physical activity........................................................................ 84 Percentage of work, transport and recreational activity contributing to total activity....................................................................................................... 84 Percentage of respondents not engaging in vigorous physical activity.................... 85 Minutes spent in sedentary activities on average per day........................................ 85

Blood pressure Table 9.1 Table 9.2 Table 9.3 Table 9.4 Table 9.5 Table 9.6 Blood pressure measurement and diagnosis........................................................... 86 Currently taking drugs (medication) for raised blood pressure prescribed by doctor or health worker among those diagnosed.............................................. 86 Percentage of previously diagnosed hypertensive respondents who have visited or received treatment from a traditional healer............................................ 87 Mean blood pressure among all respondents, including those currently on medication for raised blood pressure...................................................................... 87 Percentage of respondents with raised blood pressure........................................... 88 Percentage of respondents with treated and/or controlled of raised blood pressure among those with raised blood pressure(SBP >140 and/or DBP > 90 mmHg) or currently on medication for raised blood pressure.................. 89 Mean heart rate (beats per minute) of respondents by sex and age....................... 89

Table 9.7

Blood glucose Table 10.1 Table 10.2 Table 10.3 Table 10.4 Table 10.5 Blood sugar measurement and diagnosis................................................................ 90 Percentage of respondents currently taking oral medication and insulin prescribed for diabetes among those previously diagnosed.......................... 90 Percentage of respondents who have sought advise or treatment from a traditional healer for diabetes among those previously diagnosed....................... 90 Mean fasting blood glucose results including those currently on medication for diabetes (non–fasting recipients excluded) by sex, age and residence..................... 91 Categorization of respondents into blood glucose level categories and percentage of respondents currently on medication for raised blood glucose (non–fasting recipients excluded) by sex and age............................. 91

Abnormal lipids Table 11.1 Table 11.2 Table 11.3 Mean total cholesterol among respondents including those currently on medication for raised cholesterol....................................................................... 93 Percentage of respondents with raised total cholesterol or on medication for raised cholesterol by sex and age...................................................................... 93 Total cholesterol measurement and diagnosis among respondents in last 12 month by sex and age..................................................................................................... 94

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Combined risk factors and cardiovascular disease risk prediction Table 12.1 Table 12.2 Table 12.3 Table 12.4 Summary of Combined Risk Factors........................................................................ 95 Percentage of respondents having ever had a heart attack or chest pain from heart disease or a stroke, by age and sex....................................................... 95 Percentage of respondents currently taking asprin/statins regularly to prevent or treat heart disease............................................................................ 96 Percentage of respondents aged 40–69 years with a 10–year cardiovascular disease (CVD) risk >30% or with existing CVD................................. 96

Lifestyle advice by health care provider Table 13.1 Table 13.2 Percentage of respondents who received lifestyle advice from a doctor or health worker during the past three months among all respondents.................. 97 Percentage of female respondents who have ever had a screening test for cervical cancer among all female respondents................................................... 98

Mental health Table 14.1 Table 14.2 Table 14.3 Table 14.4 Table 14.5 Table 14.6 Table 14.7 Table 14.8 Percentage of respondents who seriously considered attempting suicide in the last 12 months among all respondents......................................................... 99 Percentage of respondents who sought professional help among those who considered attempting suicide in the past 12 months............................................. 99 Percentage of respondents who made a plan about how to attempt suicide in the past 12 months............................................................................................ 99 Percentage of respondents who have ever attempted suicide among all respondents........................................................................................................... 99 Percentage of respondents who have attempted suicide in the past 12 months among those who have ever attempted suicide.................................. 100 Percentage of different methods used the last time suicide was attempted among those respondents who have ever attempted suicide:Women.................. 100 Percentage of respondents who sought medical care the last time they attempted suicide among those who have ever attempted suicide............... 100 Percentage of respondents who were admitted to the hospital due to the last time they attempted suicide among those who sought medical care for having ever attempted suicide......................................................................... 100 Percentage of respondents who have ever had anyone in their close family attempt suicide.......................................................................... 101

Table 14.9

Table 14.10 Percentage of respondents who have ever had anyone in their close family die from suicide......................................................................... 101 Family history of chronic disease conditions Table 15.1 Percentage with a family member who has been diagnosed with a chronic disease condition........................................................................... 102

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Overweight and obesity Table 16.1 Table 16.2 Table 16.3 Table 16.4 Table 16.5 Table 16.6 Table 16.7 Table 16.8 Mean height (cm) of respondents by sex and age................................................ 103 Mean weight (kg) of respondents by sex and age................................................ 103 Mean BMI (kg/m2) of respondents by sex and age............................................... 103 BMI classifications of respondents by sex and age................................................ 104 Percentage of respondents (excluding pregnant women) classified as overweight (BMI>25)......................................................................... 104 Mean waist circumference (cm) of respondents by sex and age........................... 105 Mean Hip circumference (cm) of respondents by sex and age.............................. 105 Mean waist / hip ratio among respondents by age and sex.................................. 105

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Acronyms BMI BP CI COPD CVD DALYs DBP body mass index blood pressure confidence interval chronic obstructive pulmonary disease cardiovascular disease disability-adjusted life years diastolic blood pressure

dl decilitre EA GYTS HDL enumeration areas Global Youth Tobacco Survey High-density lipoproteins

Hg mercury HLM JDWNRH MET mmol/L NCD NGO PDA PEN PHC PI PPS PSU SBP SEARO SSU WHA WHO WHO FCTC high-level meeting Jigme Dorji Wangchuk National Referral Hospital metabolic equivalents of task millimoles per litre noncommunicable disease nongovernmental organization personal digital assistant WHO Package of Essential NCD primary health care principal investigator probability proportionate to size primary sampling unit systolic blood pressure (WHO) South-East Asia Regional Office secondary sampling unit World Health Assembly World Health Organization WHO Framework Convention on Tobacco Control

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Message Noncommunicable diseases (NCDs) are the most common cause of morbidity and mortality worldwide and in the South-East Asia Region. Planning for NCD control needs persuasive evidence generated through a strong monitoring system and surveillance of NCD risk factors. The standard protocol of the STEPs Noncommunicable Disease Risk factors survey is an opportunity to strengthen strategies to control NCDs and compare them nationally or internationally at different time intervals. WHO welcomes the initiative of Bhutan’s Ministry of Health to undertake the Stepwise NCD risk factors survey, including physical measurement and biochemical investigations at the national level. This report, based on survey results, is historical, as it presents key findings from the nationally representative survey in Bhutan and provides new insights into the health status of Bhutan’s population. It is also praiseworthy that the Ministry of Health is promoting collaboration and multisectoral approaches through integrated surveillance to address major NCD risk factors. We commend Bhutan’s efforts to control NCDs. This survey is an example of Bhutan’s commitment. The WHO Regional Office for South-East Asia is committed to supporting and facilitating the STEPs survey and NCD-related surveillance activities in all Member States. We hope that Bhutan will use the rich data contained in this document to further strengthen its NCD control programme and improve the well-being of its population.

Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region

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ROYAL GOVERNMENT OF BHUTAN MINISTRY OF HEALTH THIMPHU: BHUTAM P.B. BOX: 726

Foreword The increasing trend of Non-Communicable Diseases worldwide is leading to huge stresses on health service resources. Bhutan, like its South Asian neighbours, is also seeing an increasing trend in NCDs. While infectious diseases continue to be a cause of concern this double burden of diseases due to increasing NCDs further taxes the scarce health resources and questions the sustainability of free healthcare that the Bhutanese enjoy. Although a STEPs survey was carried out in 2007, it was restricted to Thimphu urban area and did not provide nationally representative data. Therefore, this nationwide STEPs survey has been conducted at a most opportune time. The data generated will not only form the baseline for achieving the targets set in the Global NCD Action Plan but also guide the NCD Prevention and Control Programme in adopting the best strategies. It gives me great pleasure in releasing the report of the Bhutan STEPs survey 2014. The findings of the survey highlight the issues at hand. Salt consumption is very high, almost double the WHO recommended limit. Alcohol intake is very high, with 42.4% current drinkers and 22.4% binge drinkers. Although smoking is low (7.4%) use of smokeless tobacco is very high at 19.7%. Consumption of fruits and vegetables is low and almost half of the adult Bhutanese population (aged 18 to 69 years) do not engage in vigorous physical activity. A third of the adult population (aged 18 to 69 years) has high blood pressure but do not take medication. The information generated by the Survey will be of immense help to us in planning and designing appropriate strategies for prevention and control of NCDs so that they do not become a public health concern.

TASHI DELEK!

TANDIN WANGCHUK MINISTER

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Acknowledgement The Department of Public Health would like to thank the following for their support and contribution in successfully completing this nationwide STEPs survey: (1) (2) The health workers who tirelessly worked as enumerators and supervisors in carrying out the survey and ensuring a very high response rate. Leanne Riley and Dr Lubna Bhatti from WHO Headquarters, Geneva, Dr Dhirendra N Sinha, Dr Renu Garg, Mr Naveen Agarwal from WHO SEARO, Delhi, and Prof. Anand Krishnan, AIIMS, New Delhi, for their help in designing the survey and data analysis. The WHO, for providing financial, logistical and technical support for conducting the Survey. The working group: tt tt tt tt tt

(3) (4)

Tandin Dorji, Chief, Non-Communicable Diseases Division, Dept. of Public Health Wangchuk Dukpa, Sr. Program Officer, Lifestyle Related Diseases Division Karma Doma, Deputy Chief Program Officer, Lifestyle Related Diseases Division Dorji Pelzom, Sr. Statistician, Health Research and Epidemiology Unit Mongal Sing Gurung, Research Officer, Health Research and Epidemiology Unit

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Executive summary The emerging pandemic of noncommunicable diseases (NCDs) is creating major health challenges globally. The burden of NCDs is also increasingly affecting developing countries such as Bhutan. As is the case with other low- and middle-income countries, Bhutan faces a triple burden of disease: communi­ cable diseases, re-emerging diseases and escalated prevalence of noncommunicable eases, cancer, chronic obstructive pulmonary diseases and diabetes diseases. Cardiovascular dis­ have been identified by the World Health Organization (WHO) as the four major NCDs occurring worldwide. These diseases are driven by various forces, including ageing, rapid unplanned urbanization, and the globalization of unhealthy lifestyles. Most NCDs are the result of four particular behaviours (tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol) that lead to four key metabolic/physiological changes (raised blood pressure, overweight/obesity, raised blood glucose and raised cholesterol levels). To reduce NCDs it is important to focus on decreasing the risk factors as­ sociated with these diseases, and mapping the epidemic of NCDs and their risk factors. In Bhutan, the first NCD risk factor survey was conducted in 2007–2008 in urban Thimphu to determine the preva­ lence of modifiable behavioural risk factors at the subnational level; however, this survey did not cover biological risk factors. Against this backdrop, the current study was logical risk factors – the first ever of conducted in 2014 to collect national baseline data on bio­ its kind – and determine the distribution of modifiable behavioural risk factors (NCD risk factors) among the population.

Method This national NCD risk factor survey was conducted as a cross-sectional study from March to June 2014. Prior to data collection, ethical approval was sought from the independent Research Ethics Board of Health. The main objective of the survey was to estimate the prevalence of major NCD risk factors among the different population strata in Bhutan. A sample size of 2912 was used to represent the target population (18–69 year-old adults) in Bhutan. Multi­ stage cluster sampling using a mix of probability proportionate to size (PPS) and systematic random sampling was applied, using the sampling framework from Bhutan’s Census 2005, to select the participants. The primary sampling unit (PSU) of this survey was the “Geogs”, or blocks, in rural areas and towns in urban. Sixty three PSUs in rural areas and 53 in urban were selected. Twenty households were selected from each cluster using systematic sampling. One participant out of the eligible candidates (18–69 years) in each selected household was chosen to take part in the survey using the Kish method. The survey was conducted using the WHO Stepwise Noncommunicable Disease Risk Factor Survey( STEPS) methodology, which consists of three steps for measuring NCD risk factors including physical and biochemical measurements. Sociodemographic and behavioural information were collected in STEP I. Behavioural information included tobacco use, harmful alcohol consumption, low fruit and vegetable intake, history of raised blood pressure and blood glucose levels, and the degree of dietary salt consumption. Physical measurements such as height, weight and blood pressure were collected in STEP II. Biochemical measurements were collected in STEP III using sess fasting blood glucose and total cholesterol levels. Data were collected the dry chemistry to as­

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electronically using personal digital assistants (PDAs). Data cleaning was done using SPSS 16.0 and analysis undertaken using Epi Info 3.5.1 using prior developed analysis commands. Descriptive weighted analysis was also undertaken along with complex sample analysis.

Response rate Of the 2912 targeted respondents, 2822 (96.9%) participated in STEP I and 2816 (96.7%) in STEP II. In STEP III the response rate was lower: 93.5% for blood measurements and 89.9% for urine collection for population salt intake estimation.

Background characteristics Among the 2822 respondents who participated in the survey, 1074 (38.1%) were men and 1748 (61.9%) women. The median number of years of completed schooling was 3.8 years for men and 2.8 years for women. With regard to marital status, 80.7% of respondents were married at the time of the survey. With regard to employment status, 27.7% of respondents were involved in unpaid work, 55.2% were self-employed, 5.3% were non-government employees and 11.7% were government employees.

Tobacco use The prevalence of tobacco use, both smoked and smokeless combined, was 24.8%. Nearly one third of men (33.6%) use either form of tobacco; however, among women this proportion was 13.6%. The prevalence of tobacco smoking among respondents was 7.4% (10.8% for men and 3.1% for women). This proportion increased with age among both sexes. Likewise, the prevalence of current daily smoking was 4.3% overall (men 6.0%, women 2.1%). On average, respondents started to smoke at the age of 18.9 years. About 84.1% of current daily smokers smoked manufactured cigarettes. The prevalence of smokeless tobacco use was 19.7% (men 26.5%, women 11.0%). Around 95.5% of current users consumed chewing tobacco and snuff by mouth followed by 6.1% chewing betel quid. Nearly one in five respondents (20.7%) at home and a quarter (24.6%) of respondents at the workplace had been exposed to second-hand smoke during the 30 days preceding the survey.

Alcohol consumption Nearly half of all men (50.0%) and one third of women (32.8%) surveyed drank alcohol in the preceding 30 days. Among those who drank in the preceding 12 months, 16.9% (men 20.4%, women 10.7%) drank daily. More three in ten men (29.0%), and nearly one in seven women (14.1%) were binge (heavy) drinkers (≥60 g of pure alcohol for men or ≥40 g for women on a single occasion). About 58% of alcohol consumed was home-brewed or from other unrecorded sources. Consumption of “unrecorded alcohol” was higher in rural areas than urban areas (64.2% versus 42.4%).

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Fruit and vegetable consumption The surveyed population ate fruit on an average of 1.7 days in a typical week. Vegetable consumption was relatively greater than fruit with these being eaten on an average of 5.6 days in a typical week. The quantity of intake was measured by servings: one serving of fruit was defined to be equal to a medium-sized banana or apple or equivalent and one serving of vegetables to one cup of green leafy vegetables or half a cup of cooked vegetables). WHO recommends that an adult should consume five or more servings of fruit or vegetables a day. However, only 33.1% of respondents had had the recommended 5 servings of fruits and/or vegetables in a day.

Physical activity Only 6.4% of adults did not meet WHO recommendations on physical activity for health (i.e. <150 minutes of moderate-intensity physical activity per week or its equivalent).

Dietary salt and oil Bhutanese adults consume 9 grams of salt per day, almost double the WHO recommended level of 5g/day. Around 7.8% of respondents always or often added salt before eating or while eating. Consumption of processed foods high in salt was significantly higher in urban areas than rural areas (18.8% v. 7.5%). Nearly one in 10 (11.1%) of respondents always or often consumed processed food containing high amounts of salt. The majority of respondents (92.1%) agreed that high salt consumption has adverse health effects. In the majority (97.1%) of households, vegetable oil was the most often used medium of oil or fat for the preparation of meals.

Cervical cancer screening One in six (64.1%) women aged 30–49 years have ever had a screening test for cervical cancer.

Overweight and obesity Mean body mass index (BMI) was 24.0. One third of respondents were found to have normal weight; 17.7% were overweight and 6.2% were found to be obese. Mean waist circumference was 81.9 cm for men and 79.5 cm for women.

Raised blood pressure (hypertension) Around 31.3% of the study population had never had their blood pressure measured. The prevalence of raised blood pressure or hypertension (SBP ≥140 and/or DBP ≥90), excluding those on medication, was 32.9% (men 33.6%, women 32.0 %). This figure rose to 35.7% (men 35.5%, women 35.9%) when those currently using medication were included.

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Raised blood glucose (diabetes mellitus) Around 84.6% of respondents had never had their blood glucose measured. The prevalence of diabetes within the preceding 12 months was 1.3% (men 1.1%, women 1.5%). Among those with diabetes, 35% were receiving insulin and 4.8% were taking oral drugs for diabetes. The prevalence of impaired fasting glycaemia (IFG) [defined as a plasma venous value of blood glucose ≥110 mg/dl to <126mg/dl] was 10.7% (men 11.4%, women 10.0%). The prevalence of diabetes mellitus, based on plasma venous value of blood glucose ≥126 mg/dl and including those on medication, was 6.4% (men 6.5%, women 6.3%).

Abnormal lipids The prevalence of raised total cholesterol (plasma venous value ≥190 mg/dl) including those currently on medication was 12.5% (men 11.9%, women 13.3%).

Combined risk factors The prevalence of combined risk factors was calculated using five risk factors: tt tt tt tt tt

current daily smoking, intake of less than five servings of fruit and/or vegetables per day, a low level of physical activity, overweight (BMI ≥25 kg/m2), and raised blood pressure (BP) (SBP ≥140 and/or DBP ≥90 mmHg or currently on medication for raised BP).

Only 12.7% of respondents did not have any of these risk factors, and 13.5% have three to five risk factors. The proportion of respondents in the age group 40–69 years with a 10-year CVD risk of ≥30% was found to be 1.8% (men 1.5%, women 2.2%).

Conclusion It can be inferred from these results that NCD risk factors such as use of tobacco and alcohol, unhealthy diet including high dietary salt consumption, and high blood pressure are highly prevalent among Bhutanese adults. Unless urgent and targeted interventions are made to prevent, treat and control noncommunicable diseases and their risk factors, the burden of NCDs could become unbearable in Bhutan. There is an urgent need for multisectoral interventions to prevent and control these risk factors. There are several good policies in place to control NCDs in Bhutan. There is an urgent need for effective implementation of these policies.

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1. Introduction Noncommunicable diseases (NCDs) are currently the leading cause of mortality causing 68% of all deaths globally. NCDs are largely due to four major diseases: cardiovascular diseases (CVDs), cancers, diabetes and chronic respiratory diseases. The four main NCDs share common modifiable behavioural risk factors, namely tobacco use, unhealthy diet, lack of physical activity and the harmful use of alcohol. These lead to biological risk factors such as raised blood sugar, overweight and obesity, raised blood pressure, and raised cholesterol. NCDs not only pose a tremendous health burden but also have serious social and economic consequences. Low- and middle-income countries bear the brunt of NCDs due to their fragile health systems, weak regulatory mechanisms, and limited human and financial resources. Bhutan, like many other low- and middle-income countries, is facing a transition from the disease burden due to communicable diseases to that of noncommunicable diseases. According to WHO estimates, NCDs accounted for 55% of all deaths in Bhutan in 2011. Data reported from health facilities in Bhutan indicate that mortality from NCDs increased from 25 835 cases to 35 875 between 2003 and 2007 alone. The rise in NCDs in Bhutan reflects underlying demographic and socioeconomic changes and the increase in exposure to a set of key behavioural and biological risk factors. Recognizing the emerging threat of NCDs, Bhutan adopted a National Policy and Strategy Framework on the Prevention and Control of NCDs in 2009. More recently, a multisectoral national action plan has been drafted taking into account the global and regional action plan for the prevention and control of NCDs. The existing policy and national action plan take a holistic approach to primary prevention of NCDs and provision of early detection and treatment services. Legislation related to risk factors of NCDs is advanced, but mainly focused on tobacco-related aspects. Such legislation includes a ban on import, sale and all forms of advertising of tobacco products. A policy on the harmful use of alcohol is in the draft stages. There are also public awareness campaigns on healthy nutrition and the benefits of physical activity. A pilot programme aimed at NCD prevention and control (called WHO PEN) has been implemented in two districts of Bhutan and there are plans to scale it up to the national level. The need for a comprehensive national surveillance and monitoring framework to measure progress towards the national goals and targets for prevention and control of NCDs is well recognised and artiuclated in national policy documents. Currently, however, there is no nationally representative data, or established systems for ongoing collection of data, to guide NCD-related policy and programme decision-making. The magnitude of morbidity, mortality and economic loss resulting from NCDs in Bhutan calls for a concerted effort to strengthen NCD surveillance. WHO recommends the STEP-wise approach to strengthen NCD surveillance in low- and middle-income countries. Developed by WHO in 2004, STEPS has been used worldwide in many resource-limited countries and has produced reliable and robust data on key NCD risk factors to guide the national response. WHO has identified eight major risk factors (four behavioural and four metabolic) that play a major role for developing noncommunicable diseases which have been included in the STEPS risk factor surveillance. The basis of selection of these risk factors is:

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tt tt tt tt

these have the greatest impact on NCD mortality and morbidity; modification is possible through effective prevention; measurement of these risk factors have been proven to be valid; and measurements can be obtained using appropriate ethical standards.

Rationale and objectives Available studies on NCD risk factors in Bhutan include a subnational 2007 STEPS survey (Thimphu city) and the Global Youth Tobacco Survey (GYTS) for students aged 13–15 years, latest in 2013. The 2007 STEPS survey was limited to urban Thimphu and did not collect information on the biological risk factors, namely raised blood glucose and raised blood cholesterol. Accordingly, more current and reliable nationwide data are needed on prevalence of NCD risk factors for planning and expanding NCD interventions, setting national targets, and monitoring changes over time. In addition to the use of data for the national NCD programme, Bhutan is obligated to report to these data to WHO’s World Health Assembly and Regional Committee sessions in 2015, 2020, 2025 as a follow-up to the related resolutions adopted by the Health Assembly and the regional committees. In view of the critical need for data for planning and monitoring, the Ministry of Health of the Royal Government of Bhutan undertook a nationwide survey in 2014 using the WHO STEPwise approach. The survey was to determine the prevalence of key behavioural and biological risk factors for NCDs in adult men and women aged 18–69 years. The specific objectives of the survey were to: tt tt tt tt

describe the current levels of risk factors for NCDs in adults aged 18 to 69 years in Bhutan, help track the direction and magnitude of trends in NCD risk factors, track the key indicators related to suicide in the country, collect data for projecting likely future demands for health services related to NCD prevention and management, and to support the planning and evaluation of NCD policy and programme interventions.

tt

This report outlines the methodology and results of the survey and recommends future actions for the prevention and control of noncommunicable diseases in Bhutan. The report is intended to be used by national stakeholders including the Ministry of Health and other sectors, developmental partners, research institutions, nongovernmental organizations, the media and the public.

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2. Methods Overview of scope Using the WHO STEPS survey methodology, a national cross-sectional survey was carried out to obtain nationally representative data of the adult population, aged 18 to 69 years, in Bhutan. The WHO STEPS survey protocol was used: STEP 1 included a face-to-face interview of participants to assess behavioural risk factors and health history related to NCDs; STEP 2 involved physical measurements to assess blood pressure, height, weight, waist and hip circumference; and STEP 3 enabled the assessment of fasting blood glucose, total cholesterol and urinary sodium using chemistry analysis and rapid diagnostic tests.

Sample design and sample size The Sample size to estimate the number of households to be surveyed with 95% confidence was calculated using the following formula and assumptions.

Where: Z = level of confidence measure; it represents the number of standard errors away from the mean. This describes the uncertainty in the sample mean or prevalence as an estimate of the population mean (normal deviate if alpha equals 0.05, then Z = 1.96 for 95% confidence level) P = baseline level of indicators. It is the estimated proportion of one of the indicators related to the risk factors currently being measured. The prevalence of overweight and obesity was 52.8% from the last STEPS survey carried out in Thimphu which was the closest value to 50%. d = margin of error. The expected half width of the confidence interval is taken 0.05 for this study

Four domains were chosen based on male and female and two age groups – younger (18– 39 years) and older (40–69 years) – which would provide four age/sex estimates. Taking into account the number of domains and ensuring enough representation by either age-sex groups or urban-rural in males and females, and with a design effect of 1.5 to address the issue of cluster sampling, the expected sample size was as below:

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Assuming an expected 80% response rate, the final required sample size was 2912.

� (rounded to 2912 for logistical ease)

Sampling procedure To achieve a nationally representative sample, a multistage sampling method was used to select enumeration areas, households and eligible participants at each of the selected households in three stages. The 2005 National Census was chosen as the basis for the sampling frame, with “Geogs” (blocks) in rural areas and towns in urban areas forming the primary sampling units (PSUs). Since the population distribution for urbanicity is 70:30 (rural:urban), 63 PSUs in rural and 14 PSUs in urban areas were chosen. PSUs were selected through the probability proportionate to size (PPS) sampling using the number of households in each PSU. Two secondary sampling units (SSUs) for every rural PSU and 4 SSUs for every urban PSU were selected. This led to the selection of 126 SSUs from rural and 56 SSUs from urban areas. This was also carried out by PPS sampling, using the number of households in each SSU. A total of 16 households from each SSU (both rural and urban) were selected using systematic random sampling. The sampling frame for this was the list of households with a unique identification number (ID) developed by the enumerators for the survey. At the household level, the Kish sampling method was used to randomly select one eligible member (aged 18–69 years) of the household for the survey. The Kish method ranks eligible household members in order of decreasing age, starting with males and then females, and randomly selects a respondent using the automated program for Kish selection in the handheld personal digital assistant (PDA).

Time frame The Bhutan STEPS Survey was conceptualized and planned from February 2014. By March 2014 protocols had been developed; ethical clearance sought from the Research Ethics Board for Health(REBH); logistics and implementation plans developed and all government approvals acquired. Training of enumerators was carried out from 1–5 April 2014 and field data collection started from 8 April 2014. The field work was completed by June 2014. Data management and analysis was carried out between July and September 2014, and the factsheet launched in November 2014.

Ethical clearance Ethical clearance for the survey was obtained from the Research Ethics Board for Health, Bhutan. Participation in the survey was voluntary. The survey administrator obtained two copies of written informed consent forms from the participant. One consent form was used for STEPS 1 and 2, and a separate consent form for STEP 3. After obtaining the informed consent, the interview and physical measurements (STEP 1 and STEP 2) were administered at the household level. Interviews were conducted in a manner that ensured confidentiality and the privacy of the survey respondents.

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Field work Eight survey teams were formed. Each team comprised 1 superviser (for planning and checking the completeness of questionnaires and undertaking some interviews/measurement), 3 survey administrators (for all 3 STEPS) and one driver. All survey team members were health workers, so that teams could easily undertake the anthropometric measurements and collect blood for biochemical measurements.

Adaptation of survey tools and training materials The generic WHO STEPS survey protocol and tools were adapted to local conditions in Bhutan.

Training of survey administrators and supervisers A five-day training of the survey teams was conducted from 1–5 April 2014. The training focused on teaching field workers the key aspects of recruitment of respondents, systematic sampling of households, use of the Kish method for random selection of participants from households, conducting interviews, adherence to research ethics, use of PDAs for interview and electronic data collection, conducting STEP 3 tests, accurately keeping records of interviews conducted, ensuring quality control of all field processes including questionnaires, other forms and specimens. Team supervisers were further trained on supervision of household selection at the village level, checking and correcting interview data, reviewing completed questionnaires, monitoring interviews and problem-solving in the field.

Pilot-test of field procedures A 1-day practical training in field work in Thimphu was conducted for the survey teams. This included the conduct of interviews, taking physical measurements and collection of blood samples for dry chemistry. The pilot-testing was conducted to assess the applicability of the questionnaires, gauge the reactions of the respondents to the survey procedures, assess the relevance of the field manual, estimate the time needed to administer each questionnaire, check the sequencing or flow of questions and ascertain the content validity of the questions after translation.

Field activities Immediately after the training, survey teams were allocated to the chiwog/enumeration areas where they would go to conduct the survey. Each team administered the STEP 1 (Questionnaire) and STEP 2 (Physical measurements) on the first visit to a household. The participants were then asked to fast overnight i.e. not consume any food or drinks (except water) after 10 p.m. the previous night until the blood sample was collected in the morning. A container was provided to collect urine samples prior to the beginning of the fast. Participants were asked to go to the testing centre set up by the survey team (located in the vicinity) the next morning. Here the blood samples were taken and the urine samples delivered to the survey team. Urine samples were sent by the survey team to the Jigme Dorji Wangchuk National Referral Hospital Laboratory (JDWNRH) in Thimphu for analysis of sodium and creatinine to determine mean population salt intake.

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Publicity plan A media campaign was launched to inform the public about the Bhutan STEPS survey. Daily and weekly broadcasts on radio and television, respectively, were carried out for information. At the community level, details of the survey were communicated through the dzongkhag health services, health centre staff and village health workers.

Data management Data entry Survey data were entered directly into HP iPAQ handheld devices (PDAs) by each member of the survey team to record the respondents’ answers to the STEP 1 interview and the physical and biochemical results from STEP 2 and 3. The results from the urine analysis of sodium and creatinine were separately recorded by the JDWNRH laboratory. The WHO eSTEPS software was used on the PDAs to record the survey data. A storage device (SD card) was fitted into every PDA to ensure that a backup of the data remained in case of any device failures. Data from PDAs were downloaded into a single master database following completion of the fieldwork. Data cleaning and weighting were undertaken prior to data analysis, following the guidance provided by WHO in the eSTEPS manual. This included checking ranges and combinations of variables, detecting and handling missing data, and detecting and handling outliers. Data was weighted to make the sample representative of the target population (adults in Bhutan aged 18 to 69 years). Weights were calculated to adjust for the following aspects: probability of selection (sample weight), non-response (non-response weight), and differences between the sample population and target population (population weight). From these, an overall weight was calculated for each step of the survey and applied to the final dataset.

Data analysis Data analysis was carried out in Epi Info 3.5.1, using STEPS tools and analysis commands developed by WHO and adapted for use by the Bhutan survey team. WHO provided technical support for data analysis and report writing.

Reporting Following completion of data analysis, a factsheet on NCD was generated with the support of WHO in November 2014. The WHO guidelines on developing STEPS site reports were used as the basis for developing the survey report. This included a main survey report and set of data tables. The survey report generated simple descriptive statistics with means, proportions and frequency distributions. A 95% confidence interval (CI) was used as a measure of precision on the estimated population parameters.

Reporting and disseminating of results A dissemination workshop will be planned to communicate the results of the survey at the national level. Copies of the report will be shared with all stakeholders involved in multisectoral actions to address NCDs in Bhutan.

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3. Background characteristics Response rates Out of the targeted 2912 respondents, 2822 (96.9%) participated in STEP I (behavioural measurement); and 2816 (96.7%) participated in STEP 2 (physical measurements). For STEPS 3 (biochemical measurement), the response rate for fasting blood glucose test excluding nonfasting respondents was 93.5% (2724 respondents), that for total cholesterol levels was 94.8% (2761 respondents), and for urine collection for salt estimation was 89.9% (2618 respondents).

Demographic information results Data from 2822 respondents aged between 18–69 years was included in the analysis. Of them, 38.1% were men and 61.9% women; 69.2% were from rural areas and 30.8% from urban, and 52.1% were aged 18–39 years while 47.9% were aged 40–69 years (Figure 3.1 and Annex 1, Table 3.1). Figure 3.1: Respondents by age, sex and residence 100 90 80 70 Percentage 60 50 40 30 20 10 0 18–39 years 40–69 years 18–69 years Rural Urban 34.0 42.4 38.1 39.7 34.4 Women Men 66.0 57.6 61.9 60.3 65.6

The mean number of years of completed education among all respondents was 3.2 years (n=2715), and the same was 3.8 years for men and 2.8 years for women (Annex 1, Table 3.2). Out of 2819 respondents, 62.6% had no formal schooling, 13.5% had less than primary school, 8.9% had completed primary school, 6.5% had completed secondary school, 5.4% had completed high school, 2.1% had completed college/university, and 1.0% had completed postgraduate degree studies (Annex 1, Table 3.3).

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Among the respondents (n=2820), 80.7% were currently married, 1.3% were separated, 4.2% were divorced, 5.7% were widowed, 0.1% were in cohabitation, and 8.0% had never been married (Annex 1, Table 3.4). With regard to employment status, 11.7% of respondents were government employees, 5.3% were nongovernment employees, 55.2% were self-employed, and 27.7% did not have paid employment. More women (36.8%) did not have paid employment than men (13.0%). The percentage of government employees was higher for men (23.0%) than women (4.8%) (Annex 1, Table 3.5). Out of the 782 respondents who did not have paid employment, 1.9% were non-paid, 7.5% were students, 71.5% were homemakers, 2.2% were retired, 15.3% were able-to-work unemployed, and 1.5% were not-able-to-work unemployed (Annex 1, Table 3.6). The reported mean per capita annual income of respondents was Nu. 67 622.70 (Annex 1, Table 3.7).

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STEP 1: Behavioural measurements 4. Tobacco use The frequency and patterns of tobacco use were analysed by age, sex, forms of tobacco (smoked and smokeless), and place of residence.

Current tobacco use Of all 2820 respondents, 24.8% were current tobacco users (includes smoked and smokeless). More men use tobacco (33.6%) than women (13.6%). More men aged 18–39 years (38.1%) were tobacco users than men aged 40–69 years (25.2%). There was no significant difference in tobacco use by residence (Figure 4.1). Figure 4.1: Percentage of current tobacco users by age groups, residence and sex 50 45 40 35 Percentage 30 25 20 15 10 5 0 18 –39 years 40 –69 years Rural Urban Total 12.4 16.0 26.8 25.2 21.1 15.3 10.3 13.6 38.1 35.6 32.8 25.3 33.6 Men Women Both sexes

23.7

24.8

Current tobacco smoking Overall, 7.4% of the respondents reported current use (past 30 days) of smoked tobacco products such as cigarettes, cigars or pipes. The percentage of current smoking was higher among men (10.8%) compared with women (3.1%). The percentage of current smoking was higher among younger men aged 18–39 years (14.5%) compared with older men aged 40–69 years (3.8%). The percentage of current smoking was higher among urban residents compared with rural residents (11.0% versus 5.8%) (Figure 4.2).

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Figure 4.2: Percentage of current tobacco smokers by age groups, residence and sex 25 Men 20 16.7 15 14.5 11.0 10 9.5 8.3 5.8 5 3.1 3.8 3.1 3.5 2.3 4.7 3.1 10.8 7.4 Women Both sexes

Percentage

0 18 –39 years 40 –69 years Rural Urban Total

Among current smokers, the most common smoked tobacco product was manufactured cigarette smokers (74.2%), followed by bidi (18.9%) (Figure 4.3). Figure 4.3: Percentage of current smokers smoking by product and sex 100 90 80 70 Percentage 60 50 40 30 20 10 0 Manufactured cigarette Hand-roll cigarette Bidi Cigars, cheroots, cigarillos Others 10.9 22.1 13.0 20.4 11.9 4.6 18.9 9.8 5.6 5.6 8.3 6.1 77.2 60.8 74.2 Men Women Both sexes

Of all respondents, 4.3% were current daily smokers while 3.1% were current non-daily smokers. 19.6% of the non-smokers were former smokers (Figure 4.4). The mean age of starting to smoke was 18.9 years and the mean duration of smoking was 13.0 years (Annex 1, Table 4.4). Among current smokers, 69.0% have tried to stop smoking in last 12 months. More women (82.1%) have tried to stop smoking than men (66.0%) (Annex 1, Table 4.13).

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Figure 4.4: Proportion of never smokers, former smokers, non-daily and daily users of smoked tobacco products by sex 100 90 80 70 Percentage 60 50 40 30 20 10 0 26.7 19.6 4.8 6.0 Men Never smokers 10.4 1.0 2.1 Women Former smokers Non-daily users Both sexes Daily users 3.1 4.3 62.5 73.0 86.4

Current smokeless tobacco use As shown in Figure 4.5, 19.7% of respondents were current users of smokeless tobacco products such as snuff, chewing tobacco or betel quid with tobacco. One fourth of men (26.5%) reported currently using any smokeless tobacco products compared with 11.0% of women. Among women, smokeless tobacco use was twice as much in rural areas than urban. Figure 4.5: Percentage of current smokeless users by age groups, residence and sex 50 Men 40 Women Both sexes

Percentage

30

28.6 22.7 20.3

27.4 21.5 18.7

24.4

26.5 19.7 15.8

20

13.5 10 9.7

13.5 6.1

11.0

0 18 –39 years 40 –69 years Rural Urban Total

Of 2820 respondents, 18.5% were current daily users of smokeless tobacco. More men (25.2%) were current daily users of smokeless tobacco than women (9.9%). Of the total

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respondents, 12.9% used smokeless tobacco in the past but have stopped using it at the time of the survey (Figure 4.6). Figure 4.6: Proportion of never users, past users, non-daily and daily users of smokeless tobacco products classified by sex 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Never used 25.2 13.9 1.3 11.5 1.1 9.9 Women Past users Non-daily users 12.9 1.2 18.5 59.5 77.4 67.4

Both sexes Daily users

Most common type of smokeless tobacco consumed was chewing tobacco and snuff by mouth (95.5%), followed by betel quid with tobacco (6.1%) (Figure 4.7). Among smokeless tobacco users, on average, snuff by mouth/chewing tobacco was used 12.4 times per day, betel quid with tobacco was used 0.6 times per day, and snuff by nose was used 0.3 times per day (Annex 1, Table 4.9). Figure 4.7: Percentage of smokeless tobacco products using by current smokeless tobacco users 100 90 80 70 Percentage 60 50 40 30 20 10 0 Chewing tobacco/Snuff by mouth Snuff by nose Betel quid Other 3.6 3.7 3.7 4.6 10.9 6.1 5.9 96.4 92.7 95.5 Men Women Both sexes

2.4

3.3

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Exposure to second-hand smoke (SHS) One fifth of all respondents (20.7%) reported being exposed to second-hand smoke at home during the 30 days preceding the survey. One fourth (24.6%) of respondents were exposed to second-hand smoke in the workplace during the 30 days preceding the survey (Figure 4.8). Figure 4.8: Percentage of respondents who reported being exposed to second-hand smoke at home or in the workplace classified by sex 50 Home Workplace

40

Percentage

30 20.7 20

29.0 24.6 20.7 19.1 20.7

10

0 Men Women Both sexes

Tobacco policy During the past 30 days preceding the survey, 21.0% of respondents noticed information about the dangers of smoking or information that encourages quitting in newspapers or magazines; 64.3% noticed such information on television; and 44.4% heard such information over the radio. While there was no significant difference between gender and age group of the respondents with regard to the information being noticed on television or radio, a significantly higher percentage of respondents from the younger age groups noticed information in newspapers or magazines as compared with respondents from the older age groups. The figures for these two were 24.3% and 14.1% respectively (Figure 4.9, Annex 1, Table 4.24). Among the current smokers 69.8% noticed health warnings on cigarette packages during the 30 days preceding the survey. Of this group, 84.3% had thought about quitting due to the health warnings they saw on cigarette packages (Annex 1, Tables 4.25 and 4.26). The average price paid for 20 manufactured cigarettes, based on the last cigarette purchased, was Ngultrum 269.3 (95% CI: 162.9-375.7) (Annex 1, Table 4.27).

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Figure 4.9: Percentage of respondents who noticed information in the media about the dangers of smoking or that encourages quitting during past 30 days 100 90 80 70 60 Percentage 50 40 30 20 10 0 Men Women Both sexes 25.2 15.4 21.0 45.5 43.0 44.4 64.3 64.3 64.3 Newspapers or magazines Television Radio

One third of the respondents (31.8%) were advised to stop smoking by a health-care provider in the past 12 month (Annex 1, Table 4.14).

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5: Alcohol consumption Consumption of alcohol In Bhutan, 39.0% of all respondents had never consumed any alcohol (lifetime abstinence). More women (49.8%) reported lifetime abstinence as compared with men (30.6%). Half of the men (50%) reported being current drinkers of alcohol (past 30 days) as compared with 32.8% of women. There was no significant difference between the younger and the older age groups (Figure 5.1, Annex 1, Table 5.1). Figure 5.1: Alcohol consumption status by sex 100 30.6 49.8 Percentage 60 12.1 7.4 40 50.0 32.8 9.3 8.2 42.4 10.8 7.7

80

39.0 Lifetime abstainer Past 12 months abstainer Drank in past 12 months, not current Current drinker

20

0 Men Women Both sexes

Among former drinkers who had abstained over the past 12 months, 57.9% had stopped drinking due to a negative impact of drinking on their health or following the advice of a doctor or other health worker. This percentage was similar among men and women but was significantly higher in older respondents aged 40–69 years than in younger ones aged 18–39 years (75.8% versus 47.2%) (Figure 5.2, Annex 1, Table 5.2). Figure 5.2: Having stopped drinking due to health reasons 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 47.8 58.1 46.2 57.5 47.2 57.9 75.9 75.7 75.8 18–39 years 40–69 years Total

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Frequency of alcohol consumption Among respondents who had consumed alcohol in the past 12 months preceding the survey, 16.9% had had at least one standard alcoholic drink daily. The frequency of daily drinking was significantly higher in men than women (20.4% versus 10.7%) (Figure 5.3, Annex 1, Table 5.3). Figure 5.3: Frequency of alcohol consumption in the past 12 months 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men 12.2 6.7 20.4 29.3 16.1 27.4 24.0 11.5 10.4 4.2 10.7 Women 5.8 16.9 Both sexes 16.7 34.7 14.7 15.2 <once a month 1-3 days/month 1-2 days/week 3-4 days/week 5-6 days/week Daily 23.2

Among the current (past 30 days) drinkers, 19.9% had consumed alcohol daily in the past 7 days, 8.3% had consumed alcohol on 5–6 days, 15.7% had consumed on 3–4 days, 41.1% had consumed over the last 1–2 days, and 14.9% did not consume alcohol in the past 7 days (Figure 5.4). Figure 5.4: Frequency of alcohol consumption in the past 7 days among current (past 30 days) drinkers 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 23.9 16.5 8.7 14.1 7.5 11.8 19.9 15.7 8.3 38.7 46.1 41.1 0 days 1–2 days 3–4 days 5–6 days Daily 12.2 20.5 14.9

Among current (past 30 days) drinkers, the average number of standard drinks consumed on a drinking occasion was 7.0 for men and 5.0 for women (Annex 1, Table 5.5).

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Level of alcohol consumption Of the 2756 respondents, 4.7% responded drinking at the high-end level (>60g of pure alcohol on average per occasion among men and >40g of pure alcohol on average per occasion among women). Another 2.2% of the respondents drank at the intermediate level (40–59.9g of pure alcohol on average per occasion among men and 20–39.9g of pure alcohol on average per occasion among women). A total of 34.3% of respondents drank at the lower-end level (<40g of pure alcohol on average per occasion among men and <20g of pure alcohol on average per occasion among women) (Figure 5.5, Annex 1,Table 5.6). Figure 5.5: Percentage of respondents drinking pure alcohol at different levels among all respondents on average per occasion classified by sex 50 45 40.6 40 35 30 Percentage 25 20 15 10 5 0 Men Women Both sexes 5.8 2.5 3.2 1.8 26.2 Men Women High-end <40g <20g Intermediate 40-59.9g 20-39.9g Lower-end >=60g >=40g 34.3

4.7 2.2

Among the current (past 30 days) drinkers, 11.3% reported high-end-level drinking, 5.4% were intermediate, and 83.3% were lower-end-level drinkers (Figure 5.6). Figure 5.6: Percentage current (past 30 days) drinkers with different drinking levels classified by sex 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 5.2 11.8 5.7 10.3 5.4 11.3 83.0 83.9 83.3 Women Men Lower-end <20g <40g Intermediate 40-59.9g 20-39.9g High-end >=40g >=60g

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The largest number of standard drinks consumed during a single occasion in the past 30 days among current (past 30 days) drinkers was on an average 8.2; with 9.2 drinks for men and 6.1 drinks for women (Annex 1, Table 5.8).

Heavy episodic drinking Heavy episodic drinking (binge drinking) was defined as having had six or more standard drinks on any occasion in the past 30 days at a single instance. Binge drinking was 22.4% among all adults; and was significantly higher in males (29%) than females (14.1%). Binge drinking was slightly higher in rural areas (24.1%) than urban areas (18.7%), though the difference was not significant (Figure 5.7). Figure 5.7: Heavy episodic drinking on a single occasion at least once during the past 30 days 50 45 40 35 Percentage 30 25 20 15 10 5 0 18 –39 years 40 –69 years Rural Urban Total 11.0 28.2 20.7 30.3 25.7 19.8 16.2 9.8 30.0 24.1 26.6 18.7 14.1 29.0 22.4 Men Women Both sexes

The mean number of drinking occasions among the current drinkers in the past 30 days was 8.5 (9.5 for men and 6.7 for women). The average number of standard drinks consumed on each occasion was 6.3 (7.0 in men and 5.0 in women) (Annex 1, Tables 5.4 and 5.5). The mean number of standard drinks per drinking occasion in the past 7 days among current drinkers was 2.4 (2.8 for men and 1.7 for women). The mean number of standard drinks of unrecorded alcohol in the past 7 days was 1.4 (1.5 for men and 1.3 for women) (Annex 1, Table 5.12).

Unrecorded alcohol consumption Overall, 57.9% respondents reported having consumed unrecorded alcohol. This proportion was similar among younger and older populations and among men and women. Consumption of unrecorded alcohol was significantly higher in the rural population (64.2%) than the urban population (42.4%) (Figure 5.8).

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National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Figure 5.8: Consumption of unrecorded alcohol by sex, age and residence of respondents 100 Men 80 62.0 60.4 64.6 63.5 64.2 58.4 56.8 57.9 42.6 42.1 42.4 40 Women Both sexes

Percentage

60

57.8

53.5 56.4

59.5

20

0 18-39 years 40-69 years Rural Urban Total

Overall, 47.6% of all alcohol consumed was unrecorded alcohol in the past 7 days (Annex 1, Table 5.14). Of the respondents who reported consuming unrecorded alcohol in the past 7 days, 50.1% had home-brewed spirits, 43.9% had home-brewed beer/wine and 5.3% had bought it from across the border (Annex 1, Table 5.15).

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6. Dietary habits Consumption of fruits and vegetables In a typical week, respondents reported eating fruits on 1.7 days. Among the sexes, both urban men and women have a significantly higher weekly consumption of fruits compared with their rural counterparts [urban women, 2.6 (95% CI 2.3–2.9), rural women, 1.6 (95% CI 1.3–1.8), urban men, 2.4 (95% CI 2.0–2.9), rural men, 1.2 (95% CI 1.0–1.5)]. People in urban areas have a higher level of fruit consumption in a typical week (urban 2.5, rural 1.4) (Figure 6.1, Annex 1, Table 6.1). Figure 6.1: Mean number of days fruits are consumed in a typical week by age, sex and residence 4 Men 3 Mean number 2.4 2 2.0 1.7 1.8 1.4 1 2.6 2.5 1.9 1.5 1.2 1.6 1.4 1.6 Women Both sexes

1.7

1.7

0 18 –39 years 40 –69 years Rural Urban Total

Consumption of vegetables was higher at a mean of 5.6 days in a week. Urban women also had a significantly higher weekly consumption of vegetables compared with their rural counterparts [urban women 5.9% (95% CI 5.6–6.2), rural women 5.3% (95% CI 5.1–5.5) (Figure 6.2, Annex 1, Table 6.1). Figure 6.2: Mean number of days vegetables are consumed in a typical week by age, sex and residence 7 6 5 Mean number 4 3 2 1 0 18 –39 years 40 –69 years Rural Urban Total 5.7 5.5 5.6 5.6 5.5 5.6 5.6 Men Women Both sexes

5.9 5.9 5.9 5.3 5.4

5.6 5.5 5.6

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The quantity of intake was measured by servings: one serving of fruit was defined as equal to a medium-sized banana or apple or equivalent and one serving of vegetables equal to one cup of green leafy vegetables or half a cup of cooked vegetables. The mean number of servings of fruit consumed in a day was 0.7. There was no difference by sex; however, people in urban areas consumed more servings of fruit (1.0) than rural areas (0.6) (Figure 6.3). Figure 6.3: Mean number of servings of fruits consumed on average per day classified by sex, age and residence of respondents 2.0 Men 1.5 Mean number 1.1 Women Both sexes

1.0 1.0 0.7 0.5 0.8 0.8 0.6 0.7

1.0 0.7 0.8 0.7

0.6

0.5

0.6 0.6

0.0 18 –39 years 40 –69 years Rural Urban Total

The mean number of servings of vegetables per day was 3.8. There was no difference by sex or residence in consumption of vegetable servings per day (Figure 6.4, Annex 1, Table 6.2). Figure 6.4: Mean number of servings of vegetables consumed on average per day classified by sex and age of respondents Men 5 4.2 4 Mean number 3 2 1 0 18 –39 years 40 –69 years Rural Urban Total 3.3 3.9 3.4 4.2 3.7 3.6 3.3 3.9 3.4 3.7 3.6 4.0 3.5 3.8 Women Both sexes

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The mean number of servings of fruits and/or vegetables per day was 4.5 (Figure 6.5). There was no difference by sex or residence in consumption of fruit and/or vegetables servings per day (Figure 6.5). Figure 6.5: Mean number of servings of fruits and/or vegetables consumed on average per day by sex, age and residence of respondents 6 5 4 Mean number 3 2 1 0 18 –39 years 40 –69 years Rural Urban Total 4.6 4.7 4.1 4.7 4.0 Men 4.5 4.4 4.4 Women 4.8 4.4 Both sexes 4.6 4.6 4.2 4.5

4.3

Two thirds of respondents (66.9%) ate less than five servings of fruits and/or vegetables, hence not meeting the WHO recommendation. There was no significant difference by sex or age groups in fruit and vegetable intake (Figure 6.6 and Annex 1, Table 6.4). Figure 6.6: Number of servings of fruit and/or vegetables on an average per day 100 90 80 70 Percentage 60 50 40 30 20 10 0 6.7 Men 7.6 Women 7.1 Total 27.4 32.1 29.5 29.9 30.7 30.3 >5 servings 3-4 servings 1-2 servings no fruit and/or vegetables 35.2 30.4 33.1

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7. Dietary salt The knowledge, attitude and behaviour of Bhutanese adults towards dietary salt consumption were assessed using structured questions.

Salt intake Four out of 10 (41.6%) respondents always or often added salt to their food when cooking or preparing foods at home. Figure 7.1: Percentage of adults who always or often add salt when cooking or preparing food at home classified by age and sex of respondents 50 45 40 35 Percentage 30 25 20 15 10 5 0 18 –39 years 40 –69 years Total 43.9 40.8 42.2 43.8 40.6 36.6 Men Women Both sexes 41.8 41.4 41.6

Nearly one in 10 respondents reported that they add salt always or often before eating or when eating (Figure 7.2). Figure 7.2: Percentage of adults who always or often add salt before eating or when eating classified by age, sex and residence of respondents Men 10 9 8 7 Percentage 6 5 4 3 2 1 0 18 –39 years 40 –69 years Rural Urban Total 7.9 9.0 8.4 6.6 6.9 6.7 5.5 8.2 7.8 8.0 7.2 Women 9.2 8.3 7.4 7.8 Both sexes

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Nearly one in 10 adults (11.1%) always or often ate processed foods high in salt content (Figure 7.3). The consumption of processed food high in salt is significantly lower among rural people compared with their urban counterparts and even by gender [both sexes rural 7.5% (5.6–9.5), both sexes urban 18.8% (15.1–22.6), rural men 7.2% (4.7–9.6), urban men 20.1% (14.2–26.0), rural women 8.0% (5.4–10.7), urban women 17.4% (14.1–20.7)]. The consumption of processed food high in salt is significantly higher among the younger age group and also among younger women (both sexes age group 18–39 13.6%, both sexes age group 40–69 6.4%, women 18–39 15.0%, women 40–69 4.1%) (Figures 7.3 and Annex 1, Table 7.1). Figure 7.3: Percentage of adults who always or often consumed processed foods high in salt classified by age, sex and residence of respondents 25 Men Women 20.1 20 15.0 Percentage 15 12.5 17.4 13.6 11.0 10 8.1 6.4 5 4.1 7.2 8.0 7.5 11.2 11.1 Both sexes

18.8

0 18 –39 years 40 –69 years Rural Urban Total

The self-reported quantity of salt consumed in relative measures was also assessed. Nearly seven in 10 (69.9%) respondents thought that they were using just the right amount of salt. Around 16% of respondents thought that they were using too much salt whereas 12.8% of respondents thought that they were using too little salt. Responses from men and women were not significantly different, as shown in Figure 7.4. Figure 7.4: Self-reported quantity of salt consumed 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men 16.4 0.6 15.5 Women 0.7 16.0 Total 0.7 Too much Far too much 70.3 69.4 69.9 Just Right Far too little Too Little 12.1 0.5 13.6 0.9 12.8 0.7

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Awareness on lowering salt intake Nearly two thirds (64.8%) of the respondents (men 66.2%, women 62.9%) thought that lowering salt in their diet would be very important. Around one third of the respondents (31.3%) thought it would be somewhat important. This proportion was a little higher among women (32.6%) than men (29.9%). Only 4.1% (men 3.8%, women 4.5%) thought lowering salt intake would not be at all important (Figure 7.5). Figure 7.5: Percentage of those who agreed with the importance of lowering salt in diet 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Total 66.2 62.9 64.8 Not important Somewhat important Very important 29.9 32.6 31.1 3.8 4.5 4.1

Of 2561 respondents, 92.1% thought consuming too much salt could cause a serious health problem (Annex 1, Table 7.5).

Actions to reduce salt intake The survey also assessed the various actions which were used by respondents regularly to control their salt intake. In order to control salt intake 40.3% respondents limited consumption of processed foods, 9.5% looked at the salt or sodium content on food labels, 7.4% bought low salt/sodium alternatives, 12.5% used spices other than salt when cooking, 28.1% avoided eating foods prepared outside of a home, and 10.1% took other steps specifically to control salt intake (Figure 7.6). Figure 7.6: Steps taken on a regular basis to reduce salt intake 50 40.2 40.4 40.3

40

Percentage

30

27.4

29

28.1

20 11.3 10 7.1 12.4 10.3 12.6 7.2 7.7 9.9 9.5 12.5 7.4 10.1

0 Men Limit consumption of processed foods Buy low salt alternatives Avoid eating outside Women Total Look at salt content on food labels Use spice other than salt Other thing to control salt 25

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Type of oil used for cooking In 97.1% of households, vegetable oil was the most often used type of oil or fat for meal preparation in the household. Butter was used in 2.3% of households, and 0.1% of households used other type of oil or fat (Figure 7.7). Figure 7.7: Type of oil or fat most often used for meal preparation in households

Vegetable oil 97.1%

Butter 2.3%

None in particular 0.4% Other 0.1%

Lard 0%

Eating outside the home On an average per week, adults consumed 0.9 meals (breakfast, lunch and dinner) that were not prepared at home (Annex 1, Table 7.9).

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8. Physical inactivity Physical activity of the survey population was assessed by evaluating the intensity and duration of activities undertaken during work, travel and recreation.

Not meeting WHO recommendations of physical activity As per the results of the survey, Bhutanese adults in the age group 18–69 are physically active, with only 6.4% of all adults not meeting WHO recommendations on physical activity for health (i.e. <150 minutes of moderate-intensity physical activity per week, or equivalent). Significantly higher percentages of women (9.6% CI 6.8–12.4) do not meet the WHO recommendations as compared with men (3.8% CI 2.5–5.0). While there is no difference between the two age groups, the percentage of respondents not meeting the requirement is significantly higher in urban areas (13.2%) then rural (3.2%) (Figure 8.1, Annex 1,Table 8.2). Figure 8.1: Percentage not meeting WHO recommendations on physical activity for health 25 Men Women Both sexes 18.6

20

Percentage

15 10.1 10 6.4 5 3.5 4.5 1.9 0 18 –39 years 40 –69 years Rural 8.7 6.4 4.9 3.2 8.4

13.2 9.6 6.4 3.8

Urban

Total

Physical activity by domain (work/household, transport and leisure time) Among all respondents, 77.8% reported low levels of total physical activity, 10.5% reported moderate level of total physical activity, and 11.7% reported high level of total physical activity. More men reported higher levels of total physical activity (83.2%) than women (70.9%). A significantly higher percentage of women (16.6% CI 13.5–19.8) reported low level of total physical activity as compared with men (7.7% CI 5.5–10.0) (Figure 8.2, Annex 1, Table 8.3). The mean minutes of total physical activity on average per day was 350.5 minutes. It was significantly higher for men (383.7 minutes, CI 357.3–410.2) than for women (308.3 minutes, CI 283.9–332.8). For all respondents, the median minutes of total physical activity on average per day was 330.0 minutes. The figure was 367.1 minutes for men and 274.3 minutes for women (Annex 1, Table 8.4).

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Figure 8.2: Level of total physical activity 100 90 80 70 Percentage 60 50 40 30 20 10 0 9.0 7.7 Men 12.4 10.5 16.6 Women 11.7 Both sexes 70.9 83.2 77.8 High Moderate Low

The mean time (minutes) spent in work-related physical activity on average per day was 274.5 minutes (293.4 for men and 250.6 for women). The mean minutes spent in transport-related physical activity on average per day was 56.9 minutes (61.8 for men and 50.6 for women); and the mean minutes spent in recreation-related physical activity on average per day was 19.1 minutes (28.5 for men and 7.2 for women). The mean minutes spent in recreation-related physical activity on average per day was significantly higher in younger group respondents (24.6 minutes) than older group respondents (8.5 minutes) (Figure 8.3, Annex 1, Table 8.5). Figure 8.3: Mean minutes spent on physical activity on average per day 350 300 250 Mean minutes 200 150 100 50 0 Men Women Both sexes Work-related Transport-related Recreation-related 61.8 28.5 7.2 50.6 56.9 19.1 293.4 274.5 250.6

Of all respondents, 13.8% said they did not engage in any work-related physical activity (12.1% for men and 16.0% for women), 38.3% did not perform transport-related physical activity (36.6% for men and 40.3% for women), and 73.6% did not do any recreational-related physical activity (61.5% for men and 89.0% for women). Significantly higher percentages (85.6%) of older respondents did not do recreational-related physical activity than respondents from the younger group (67.4%) (Figure 8.4, Annex 1, Table 8.7).

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Figure 8.4: Percentage of respondents not doing any work-, transport-, or recreation-related physical activity 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 12.1 16.0 13.8 36.6 40.3 38.3 61.5 No work-related physical activity No transport-related physical activity No recreation-related physical activity 89.0 73.6

Contribution of domain-specific physical activity to total physical activity When the composition of total physical activity of all respondents was analysed, 70.8% of the total activity was contributed by work activity, 20.3% was contributed by transport-related activity, and 8.9% was contributed by recreational activity. The contribution of recreational activity to the total corpus of activity for men was significantly higher (13.1%) than for women (3.2%), and was also significantly higher (10.9%) for the younger age group than the older group respondents (4.9%) (Figure 8.5, Annex 1, Table 8.8). Figure 8.5: Contribution of work-, transport- and recreation-related physical activity to total activity 100 90 80 70 Percentage 60 At leisure time 50 40 30 20 10 0 Men Women Both sexes 68.2 74.3 Transport-related 70.8 Work-realted 13.1 22.5 18.7 20.3 3.2

8.9

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Engagement in vigorous physical activities Nearly half (48.8%) of all respondents were not engaging in any vigorous physical activity. The percentage of women not engaging in vigorous physical activity was significantly higher (66.0%) than men (35.2%) (Figure 8.6, Annex 1, Table 8.9). Figure 8.6: Percentage of respondents not engaging in vigorous physical activity 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 31.2 43.3 35.2 47.4 68.1 62.0 66.0 51.6 48.8 18–39 years 40–69 years Total

Time spent being sedentary The mean minutes spent on sedentary activities in a typical day was 148.0 minutes (137.0 minutes for men and 161.9 for women) and the median minutes spent on sedentary activities in a typical day was 120.0 (the median minutes was the same irrespective of gender and age group) (Figure 8.7, Annex 1, Table 8.10). Figure 8.7: Mean and median minutes spent on sedentary activity on a typical day 180 161.9 160 140 Mean\Median 120 100 80 60 40 20 0 Mean Median Men Women Both sexes 137.0 120.0 120.0 120.0 148.0

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9. History of raised blood pressure The current health status and health-seeking behaviours of the study population related to high blood pressure were assessed by asking respondents about the history of blood pressure and their treatment history. In addition, blood pressure of the respondents (who consented) was also measured by trained health-care workers. Of all respondents, 31.3% had never had their blood pressure measured, 52.2% of them had it measured but not diagnosed with raised blood pressure, 4.9% of them were diagnosed with raised blood pressure but not within the preceding 12 months. Of all adults, 11.7% were diagnosed with raised blood pressure within the preceding 12 months. One fifth (19.9%) of the respondents aged 40–69 years were diagnosed with raised blood pressure within the past 12 months but only 7.3% of younger respondents aged 18–39 years were diagnosed with raised blood pressure within the preceding 12 months (Figure 9.1 and Annex 1, Table 9.1). Figure 9.1 Blood pressure measurement and diagnosis among adults 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 37.2 23.7 31.3 49.7 55.3 52.2 Diagnosed within past 12 months Diagnosed, not in past 12 months Measured, not diagnosed Never measured 9.1 3.9 14.9 6.1 11.7 4.9

Among those diagnosed with raised blood pressure, approximately one third (28.6%) were currently taking drugs (medication) for raised blood pressure that were prescribed by a doctor or health worker (Figure 9.2). Figure 9.2: Proportion of adults currently taking drugs (medication) for raised blood pressure prescribed by a doctor or health worker among those diagnosed, by sex and age 50 45 40 35 Percentage 30 25 20 15 10 5 0 Men 18–39 years Women 40–69 years Total 31 Both sexes 13.5 8.8 10.8 27.8 38.0 29.3 46.5 42.6

28.6

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Of those previously diagnosed with raised blood pressure (n=566), 9.4% had sought advice or received treatment from a traditional healer for raised blood pressure while 4.1% were currently seeking herbal or traditional remedies for raised blood pressure. However, more respondents aged 40–69 years seen traditional healer or taking traditional remedy for raised blood pressure as compared with respondents aged 18–39 years (14.3% v. 3.2% respectively seen traditional healer) and (6.5% v. 0.9% respectively were taking traditional remedies) (Figure 9.3, Annex 1, Table 9.3). Figure 9.3: Percentage of previously diagnosed hypertensive respondents who visited or received treatment from a traditional healer 20 18 16 14 Peercentage 12 10 8 6 4 2 0 18 –39 years 40 –69 years Seen a traditional healer Total 18 –39 years 40 –69 years Total 2.5 3.6 3.2 0.3 1.3 0.9 4.8 8.6 15.4 14.3 12.9 10.0 9.4 Men Women Both sexes

8.6 6.5 5.1 3.2 4.1

Taking herbal or traditional remedies

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10. History of raised blood glucose Of all respondents, 84.6% have never had their blood sugar measured, 13.8% were measured but were not diagnosed with raised blood sugar or diabetes, and 0.4% were diagnosed with raised blood sugar or diabetes but not within the past 12 months. A small fraction of adults (1.3%) were diagnosed with raised blood sugar or diabetes within the past 12 months. More (2.9%) respondents aged 40–69 years were diagnosed with raised blood sugar or diabetes than respondents aged 18–39 years (0.4%) (Figure 10.1 and Annex 1, Table 10.1). Figure 10.1: Blood sugar measurement and diagnosis 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 86.2 82.4 84.6 Diagnosed within past 12 months Diagnosed, but not in past 12 months Measured, not diagnosed Never measured 12.3 1.1 0.3 15.6 1.5 0.5 13.8 1.3 0.4

Among those previously diagnosed with diabetes, 35.0% were currently taking drugs (medication) prescribed for diabetes, and 4.8% are currently taking insulin prescribed for diabetes (Annex 1, Table 10.2). About 11.5% of those previously diagnosed with diabetes have consulted a traditional healer for diabetes while 2.4% of those previously diagnosed are currently taking herbal or traditional treatment for diabetes (Annex 1, Table 10.3).

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11. History of raised total cholesterol Most of the respondents (96.8%) had never had their cholesterol measured. Only 0.5% of the respondents mentioned that they were diagnosed with raised cholesterol within the preceding 12 months, 0.2% of respondents were diagnosed with raised cholesterol but not within the preceding 12 months, and 2.5% have been measured but were not diagnosed with raised cholesterol (Figure 11.1). Figure 11.1: Total cholesterol measurement and diagnosis 100 90 80 70 Percentage 60 50 40 30 20 10 0 Men Women Both sexes 96.3 97.4 96.8 Diagnosed within past 12 months Diagnosed, but not in past 12 months Measured, not diagnosed Never measured 0.5 0.1 1.8 0.6 0.2 0.5 0.2

3.1

2.5

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12. History of cardiovascular diseases Of all the respondents (2819), 0.8% have had a heart attack, or chest pain from heart diseases (angina), or a stroke (cerebrovascular accident or incident). There is no significant difference here between age groups and gender (Figure 12.1, Annex 1, Table 12.2). Figure 12.1: Percentage of respondents having ever had a heart attack or chest pain from heart diseases or a stroke 18 – 39 years 1.0 0.9 0.8 0.7 Percentage 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Men Women Both sexes 0.8 0.8 0.8 0.9 0.8 40 – 69 years 0.9 0.8 0.8 0.8 Total

Among all the respondents and age groups, 0.1% are currently taking aspirin on a regular basis to prevent or treat heart disease and 0.1% are currently taking statins (lovastatin/simvastatin/ atorvastatin, or any other statin) on a regular basis to prevent or treat heart diseases. They are mainly in the age group 40–69 years (Figure 12.2). Figure 12.2: Percentage of respondents currently taking aspirin/statins on a regular basis to prevent or treat heart disease 1.0 Men Women Both sexes

0.8 Peercentage 0.5 0.4 0.3 0.3 0.1 0.0 0.0 0.0 0.0 18 –39 years 40 –69 years Taking aspirin Total 18 –39 years 40 –69 years Taking stains Total 0.2 0.1 0.0 0.1 0.0 0.0 0.0 0.1 0.0 0.2 0.1

0.5

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13. Lifestyle advice Of all respondents, 42.1% were advised by a doctor or health worker to quit using or not to start using tobacco; 49.8% were advised to reduce salt in the diet; and 56.2% were advised to eat at least five servings of fruits and/or vegetables each day. About 52.9% of respondents were advised to reduce fat in their diet; 41.3% were advised to start or do more physical activity; and 31.5% were advised to maintain a healthy body weight or to lose weight. There were no significant differences between gender and age groups (Figure 13.1 and Annex 1, Table 13.1). Figure 13.1: Lifestyle advice by doctor or health worker 56.9 55.6 56.2 Men 51.3 48.7 49.8 45.3 42.1 38.0 Women Both sexes

60 50 40 Percentage 30 20 10 0 Maintain a Start or do more healthy body physical activity weight or to lose weight 33.7 31.5 28.7 44.7

53.2 52.9 52.5 41.3 36.9

Reduce fat in the diet

Eat at least 5 Reduce salt in servings of fruits the diet and/or vegetables per day

Quit or don't start tobacco

Cervical cancer screening About half (50.7%) of the women who were interviewed (aged 18–69 years) have ever undergone a screening test for cervical cancer. There is no significant difference between the two age groups and place of residency (rural/urban). Among women aged 30–49 years, 64.1% in total – 73.2% from urban areas and 59.5 % from rural areas – reported being screened for cervical cancer (Figure 13.2 and Annex 1, Table 13.2). Figure 13.2 Percentage of female respondents who have ever had a screening test for cervical cancer among all female respondents 100 90 80 70 Percentage 60 50 40 30 20 10 0 30 –49 years 36 18 –69 years 59.5 73.2 64.1 55.4 48.3 50.7 Rural Urban Total

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

14. Mental health Of all respondents 2.4% had seriously considered attempting suicide in the preceding 12 months. Of them, 2.7% of respondents aged 18–39 years had seriously considered attempting suicide while 1.7% in the age group of 40–69 years had considered the same. The percentage of women who seriously considered attempting suicide in the last 12 months was significantly higher (4.2%) than their male counterparts (0.9%) (Figure 14.1, Annex 1, Table 14.1). Figure 14.1: Percentage of respondents who seriously considered attempting suicide in the preceding 12 months among all respondents 10 18 –39 years 8 40 –69 years Total

Percentage

6

5.0 4.2

4 2.7 2 2.7 1.7 1.0 0.9 0.9 2.4

0 Men Women Both sexes

Among those who considered attempting suicide in the preceding 12 months, 18.9% had sought professional help. Seeking professional help was reported in significantly more numbers among the younger age group as compared with the older (Figure 14.2, Annex 1, Table 14.2). Figure 14.2: Percentage of respondents who sought professional help among those who had considered attempting suicide in the preceding 12 months 50 18 –39 years 40 35.7 40 –69 years Total

Percentage

30 24.0 21.4 20 17.5 18.9 24.3

10 2.9 0.0 0 Men Women Both sexes 2.0

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Out of 2816 respondents, 1.3% had made a plan about how to attempt suicide in the preceding 12 months. More (2.7%) women had such a plan than men (0.2%) (Figure 14.3, Annex 1, Table 14.3). Figure 14.3: Percentage of respondents who made a plan about how to attempt suicide in the preceding 12 months 5 18 –39 years 4 40 –69 years Total

3.5 2.7

Percentage

3

2 1.1 1 0.2 0 Men Women 0.1 0.2

1.7 1.3 0.5

Both sexes

Among all female respondents, 1.4% had attempted suicide. None of the men had attempted suicide. Women only younger respondents aged (18–39 years) had attempted suicide (Figure 14.4, Annex 1, Table 14.4). Figure 14.4: Percentage of respondents who have ever attempted suicide among all respondents 3 18 –39 years 40 –69 years Total

2.1 2 Percentage 1.4

1

0.9 0.6

0.0 0

0.0 Men

0.0

0.0 Women

0.0 Both sexes

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Among the respondents, 1.5% have had someone in their close family (mother, father, brother, sister or children) who had attempted suicide and 1.8% have had someone in their close family who had committed suicide (Figures 14.5 and 14.6). Figure 14.5: Percentage of respondents who have ever had anyone in their close family attempt suicide 3 18 –39 years 2.3 2.0 2 Percentage 1.4 1.1 1 0.7 1.0 1.7 1.5 1.3 40 –69 years Total

0 Men Women Both sexes

Figure 14.6: Percentage of respondents who have ever had anyone in their close family commit suicide 4 18 –39 years 40 –69 years Total

3

2.7 2.3

Percentage

2 1.6 1.4 1.2 1 1.6

1.9 1.6

1.8

0 Men Women Both sexes

Of all respondents 28.1% used poisoning with pesticides to attempt suicide, following that 27.3% used overdose of medication; 9.1% used razor, knife or other sharp instrument and 5.9% used other poisoning items (Figure 14.7, Annex 1, Table 14.6).

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Figure 14.7: Percentage of different methods used the last time suicide was attempted among those female respondents who have ever attempted suicide

6% 9% 30%

other poisoning with pesticides overdose of medication

27% razor, knife or other sharp instrument 28% other poisoning

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15. Family history of chronic disease conditions Of all respondents, 11.9% said that a family member has been diagnosed with diabetes or high blood sugar, 34.2% said a family member has been diagnosed with raised blood pressure, 2.6% said a family member has been diagnosed with stroke, 4.5% have had a family member diagnosed with cancer or malignant tumor, 2.2% said a family member has been diagnosed with raised cholesterol, and 1.2% declared that a family member has been diagnosed with early myocardial infarction (Figure 15.1, Annex 1, Table 15.1). Figure 15.1: Percentage of people with a family member who has been diagnosed with a chronic disease condition 40 35 30 25 Percentage 20 15 10 5 0 Early myocardial infarction Raised cholesterol Cancer or malignant Stroke Raised blood pressure Diabetes or high blood sugar 1.1 1.4 1.2 2.5 1.7 2.2 4 5.1 4.5 2.6 2.7 2.6 12.7 11.9 11.3 Men Women Both sexes 34.9 34.2 33.7

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STEP 2: 16. Physical measurements Body mass index The mean body mass index (BMI) among all respondents excluding pregnant women was 24.0. Of all respondents, 3.4% were underweight (BMI <18.5), 63.6% showed normal weight (BMI 18.5–24.9), 26.7% were overweight (BMI 25.0–29.9), and 6.2% were obese (BMI >30.0). The prevalence of overweight in women (31.9%) was higher than in men (22.8%). Women (8.5%) were more frequently obese than men (4.5%). About 4.6% of those aged 18–39 years and 9.2% of all respondents aged 40–69 years were obese (Figure 16.1, Annex 1, Table 16.4). Figure 16.1: BMI classifications of respondents by sex and age (excluding pregnant women) and residence

Total Urban Both sexes Rural 40-69 years 18-39 years Total Urban Women Rural 40-69 years 18-39 years Total Urban Men Rural 40-69 years 18-39 years

3.4 2.8 3.7 2.8 3.7 2.8 2.6 2.9 1.4 3.6 3.9 3.0 4.2 4 3.8 0% 20% 52.2

63.6 35.7 68.8 57.1 67.2 56.8 46.6 61.8 52.8 59.0 68.8 56.8 73.9 60.4 73.3 40% 60% 33.7 38.6

26.7

6.2 9.3

22.7 30.9 24.5 31.9

4.8 9.2 4.6 8.5 12.2

Underweight (<18.5) Normal weight (18.5-24.9) Overweight (25.0-29.9) Obese (>30.0)

28.6

6.7 12.1

30.9 22.8 33.3 18.3 28.7 19.7 80%

6.5 4.5 6.9 3.5 6.9 3.2 100%

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Waist and hip circumference Of all respondents excluding pregnant women, the mean waist circumference was 81.9 cm for men and 79.5 cm for women. The mean hip circumference was 92.5 cm for men and 94.0 cm for women. The mean waist-to-hip ratio among all respondents excluding pregnant women was 0.9 for men and 0.8 for women (Figure 16.2, Annex 1, Table 16.8). Figure 16.2: Mean waist and hip circumference (cm) of respondents by sex 100 90 80 Mean circumference in cm 70 60 50 40 30 20 10 0 Waist Hip Men Women 81.9 79.5 92.5 94.0

Blood pressure (mmHg) The mean systolic blood pressure (SBP) among all respondents, including those currently on medication for raised blood pressure, was 126.2 mmHg. The mean diastolic blood pressure (DBP) among them, including those currently on medication for raised blood pressure, was 85.0 mmHg. Mean systolic and diastolic blood pressures were higher for older respondents aged 40–69 years than their younger counterparts (134.1 mmHg versus 121.9 mmHg and 89.8 mmHg versus 82.4 mmHg respectively) (Figure 16.3, Annex 1, Table 9.4). Figure 16.3: Mean blood pressure among all respondents, including those currently on medication for raised blood pressure, classified by age, sex and residence of respondents 180 160 125.1 117.9 121.9 133.4 135.0 134.1 128.1 125.5 127.0

Men

Women

Both sexes

140 120 Mean number 100 80 60 40 20 0

127.7 120.6 124.3

128.0 123.8 126.2

88.7 91.2 89.8

84.8 86.3 85.4

18 –39 years

40 –69 years

Rural

Urban

Total

82.5 82.3 82.4

18 –39 years

40 –69 years

Rural

84.2 83.7 84.0

Urban

Mean Systolic BP

Mean Diastolic BP 43

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

84.6 85.4 85.0

Total

Blood pressure and treatment Of all respondents, 32.9% had SBP >140 and/or DBP >90 mmHg, excluding those on medication for raised blood pressure. While there was no significant difference by gender, a significantly higher percentage of older age group respondents had SBP >140 and/or DBP >90 mmHg, as compared with younger age group respondents (47.9% versus 25.6%). Of 2816 respondents, 35.7% had SBP >140 and/or DBP >90 mmHg or were currently on medication for raised blood pressure. While there was no significant difference by gender, a significantly higher percentage of older age group respondents had SBP >140 and/or DBP >90 mmHg as compared to younger age group respondents (53.3% v. 26.3%). Out of 2660 respondents excluding those on medication for raised blood pressure, 10.6% of them have had SBP >160 and/or DBP >100 mmHg. While there was no significant difference by gender, a significantly higher percentage of older age group respondents had SBP >160 and/or DBP >100 mmHg as compared to younger age group respondents (18.9% v. 6.6%). Of 2816 respondents, 14.4% of them have SBP >160 and/or DBP >100 mmHg or are currently on medication for raised blood pressure (Figure 16.4 and Annex 1, Table 9.5). Figure 16.4: Percentage of respondents with raised blood pressure by sex 50 45 40 35 Percentage 30 25 20 15 10 5 0 SBP ≥140 and/or DBP ≥ 90 mmHg, no medication SBP ≥140 and/or DBP ≥ 90 SBP ≥160 and/or DBP ≥ 100 SBP ≥160 and/or DBP ≥ 100 mmHg or on medication mmHg, no medication mmHg or on medication

Men 33.6 35.5 35.9 35.7

Women

Both sexes

32.0 32.9

10.6 10.5 10.6

13.3

15.8

14.4

Of all respondents, 88.1% with high blood pressure (SBP>140 and/or DBP>90 mmHg) were not on medication (Annex 1, Table 9.6).

Heart rate The mean heart rate (beats per minute or bpm) of respondents was 73.8 beats per minute. While there was no significant difference between the two age groups the mean was significantly higher in women [76.4 bpm (CI: 75.5–77.2)] as compared with men [71.8 bpm (CI: 70.8–72.7)] (Annex 1, Table 9.7).

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STEP 3: 17. Biochemical measurements Fasting blood glucose The mean fasting blood glucose of all respondents, including those currently on medication for diabetes, was 88.8 mg/dl or 4.9 mmol/L. The mean fasting blood glucose for older respondents aged 40–69 years was 92.5 mg/dl or 5.1 mmol/L and 86.8 mg/dl or 4.8 mmol/L for younger respondents aged 18–39 years. There was no significant difference in mean fasting blood glucose between rural and urban respondents (Figure 17.1, Annex 1, Table 10.4). Figure 17.1: Mean fasting blood glucose (mg dl) classified by age, sex and residence 100 90 80 70 Percentage 60 50 40 30 20 10 0 18–39 40–69 Men Total Women Both sexes Rural Urban 86.7 87.0 86.8 92.5 92.5 92.5

88.7 88.9 88.8

88.4 88.7 88.6

89.3 89.2 89.3

Out of all respondents 10.7% had impaired fasting glycaemia1, 6.4% of the respondents had raised blood glucose or were currently on medication for diabetes2, and 0.6% were currently on medication for diabetes. There is no significant difference between men and women respondents; however, a significantly higher percentage of older respondents aged 40–69 years had impaired fasting glycaemia as compared with younger respondents aged 18–39 years (10.5% v. 4.3%). A significantly higher percentage of urban respondents aged 40–69 years had impaired fasting glycaemia as compared with rural respondents aged 18–39 years (8.5% vs 5.5%).

1 Impaired fasting glycaemia is defined as either plasma venous value of >6.1 mmol/L (110 mg/dl) and <7.0 mmol/L (126 mg/dl), or capillary whole blood value of >5.6 mmol/L (100 mg/dl) and <6.1 mmol/L (110 mg/dl). 2 Raised blood glucose is defined as either plasma venous value of >7.0 mmol/L (126 mg/dl) or capillary whole blood value of >6.1 mmol/L (110 mg/dl).

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A significantly higher percentage of older respondents aged 40–69 years had impaired fasting glycaemia as compared with younger respondents aged 18–39 years (13.2% v. 9.4%). There was no significant difference between rural and urban respondents with impaired fasting glycaemia (Figure 17.2 and 17.3, Annex 1, Table 10.5). Figure 17.2: Percentage of respondents with raised blood glucose, including those on medication, classified by age, sex and residence 14 12 10 Percentage 8 6 4 2 0 18-39 years 40-69 Years Rural Urban Total 4.9 3.4 5.7 5.5 5.3 4.3 9.6 11.7 10.5 9.5 8.5 7.5 6.5 6.3 6.4

Men

Women

Both sexes

Figure 17.3: Percentage of respondents with impaired fasting glycaemia, classified by sex, age and residence 16 14 12 10.2 10 Percentage 8 6 4 2 0 18-39 years 40-69 Years Rural Urban Total 8.5 9.4 13.5 12.7 13.2 11.3 9.7 10.6 11.4 10.5 11 11.4 10 10.7 Men Women Both sexes

Total cholesterol The mean total cholesterol among all respondents, including those currently on medication for raised cholesterol, was 146.1 mg/dl or 3.8 mmol/L. The mean total cholesterol is higher in respondents aged 40–69 years (156.1 mg/dl or 4.0 mmol/L) than in those aged 18–39 years (140.8 mg/dl or 3.6 mmol/L). There is no significant difference between the rural and urban respondents (Annex 1, Table 11.1).

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Of all respondents, 12.5% had raised total cholesterol (>5.0 mmol/L or >190 mg/dl) or were currently on medication for raised cholesterol. About 2.0% of them have total cholesterol of >6.2 mmol/L or >240 mg/dl or are currently on medication for raised cholesterol (Figure 17.4, Annex 1, Table 11.2). Figure 17.4: Percentage of respondents with raised cholesterol, including those on medication, classified by sex, age and residence 25 21.2 20 16.9 Percentage

Men 18.8

Women

Both sexes

15 11.8 10 9.2 9 9.1

13.2

12.4

13.5 12

12.7

13.3 11.9

12.5

5

0 18-39 years 40-69 Years Rural Urban Total

Salt intake Bhutan was the first STEPs survey country to undertake spot urine testing for sodium. The mean intake of salt was 9.0 grams per day (95% CI: 8.8–9.1). Mean salt intake for men was higher at 9.6 g/day (CI 9.4–9.8) as compared with women at 8.0 g/day (CI 7.9–8.2). There was also no significant difference between rural and urban respondents on this score (Figure 17.5, Annex 1, Table 7.6). Figure 17.5: Mean intake of salt classified by sex, age and residence 20 18 16 14 12 10 8 6 4 2 0 18–39 years 40–69 years Rural Urban Total 9.5 8.3 9.9 9.0 7.6 8.9 9.6 8.0 9.8 8.9 8.2 9.0 9.6 8.0 9.0 Men Women Both sexes

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18. Combined risk factors and cardiovascular diseases risk prediction Summary of combined risk factors All respondents were assessed for the following five risk factors: (1) (2) (3) (4) (5) current daily smoking less than five servings of fruits and/or vegetables per day not meeting WHO recommendations on physical activity for health (<150 minutes of moderate activity per week or equivalent) overweight or obese (BMI >25 kg/m2) raised BP (SBP >140 and/or DBP >90 mmHg or currently on medication for raised BP).

Overall, 13.5% of the respondents had three or more of the above-mentioned risk factors; 73.7% had 1–2 risk factors, and 12.7% of them did not have any of the risk factors (Figure 19.2). A higher proportion of older respondents aged 40–69 years had 3–5 risk factors (18.9%) than younger respondents aged 18–39 years (10.9%). Similarly, higher numbers of women (16.7%) had 3-5 risk factors than their male counterparts (11.2%). A significantly higher percentage of urban respondents (22.4%) had 3–5 risk factors compared with rural respondents (9.5%). However, a higher percentage of rural respondents (76.4%) had 1–2 risk factors than urban respondents (68.0%) (Figure 18.1, Annex 1, Table 12.1). Figure 18.1: Summary of risk factors 100 90 80 70 Percentage 60 50 40 30 20 10 0 18 –39 14.6 9.1 40 –69 12.7 Total No risk factor 14.2 Rural 1-2 risk factor 9.6 Urban 3-5 risk factors 15.3 Male 9.3 Female 74.7 72.0 73.7 76.4 68.0 73.5 74.0 10.7 18.9 13.5 9.5 22.4 11.2 16.7

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A 10-year CVD risk of >30% is defined according to age, sex, blood pressure, smoking status (current smokers or those who quit smoking less than one year before the assessment), total cholesterol, and diabetes (previously diagnosed or a fasting plasma glucose concentration of >7.0 mmol/l or 126 mg/dl). The percentage of respondents aged 40–69 years with a 10-year cardiovascular disease (CVD) risk of >30% or with existing CVD was 1.8%. The percentage among urban women was 1.5 percentage points higher than among rural women (3.3% v. 1.8%) (Figure 18.2, Annex 1, Table 12.4). Figure 18.2: Percentage of respondents in age group 40–69 years with a 10-year CVD risk >30% or with existing CVD 5

4 3.2 Percentage 3 3.3 3.3

Men

Women

Both sexes

2.2 2 1.1 1 1.8 1.4 1.5 1.8

0 Urban Rural Total

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19. Discussions and recommendations Bhutan is undergoing an epidemiological transition whereby the proportion of population aged 65 years and above as well as the older age groups will nearly double by 2025. Noncommunicable diseases have become the biggest health challenge in Bhutan in terms of the number of life years lost due to ill health, disability and early death (DALYs). The major NCDs in Bhutan are cardiovascular diseases (CVD), mental health (neuropsychiatric) conditions, injuries, respiratory diseases, cancer and diabetes. National hospital-based cancer and diabetes surveillance is in place in Bhutan. Cervical cancer screening is part of the National Reproductive Health Strategy 2012. The cost of health care due to NCDs in Bhutan is rapidly increasing. This first nationwide STEPs survey to evaluate the prevalence of NCDs and NCD risk factors in Bhutan was a comprehensive study incorporating all three STEPs, as recommend by the World Health Organization. It is the first survey in Bhutan to measure population salt intake through spot urinary sodium testing. Modules on mental health (focusing on suicide) and cervical cancer were also included. This survey – also including urban and rural comparisons – provides crucial risk factor data for focusing and prioritizing national efforts to reduce the NCD burden and setting and monitoring national targets on NCDs. Bhutan has robust tobacco control policies in place. Bhutan adopted the WHO Framework Convention on Tobacco Control in 2004. The National Tobacco Control Act was promulgated in 2010 and several rules were developed in subsequent years for its implementation. Tobacco control in Bhutan is unique in the sense that it bans production, distribution and sale of tobacco products across the country. In addition it also has other components such as a ban on smoking in public places and a ban on all kinds of tobacco. In spite of these rules nearly a quarter of the adult population uses tobacco and is exposed to second-hand smoke in public places. This shows that enforcement of the existing policy needs to be further strengthened. Among current smokers, 69.0% have tried to stop smoking during the preceding 12 months of the survey. Bhutan is trying to get its health professionals trained in tobacco cessation and to establish smoking cessation guidelines. However, the challenges to establishing tobacco cessation at the community level are still considerable. While any degree of alcohol consumption is harmful for health, hazardous drinking such as in excess of the recommended daily limit is damaging to health. Alcohol drinking is also common in Bhutan. Nearly half of all men and a third of women consume alcohol on a regular basis. Binge drinking is a serious problem in Bhutan (22.4%). Apart from increasing risks for CVDs, the harmful use of alcohol will also increase the number road traffic injuries. Intake of fruits and vegetables plays a protective role in the prevention of cancers, heart diseases and many other diseases. WHO recommends a minimum of five daily servings of fruits and/or vegetables. The survey reveals a huge gap in consumption of fruits and/or vegetables in the population with more than two thirds not consuming the recommended number of five servings per day. This is not only a health literacy issue but is also determined by the underlying social and economic factors such as pricing and affordability. This should be changed through

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broad and supportive public and economic policy reforms. Awareness at the national level is needed through regular campaigns to increase health literacy. It may be included in the school curriculum too. The benefits of physical activity include prevention of heart diseases and diabetes, reduction in obesity, blood pressure and cholesterol, and improved mental health conditions. However, only 6.4% (men 3.8%, women 9.6%) of the population did not attain the WHO recommended level of physical activity (>150 minutes of moderate intensity physical activity per week or equivalent). Strategic national health promotion activities should encourage sports and other recreational opportunities. Taking the stairs at home and in public places instead of the elevators, observance of car-free days and regular use of bicycles are other good examples of ways to increase the level of physical activity among the general population. Rural populations showed better performance than urban with regard to physical activity. Median minutes of physical activity among rural population were 390 minutes as compared with 180 minutes for the urban population. Such disparities call for greater urban health promotion, such as regular health activities, the conduct of marathon races and the availability of more fitness centres. The metabolic risk factors for NCDs are raised blood pressure, obesity, and raised cholesterol and blood sugar levels. These will lead to a growing burden of NCDs. Nearly half the population above 18 years has raised blood pressure, and 10.7% have impaired fasting glycaemia. Those living with metabolic abnormalities or already suffering from NCDs do not receive the required treatment. Health-seeking behaviour for NCD management is low: nearly nine out of 10 persons have never had their blood sugar (85%) and blood cholesterol (96%) measured. As many as 97.3% of people with raised blood pressure were not receiving treatment. Even among those diagnosed with hypertension or raised cholesterol, or diabetes, the majority are not receiving treatment. This survey also shows that mean intake of salt among Bhutanese adults is nine grams per day. This is due to cultural factors that calls for salted preservatives for food and adding salt to food. Processed foods are consumed more frequently in urban areas (18.8%) than rural (7.5%). Health systems should be made more responsive to address treatment issues and healthseeking behaviours. Both private and public health systems should be involved in integrating NCD services to promote health as well as manage NCD patients. Access to cervical cancer is poor for the rural population. Cervical cancer screening coverage was reported to be lower for women aged 30–49 years in rural areas (59.5%) as compared to urban area ( 73.2% ) . The degree of public health initiatives taken by health-care providers is poor in Bhutan. Less than half of all health-care providers have advised patients to quit using tobacco or not start using, or to reduce salt in diet, or to start or do more physical activity, maintain a healthy body weight or lose weight. The prevalence of combined risk factors such as current daily smoking, less than five servings of fruits and vegetables per day, insufficient physical activity, overweight and raised blood pressure also need to be taken into account. Nearly three fourths of the population is exposed to 1–2 risk factors and nearly one in 10 are exposed to three or more of the risk factors. Those in the higher age group (45–69 years) are more exposed (18.9%) than those in the younger age group (18–44 years) (10.7%). Females had a higher prevalence (16.7%) of three or more risk factors

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than males (11.2%). Exposure to a single risk factor as well as a combination of more risk factors substantially increases the risk of developing NCDs. One out of 10 individuals in Bhutan is already exposed to three or more NCD risk factors. NCDs will potentially emerge as the biggest public health challenge in Bhutan due to the high prevalence of NCD risk factors and the existing gap between prevalence and treatment. Best buys to control NCDs in Bhutan are the formulation of the correct policies and effective implementation with the help of several sectors. Sustainable health literacy programmes also need to be increased. Bhutan adopted a National Policy and Strategy Framework on the Prevention and Control of NCDs in December 2009. Bhutan has a set of time-bound national targets for NCD indicators (11th Five Year Plan). Bhutan has a national NCD policy, strategy or action plan which integrates several NCDs and their risk factors (National Policy and Strategic Framework on Prevention and Control of NCDs). The National NCD Action Plan 2015–2020 and the National Policy and Strategy to Control Harmful Effects of Alcohol are at different stages of development. National Food-Based Dietary Guidelines serve as a roadmap for reducing unhealthy diets related to NCDs and for promoting in tandem healthy diets. A national public awareness programme on healthy food has been launched through national television and the medium of posters. Bhutan`s Health Promotion Plan 2013–2023 addresses several NCD risk factors including increased physical exercise. Bhutan is gradually integrating NCDs prevention and treatment into its primary care system. Treatment of several NCDs is still referred, and the country has not yet developed a sustainable strategy to enhance skills of health professionals in NCDs. Basic health units that deliver primary health care consist of a health assistant, an assistant nurse-midwife and a basic health worker. NCD training is not included in the Village Health Worker programme. In general, there is a conspicuous lack of health-care professionals in adequate numbers in the country, especially for NCDs. In the past few health care professionals on NCD control. Currently neither in-country training facilities for NCDs nor institutionalized international exchange programmes are available to address the training gap that exists among Bhutanese health-care professionals. The Ministry of Health of the Royal Government of Bhutan through its Department of Public Health initiated the implementation of PEN interventions in two pilot districts (Paro and Bunthang) in 2009. A performance assessment study of the PEN pilot was conducted by the MoH over a three-month period during 2012. Changes in the behavioural and biological risk factors could be assessed as patient data were recorded during each clinic visit in individual case records. Comparisons of the characteristics of patients revealed a significant improvement with regard to reduced CVD risk due to better control of hypertension and diabetes through the regular intake of medications, and the reduction in alcohol and tobacco use.

Recommendations The following recommendations were made on the basis of findings from this survey in the following areas:

Strengthening health services delivery tt

Bhutan should assign greater priority to the development of NCD-related skills among its health workforce. Both the number of workers and the type of skill sets available with them need to be expanded.

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tt

There should be a framework for monitoring accessibility (e.g. drugs), action plans and their evaluation, and the like. Facilities need to be equipped with basic diagnostic and management infrastructure. Essential NCD drugs could be made more available and accessible, especially for the poor. Bhutan should use regional education and training capacities to improve staffing and skill levels. Health system delivery should reach people at the grassroot level.

tt

tt tt

Strengthening enforcement of obacco control legislation and legislation regulating use of alcohol tt

While the tobacco ban and alcohol-related restrictions are commendable, the government should place greater emphasis on their enforcement. Health risk literacy regarding tobacco and more broadly on all NCD risk factors is needed urgently.

tt

Strengthening implementation of new NCD plans tt

The government and major stakeholders should work jointly for implementation of the national NCD policy.

Evaluating programmes and policies tt

An objective evaluation of the tobacco policy and NCD policies would provide an evidence base for future efforts. A health technology assessment institution should be established to improve the comparative effectiveness of interventions for NCDs and other conditions.

tt

Developing national NCD surveillance tt

This is the first national NCD risk factor survey. Bhutan should integrate periodic risk factor surveys in their national programme. Notwithstanding the initial efforts, much needs to be done to strengthen the national health system. Vital registration systems for mortality should go beyond hospitals (population based). Surveillance of morbidity and risk factors should be institutionalized and recorded. Public and private institutions have to be included to build up a surveillance system.

tt

tt tt

Developing and strengthening policies to address all risk factors tt

Standardizing and mandating food labelling through a policy to improve knowledge and awareness of food composition needs to be implemented. Collaboration on group purchase of essential medications to increase access and affordability is recommended. Mulisectoral high level committee should be made for effective implementation of the existing NCD policies and time to time modification of the programmes based on the mod term evaluation and lessons learnt.

tt

tt

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53

Bibliography Word Health Organization. Disease and injury country estimates: burden of disease. Geneva: WHO. http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html - accessed 22 December 2015. World Health Organization, Regional Office for South-East Asia. Approaches to establishing country-level, multisectoral coordination mechanisms for the prevention and control of noncommunicable diseases. New Delhi: WHO-SEARO, 2015. The World Bank, South Asia Human Development, Health Nutrition, and Population. NCDs policy brief: Bhutan. 2011. http://siteresources.worldbank.org/SOUTHASIAEXT/Resources/223546-1296680097256/77074371296680114157/NCD_BH_Policy_Feb_2011.pdf - accessed 22 December 2015. Royal Government of Bhutan, Ministry of Health, Department of Medical Service. Managing diabetes mellitus: guide for health workers. Thimphu, 2007. Royal Government of Bhutan, Ministry of Health, Department of public health. Package of essential NCD (PEN) interventions for hospitals. Thimphu, 2015. Wangchuk D, Virdi NK, Garg R, Mendis S, Nair N, Kumar R. Package of essential noncommunicable disease (PEN) interventions in primary health-care settings of Bhutan: a performance assessment study. WHO South-East Asia J Public Health. 2014;3(2): 154-160. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO, 2011. World Health Organization. The WHO STEP-wise approach to surveillance of noncommunicable diseases (STEPS). Geneva: WHO, 2003. http://www.who.int/ncd_surveillance/en/stepsinstrumentcore_exp_v1.4.pdf - accessed 22 December 2015. Royal Government of Bhutan, Ministry of Health. Annual health bulletin. Thimphu: Policy and Planning Department, 2012. Royal Government of Bhutan, Ministry of Health. Report on 2007 STEPS survey for risk factors and prevalence of non-communicable diseases in Thimphu. Thimphu, 2009. http://www.who.int/chp/ steps/2007NCDreport.pdf - accessed 22 December 2015. World Health Organization. Package of essential noncommunicable (PEN): disease interventions for primary health care in low-resource settings. Geneva: WHO, 2010. Royal Government of Bhutan, Ministry of Health. Package of essential NCD (PEN) interventions for basic health units. Thimphu, 2011. World Health Organization. Noncommunicable disease progress monitor 2015. Geneva: WHO, 2015. World Health Organization. Preventing chronic diseases: a vital investment. Geneva: WHO, 2005.

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Annex 1: Data tables Background characteristics

*Table 3.1: Age group and sex of respondents Men n Age Group (years) 18–39 40–69 Total Residence Rural Urban Total 775 299 1074 39.7 34.4 38.1 1177 571 1748 60.3 65.6 61.9 1952 870 2822 69.2 30.8 100 500 574 1074 34.0 42.4 38.1 969 779 1748 66.0 57.6 61.9 1469 1353 2822 52.1 47.9 100 % n Women % n Both Sexes %

Table 3.2: Mean number of years of education Age Group (years) 18–39 40–69 Total Men n 492 553 1045 Mean 5.5 2.2 3.8 n 938 732 1670 Women Mean 4.3 0.9 2.8 n 1430 1285 2715 Both Sexes Mean 4.8 1.4 3.2

Table 3.3: Highest level of education by sex and age Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total 969 777 1746 52.3 88.2 68.3 14.0 5.5 10.3 11.2 4.6 8.3 10.5` 1.0 6.3 8.7 0.4 5.0 2.2 0.3 1.3 1.0 0.0 0.6 500 573 1073 36.6 68.2 53.5 20.2 17.6 18.8 14.4 5.9 9.9 9.8 4.0 6.7 11.6 1.0 6.0 5.2 1.7 3.4 2.2 1.4 1.8 % No formal schooling % Less than primary school %Primary school completed %Secondary school completed %High school completed %College/ University completed % Post graduate degree completed

n

* First digit of table number are matching with chapter numbers for ease of understanding. National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014 55

Age Group (years) Both Sexes 18–39 40–69 Total

n

% No formal schooling

% Less than primary school 16.1 10.7 13.5

%Primary school completed

%Secondary school completed

%High school completed

%College/ University completed

% Post graduate degree completed 1.4 0.6 1.0

1469 1350 2819

47.0 79.7 62.6

12.3 5.2 8.9

10.3 2.3 6.5

9.7 0.7 5.4

3.2 0.9 2.1

Table 3.4: Marital status of respondents by sex and age Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1469 1351 2820 13.1 2.4 8.0 81.3 80.0 80.7 1.0 1.6 1.3 3.5 5.0 4.2 1.0 11.0 5.7 0.1 0.0 0.1 969 778 1747 10.4 2.6 6.9 82.7 73.3 78.5 1.3 1.8 1.5 4.4 7.2 5.7 1.1 15.2 7.4 – – – 500 573 1073 18.4 2.1 9.7 78.8 89.2 84.3 0.2 1.4 0.8 1.6 2.1 1.9 0.6 5.2 3.1 0.4 0.0 0.2 n % Never married % Currently married % Separated % Divorced % Widowed % Cohabiting

Table 3.5: Employment status of respondents by sex and age Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total 969 778 1747 7.0 2.1 4.8 5.5 1.9 3.9 47.7 63.0 54.5 39.8 33.0 36.8 500 573 1073 31.0 16.1 23.0 9.8 5.6 7.5 45.2 66.3 56.5 14.0 12.0 13.0 n % Government employee % Nongovernment employee % Selfemployed % Unpaid

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National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Age Group (years) Both Sexes 18–39 40–69 Total

n

% Government employee

% Nongovernment employee 6.9 3.5 5.3

% Selfemployed

% Unpaid

1469 1351 2820

15.2 8.0 11.7

46.8 64.4 55.2

31.0 24.1 27.7

Table 3.6: Proportion unpaid work and unemployed among respondents by age and sex Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 456 326 782 1.3 2.8 1.9 12.9 0.0 7.5 71.7 71.2 71.5 0.0 5.2 2.2 12.7 19.0 15.3 1.3 1.8 1.5 386 257 643 0.8 1.2 0.9 9.1 0.0 5.4 81.9 84.4 82.9 – – – 7.3 13.6 9.8 1.0 0.8 0.9 70 69 139 4.3 8.7 6.5 34.3 0.0 17.3 15.7 21.7 18.7 0.0 24.6 12.2 42.9 39.1 41.0 2.9 5.8 4.3 n % Nonpaid % Student %Homemaker Unemployed % Retired % Able to work % Not able to work

Table 3.7: Per capita annual income Mean annual per capita income n 2739 Mean 67622.70

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Tobacco use Table 4.1: Percentage of current smokers by sex, age and residence of respondents Age Group (years) Men n 500 573 775 298 1073 % 14.5 3.8 8.3 16.7 10.8 95% CI 10.8–18.3 1.9–5.8 5.3–11.4 11.1–22.2 8.1–13.6 n 969 778 1176 571 1747 Women % 3.1 3.1 2.3 4.7 3.1 95% CI 1.7–4.5 1.2–5.1 1.2–3.4 2.3–7.1 2.0–4.2 n 1469 1351 1951 869 2820 Both Sexes % 9.5 3.5 5.8 11.0 7.4 95% CI 7.3–11.7 2.2–4.8 3.9–7.6 8.1–14.0 5.8–9.0

Age Group (Years) 18–39 40–69 Residence Rural Urban Total

Table 4.2: Smoking status Age Group (years) Men 18–39 40–69 Residence Rural Urban Total Women 18–39 40–69 Residence Rural Urban Total Both Sexes 18–39 40–69 Residence Rural Urban Total 1951 869 2820 2.7 7.9 4.3 1.7–3.7 5.7–10.1 3.2–5.4 3.1 3.2 3.1 1.6–4.6 1.4–5.0 1.9–4.3 19.2 20.5 19.6 16.2–22.1 16.4–24.5 17.2–21.9 75.1 68.5 73.0 71.2–79.0 64.1–72.8 69.9–76.1 1469 1351 5.7 1.7 4.2–7.2 0.9–2.6 3.8 1.8 2.1–5.5 0.8–2.8 16.9 24.6 13.9–19.8 21.2–28.0 73.6 71.8 69.8–77.5 68.1–75.5 1176 571 1747 1.3 3.7 2.1 0.6–2.0 1.8–5.7 1.3–3.0 1.0 1.0 1.0 0.3–1.7 0.2–1.7 0.4–1.5 10.7 10.0 10.4 7.8–13.5 6.3–13.6 8.2–12.7 87.0 85.3 86.4 83.7–90.3 80.9–89.8 83.8–89.1 969 778 2.3 1.9 1.1–3.4 0.7–3.0 0.8 1.3 0.2–1.4 0.1–2.5 7.5 15.9 5.3–9.8 12.1–19.7 89.4 80.9 86.6–92.2 76.4–85.4 775 298 1073 3.7 11.5 6.0 2.1–5.3 7.5–15.5 4.2–7.8 4.7 5.1 4.8 2.1–7.2 1.7–8.6 2.7–6.9 25.4 29.8 26.7 21.3–29.6 23.1–36.4 23.2–30.3 66.2 53.6 62.5 60.8–71.6 46.7–60.5 58.0–66.9 500 573 8.4 1.6 5.8–10.9 0.4–2.8 6.2 2.2 3.2–9.1 0.7–3.8 24.2 31.5 19.6–28.8 26.2–36.7 61.3 64.7 55.5–67.0 59.3–70.1 Current smoker n % Daily 95% CI % Nondaily 95% CI % Former smoker Non-smokers 95% CI % Never smoker 95% CI

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Table 4.3: Current daily smokers among smokers Age Group (years) 18–39 40–69 Total Men n 76 25 101 % Daily smokers 57.5 41.9 55.6 95% CI 43.2–71.9 17.3–66.5 43.0–68.2 n 32 23 55 Women % Daily smokers 73.2 59.2 68.3 95% CI 58.0–88.5 36.1–82.3 55.3–81.3 n 108 48 156 Both Sexes % Daily smokers 59.8 48.7 57.9 95% CI 47.2–72.4 30.6–66.7 47.4–68.5

Table 4.4: Mean age started smoking and mean duration of smoking among current daily smokers Age Group (years) 18–69 18–69 Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Mean age started smoking 57 57 19.0 11.9 17.3–20.8 9.6–14.2 * * * * * * 93 93 18.9 13.0 17.5–20.3 10.8–15.2 Mean duration of smoking * Less than 50 respondents.

Table 4.5: Manufactured cigarette smokers among daily smokers Age Group (years) 18–69 Men n 56 % 90.1 95% CI 82.2–98.0 n * Women % * 95% CI * n 93 Both Sexes % 84.1 95% CI 76.3–92.0

* Less than 50 respondents.

Table 4.6: Manufactured cigarette smokers among current smokers Age Group (years) Rural Urban Total Men n 57 * 98 % 71.5 * 81.5 95% CI 57.1–85.9 * 71.4–91.6 n * * 54 Women % * * 61.2 95% CI * * 43.4–79.1 n 88 64 152 Both Sexes % 65.0 91.1 77.6 95% CI 52.6–77.5 83.3–98.9 68.5–86.7

* Less than 50 respondents.

Table 4.7: Mean amount of tobacco used by daily smokers by type Age Group (years) n Mean # of manufac­ tured cig. 95% CI n Mean # of handrolled cig. 95% CI n Mean # 95% CI of bidi n Mean # of cigars, cheerots, cigarillos 95% CI n Mean # of other type of tobacco 95% CI

Men 18–69 55 3.7 2.6–4.8 56 0.4 0.0–0.8 57 1.3 0.2–2.4 57 0.1 0.0–0.4 57 0.2 0.0–0.5

Both Sexes 18–69 89 3.5 2.6–4.3 93 0.6 0.1–1.0 92 1.2 0.3–2.1 92 0.2 0.0–0.4 93 0.3 0.0–0.7

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Table 4.8: Percentage of current smokers smoking by products, sex and age Age Group (years) n % Manuf. cigs. 95% CI % Handrolled cigs. 95% CI % bidi 95% CI n % Cigars, cheroots, cigarillos 95% CI % Other 95% CI

Men 18–69 101 77.2 66.5–87.9 10.9 3.5–18.3 20.4 11.2–29.7 101 4.6 0.2–9.1 5.6 0.4–10.8

Women 18–69 55 60.8 44.7–76.9 22.1 8.1–36.2 11.9 2.8–21.1 55 9.8 0.2–19.3 8.3 0.0–18.5

Both Sexes Total 156 74.2 64.9–83.5 13.0 6.3–19.6 18.9 11.2–26.6 156 5.6 1.5–9.7 6.1 1.5–10.7

Table 4.9: Percentage of daily smokers smoking given quantities of manufactured or hand-rolled cigarettes per day: Both Sexes Age Group (years) 18–69 n 68 % <5 Cigs. 56.2 95% CI 40.9–71.5 % 5–9 Cigs. 27.4 95% CI 13.3–41.5 % 10–14 Cigs. 13.9 95% CI 3.6–24.2 % 15–24 Cigs. 2.4 95% CI 0.0–5.8

Table 4.10: Former daily smokers (who don’t smoke currently) among respondents Age Group (years) 18–39 40–69 Total Men n 500 573 1073 % 16.3 25.0 19.3 95% CI 12.6–20.0 20.8–29.2 16.5–22.2 n 969 778 1747 Women % 3.1 11.0 5.9 95% CI 1.6–4.7 7.6–14.4 4.2–7.5 n 1469 1351 2820 Both Sexes % 10.5 18.9 13.4 95% CI 8.1–12.9 16.1–21.6 11.6–15.3

Table 4.11: Former daily smokers (who don’t smoke currently) among ever daily smokers Age Group (years) 18–39 40–69 Total Men n 125 147 272 % 66.1 94.0 76.3 95% CI 57.6–74.6 89.8–98.1 70.7–81.9 n 53 95 148 Women % 58.1 85.5 73.4 95% CI 42.1–74.1 77.8–93.2 65.0–81.9 n 178 242 420 Both Sexes % 64.9 91.6 75.7 95% CI 57.3–72.5 87.9–95.4 71.0–80.5

Table 4.12: Mean years since cessation Age Group (years) 18–39 40–69 Total Men n 122 171 293 Mean 6.6 21.2 12.5 95% CI 5.3–7.9 18.5–23.8 10.8–14.2 n 77 110 187 Women Mean 6.9 19.7 13.6 95% CI 5.0–8.7 16.6–22.9 11.7–15.6 n 199 281 480 Both Sexes Mean 6.7 20.8 12.8 95% CI 5.5–7.8 18.6–22.9 11.4–14.2

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National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Table 4.13: Current smokers who have tried to stop smoking in the last 12 months Age Group (years) 18–69 Men n 101 % 66.0 95% CI 55.2–76.8 n 55 Women % 82.1 95% CI 68.6–95.7 n 156 Both Sexes % 69.0 95% CI 59.8–78.1

Table 4.14: Current smokers who have been advised by doctor to stop smoking Age Group (years) 18–69 Men n 80 % 33.2 95% CI 22.2–44.3 n * Women % * 95% CI * n 124 Both Sexes % 31.8 95% CI 22.6–41.0

* Less than 50 respondents.

Table 4.15: Percentage of current users of smokeless tobacco by sex, age and residence of respondents Age Group (years) 18–39 40–69 Residence Rural Urban Total 775 298 1073 27.4 24.4 26.5 21.7–33.1 17.9–30.9 22.1–31.0 1176 571 1747 13.5 6.1 11.0 10.0–17.0 3.9–8.2 8.6–13.5 1951 869 2820 21.5 15.8 19.7 17.2–25.8 12.1–19.5 16.5–22.9 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Age Group (years) 500 573 28.6 22.7 23.1–34.1 17.2–28.2 969 778 9.7 13.5 7.0–12.4 9.9–17.2 1469 1351 20.3 18.7 16.5–24.0 15.0–22.4

Table 4.16: Percentage of smokeless tobacco use history by sex and age Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1469 1351 2820 18.9 17.7 18.5 15.2–22.6 14.0–21.4 15.3–21.7 1.4 1.0 1.2 0.6–2.2 0.3–1.6 0.7–1.8 10.0 18.3 12.9 7.8–12.2 15.0–21.5 10.8–15.0 69.7 63.1 67.4 65.7–73.8 58.2–67.9 63.6–71.2 61

Current user n % Daily 95% CI % Nondaily 95% CI % Past user 11.4 18.8 13.9 8.3 17.6 11.5

Non user 95% CI % Never used 60.1 58.5 59.5 82.0 68.9 77.4 95% CI

500 573 1073 969 778 1747

27.0 21.8 25.2 8.6 12.5 9.9

21.5–32.5 16.3–27.2 20.7–29.7 5.9–11.2 8.9–16.2 7.5–12.4

1.5 1.0 1.3 1.1 1.0 1.1

0.3–2.8 0.0–2.0 0.5–2.2 0.2–2.0 0.3–1.7 0.5–1.7

7.8–14.9 14.3–23.3 10.8–17.0 6.1–10.6 14.0–21.2 9.6–13.5

54.1–66.0 52.1–64.9 54.3–64.7 78.4–85.6 63.9–73.8 74.2–80.6

National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Table 4.17: Former daily smokeless tobacco users (who don’t use tobacco currently) among all respondents Age Group (years) 18–39 40–69 Total Men n 500 573 1073 % 9.9 17.1 12.4 95% CI 6.6–13.3 12.8–21.5 9.6–15.2 n 969 778 1747 Women % 7.4 15.8 10.4 95% CI 5.2–9.7 12.6–19.1 8.5–12.2 n 1469 1351 2820 Both Sexes % 8.8 16.6 11.5 95% CI 6.8–10.9 13.5–19.6 9.6–13.4

Table 4.18: Former daily smokeless tobacco users (who don’t use tobacco currently) among ever daily users Age Group (years) 18–39 40–69 Total Men n 180 217 397 % 26.9 44.1 33.1 95% CI 18.7–35.1 34.3–53.8 26.6–39.5 n 142 205 347 Women % 46.5 55.8 51.0 95% CI 35.6–57.4 46.7–64.9 43.7–58.4 n 322 422 744 Both Sexes % 31.9 48.3 38.4 95% CI 24.8–38.9 41.2–55.4 32.8–44.0

Table 4.19: Mean times per day smokeless tobacco used by daily smokeless tobacco users by type Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 203 196 399 13.2 10.8 12.4 10.9–15.6 9.1–12.5 10.6–14.2 212 205 417 0.3 0.1 0.3 0.0–0.7 0.0–0.3 0.0–0.5 211 204 415 0.2 1.3 0.6 0.0–0.4 0.5–2.1 0.2–0.9 211 206 417 0.1 0.2 0.1 0.0–0.2 0.0–0.4 0.0–0.2 77 80 157 11.2 11.5 11.3 8.9–13.5 9.0–14.0 9.5–13.2 79 83 162 0.0 0.4 0.2 0.0–0.0 0.0–1.0 0.0–0.4 79 82 161 0.5 2.0 1.2 0.0–1.3 0.2–3.7 0.3–2.0 79 84 163 0.2 0.1 0.2 0.0–0.4 0.0–0.2 0.0–0.3 126 116 242 13.8 10.5 12.8 11.0–16.5 8.5–12.6 10.6–14.9 133 122 255 0.4 0.0 0.3 0.0–0.9 0.0–0.1 0.0–0.7 132 122 254 0.1 1.0 0.4 0.0–0.3 0.2–1.8 0.1–0.7 132 122 254 0.1 0.2 0.1 0.0–0.2 0.0–0.5 0.0–0.2 n Chewing tobacco/ Snuff by mouth 95% CI n Snuff by nose 95% CI n Betel quid 95% CI n Other 95% CI

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National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Table 4.20: Percentage of current users of smokeless tobacco using each of the following products Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total 18–39 40–69 Total Both Sexes 227 222 449 96.7 92.9 95.5 94.2–99.3 88.7–97.1 93.2–97.8 4.5 1.9 3.7 0.0–9.3 0.2–3.7 0.3–7.0 3.0 12.5 6.1 0.8–5.2 6.2–18.7 3.3–8.9 3.7 2.4 3.3 1.1–6.3 0.0–4.8 1.2–5.3 86 94 180 93.5 91.5 92.7 87.5–99.6 85.6–97.4 87.9–97.4 3.5 4.1 3.7 0.0–8.5 0.3–7.9 0.0–7.7 6.7 16.5 10.9 1.2–12.2 5.0–28.0 5.1–16.7 8.7 2.3 5.9 2.3–15.1 0.0–4.9 1.8–10.1 141 128 269 97.6 93.6 96.4 94.7–100.0 87.8–99.3 93.8–99.0 4.8 0.9 3.6 0.0–10.8 0.0–2.8 0.0–8.0 2.0 10.6 4.6 0.0–4.3 4.0–17.1 1.8–7.3 2.4 2.4 2.4 0.0–5.2 0.0–5.8 0.2–4.6 %Chewing tobacco/ Snuff by mouth % Snuff by nose % Betel quid

n

95% CI

95% CI

95% CI

% Other

95% CI

Table 4.21: Percentage of current tobacco users by sex, age and residence of respondents Age Group (years) 18–39 40–69 Residence Rural Urban Total 775 298 1073 32.8 35.6 33.6 26.4–39.1 29.0–42.3 28.8–38.5 1176 571 1747 15.3 10.3 13.6 11.6–19.1 6.9–13.6 10.9–16.4 1951 869 2820 25.3 23.7 24.8 20.6–30.0 19.8–27.7 21.4–28.3 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Age Group (Years) 500 573 38.1 25.2 32.4–43.9 19.6–30.7 969 778 12.4 16.0 9.4–15.5 11.8–20.1 1469 1351 26.8 21.1 22.8–30.8 17.3–25.0

Table 4.22: Daily tobacco users Age Group (years) 18–39 40–69 Residence Rural Urban Total 775 298 1073 30.0 30.0 30.0 24.1–35.9 23.4–36.6 25.4–34.6 1176 571 1747 13.5 8.4 11.8 9.9–17.1 5.6–11.2 9.2–14.4 1951 869 2820 23.0 19.8 22.0 18.4–27.5 16.3–23.4 18.7–25.3 Men n 500 573 % 33.9 22.7 95% CI 28.4–39.4 17.2–28.3 n 969 778 Women % 10.6 13.9 95% CI 7.8–13.5 10.1–17.8 n 1469 1351 Both Sexes % 23.6 18.9 95% CI 19.9–27.4 15.0–22.7

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Table 4.23: Exposed to second-hand smoke in home and workplace during the past 30 days Age Group (years) Home 18–39 40–69 Total Workplace 18–39 40–69 Total 434 479 913 33.6 19.8 29.0 28.0–39.3 14.7–24.9 24.6–33.4 838 676 1514 22.1 13.6 19.1 18.0–26.2 9.6–17.5 15.9–22.3 1272 1155 2427 28.6 17.0 24.6 24.6–32.6 13.4–20.6 21.5–27.7 500 573 1073 23.3 15.8 20.7 18.6–28.0 11.6–20.0 17.0–24.4 969 778 1747 23.7 15.0 20.7 20.0–27.5 11.4–18.6 17.8–23.6 1469 1351 2820 23.5 15.4 20.7 20.2–26.8 12.3–18.6 18.0–23.4 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Table 4.24: Percentage of all respondents who noticed information in media about the dangers of smoking or that encourages quitting during the past 30 days. Age Group (years) 18–39 40–69 Total Television 18–39 40–69 Total Radio 18–39 40–69 Total 477 536 1013 44.2 48.0 45.5 37.6–50.9 41.3–54.7 40.1–50.9 895 729 1624 43.5 42.3 43.0 38.4–48.5 36.9–47.6 38.8–47.3 1372 1265 2637 43.9 45.5 44.4 39.0–48.8 40.6–50.3 40.3–48.6 487 547 1034 65.2 62.6 64.3 58.7–71.8 56.4–68.9 59.1–69.6 934 745 1679 67.1 58.9 64.3 61.0–73.2 52.4–65.4 59.1–69.4 1421 1292 2713 66.1 61.0 64.3 60.9–71.2 55.7–66.3 59.8–68.8 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Newspapers or magazines 460 498 958 27.9 19.7 25.2 22.5–33.3 15.5–24.0 21.2–29.2 852 651 1503 19.6 6.9 15.4 15.6–23.6 4.2–9.6 12.5–18.2 1312 1149 2461 24.3 14.3 21.0 20.6–28.1 11.4–17.1 18.2–23.7

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Table 4.25: Percentage of current smokers who noticed health warnings on cigarette packages during the past 30 days. Age Group (years) 18–69 Men n 97 % 68.7 95% CI 55.7–81.8 n * Women % * 95% CI * n 145 Both Sexes % 69.8 95% CI 58.3–81.2

*Less than 50 respondents

Table 4.26: Percentage of current smokers who noticed health warnings on cigarette packages during the past 30 days that thought about quitting due to the health warnings they saw. Age Group (years) 18–69 Men n 66 % 83.1 95% CI 73.1–93.1 n * Women % * 95% CI * n 99 Both Sexes % 84.3 95% CI 76.1–92.6

*Less than 50 respondents

Table 4.27: Average price paid for 20 manufactured cigarettes, based on the last manufactured cigarette purchase (in Ngultrum). Age Group (years) 18–69 Men n 76 Mean 252.4 95% CI 137.5–367.2 n * Women Mean * 95% CI * n 111 Both Sexes Mean 269.3 95% CI 162.9–375.7

*Less than 50 respondents

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Alcohol consumption Table 5.1: Alcohol consumption status by sex and age Age Group (years) Men 18–39 40–69 500 572 48.3 53.3 42.0–54.6 47.5–59.0 9.1 4.1 5.9–12.3 2.0–6.2 11.7 12.8 7.7–15.6 9.3–16.3 30.9 29.8 24.9–36.9 25.0–34.7 % Current drinker (past 30 days) % Drank in past 12 months, not current % Past 12 months abstainer % Lifetime abstainer

n

95% CI

95% CI

95% CI

95% CI

Residence Rural Urban Total Women 18–39 40–69 969 778 30.8 36.5 27.4–34.2 31.3–41.7 9.3 6.1 6.9–11.7 4.0–8.2 8.8 10.2 5.6–11.9 7.4–13.0 51.2 47.2 46.5–55.9 41.9–52.5

775 297 1072

51.4 46.7 50.0

45.9–56.9 39.2–54.2 45.5–54.5

5.9 10.7 7.4

3.5–8.4 5.4–16.0 5.0–9.7

10.8 15.1 12.1

7.9–13.7 8.7–21.5 9.2–14.9

31.9 27.5 30.6

26.7–37.0 19.3–35.7 26.2–35.0

Residence Rural Urban Total Both Sexes 18–39 40–69 1469 1350 40.6 45.9 36.8–44.4 41.7–50.1 9.2 5.0 7.0–11.4 3.5–6.5 10.4 11.7 7.8–13.0 9.1–14.3 39.8 37.5 35.6–44.1 33.8–41.2

1176 571 1747

33.9 30.6 32.8

29.5–38.2 26.2–35.0 29.5–36.0

6.9 10.7 8.2

4.8–9.0 7.5–14.0 6.4–10.0

8.9 10.1 9.3

5.8–11.9 6.8–13.4 7.0–11.6

50.4 48.6 49.8

45.3–55.5 42.9–54.3 45.9–53.7

Residence Rural Urban Total

1951 868 2819

43.9 39.2 42.4

39.9–47.9 34.7–43.6 39.3–45.5

6.3 10.7 7.7

4.6–8.1 7.3–14.2 6.1–9.4

10.0 12.7 10.8

7.7–12.2 8.9–16.6 8.8–12.8

39.8 37.4 39.0

35.8–43.8 31.7–43.0 35.7–42.3

Table 5.2: Stop drinking due to health reasons Age Group (years) 18–39 40–69 Total Men n 61 76 137 % 47.8 75.9 58.1 95% CI 31.3–64.3 64.3–87.5 45.9–70.4 n 76 96 172 Women % 46.2 75.7 57.5 95% CI 34.6–57.9 66.1–85.4 49.3–65.7 n 137 172 309 Both Sexes % 47.2 75.8 57.9 95% CI 36.0–58.4 67.1–84.6 49.4–66.4

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Table 5.3: Frequency of alcohol consumption in the past 12 months Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 703 653 1356 11.8 26.2 16.9 7.8–15.9 20.8–31.6 13.1–20.7 4.6 7.9 5.8 2.2–7.1 5.0–10.7 3.9–7.7 9.8 14.7 11.5 7.1–12.6 11.1–18.2 9.3–13.8 30.9 21.0 27.4 25.2–36.6 17.4–24.6 23.5–31.3 16.7 12.4 15.2 13.0–20.4 8.6–16.2 12.4–17.9 26.2 17.8 23.2 20.9–31.4 13.9–21.7 19.3–27.1 420 320 740 7.3 16.6 10.7 4.1–10.5 11.1–22.1 7.7–13.6 2.1 7.8 4.2 0.5–3.7 3.7–11.8 2.1–6.2 8.9 13.0 10.4 5.4–12.4 8.5–17.5 7.3–13.4 24.9 22.4 24.0 18.7–31.1 17.0–27.8 19.7–28.3 18.1 12.5 16.1 13.0–23.3 7.8–17.1 12.3–19.9 38.7 27.8 34.7 31.7–45.7 21.3–34.3 29.3–40.2 283 333 616 14.3 31.8 20.4 8.7–19.9 24.7–38.9 15.3–25.6 6.0 7.9 6.7 2.2–9.9 4.3–11.5 3.9–9.5 10.3 15.6 12.2 6.6–14.0 11.2–20.1 9.4–15.0 34.2 20.3 29.3 27.5–40.9 15.2–25.4 24.5–34.1 15.9 12.3 14.7 10.7–21.1 7.7–16.9 10.8–18.5 19.2 12.0 16.7 13.4–25.0 7.8–16.3 12.5–20.9 N % Daily 95% CI % 5–6 days/ week 95% CI % 3–4 days/ week 95% CI % 1–2 days/ week 95% CI % 1–3 days/ mon 95% CI % < once a month 95% CI

Table 5.4: Mean number of drinking occasions in the past 30 days among current (past 30 days) drinkers Age Group (years) 18–39 40–69 Total Men n 233 290 523 Mean 8.1 12.0 9.5 95% CI 6.5–9.6 10.2–13.8 8.2–10.8 n 302 259 561 Women Mean 5.3 8.9 6.7 95% CI 4.2–6.3 6.9–10.9 5.5–7.8 n 535 549 1084 Both Sexes Mean 7.2 10.9 8.5 95% CI 6.0–8.3 9.5–12.3 7.5–9.6

Table 5.5: Mean number of standard drinks per drinking occasion among current (past 30 days) drinkers Age Group (years) 18–39 40–69 Total Men n 238 299 537 Mean 7.1 6.8 7.0 95% CI 5.3–8.9 5.6–8.0 5.7–8.2 n 306 262 568 Women Mean 4.6 5.6 5.0 95% CI 3.6–5.5 4.7–6.5 4.2–5.7 n 544 561 1105 Both Sexes Mean 6.3 6.4 6.3 95% CI 5.0–7.5 5.5–7.3 5.4–7.2

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Table 5.6: Percentage of respondents drinking at high-end, intermediate and lower-end level among all respondents of pure alcohol on average per occasion by sex and age Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both sexes 18–39 40–69 Total 1444 1312 2756 3.9 6.1 4.7 2.4–5.3 4.1–8.2 3.3–6.0 1.9 2.8 2.2 1.0–2.8 1.6–3.9 1.5–2.9 33.8 35.1 34.3 29.9–37.7 31.2–39.0 31.2–37.3 951 759 1710 493 553 1046 n % highend (≥60g) 5.3 6.7 5.8 (≥40g) 2.0 5.5 3.2 0.8–3.3 3.1–7.8 1.9–4.5 3.0–7.6 3.9–9.4 3.9–7.7 95% CI % inter­ mediate (40–59.9g) 2.0 3.6 2.5 (20–39.9g) 1.8 1.7 1.8 0.9–2.7 0.7–2.8 1.1–2.5 0.6–3.4 1.8–5.4 1.4–3.6 95% CI % lowerend (<40g) 40.2 41.3 40.6 (<20g) 25.7 27.2 26.2 22.6–28.7 22.5–32.0 23.4–29.0 33.8–46.6 35.6–47.1 36.0–45.2 95% CI

Table 5.7: Percentage of current (past 30 days) drinkers with different drinking levels. Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both sexes 18–39 40–69 Total 531 543 1074 9.8 13.9 11.3 6.1–13.5 9.6–18.3 8.2–14.5 4.9 6.3 5.4 2.6–7.1 3.8–8.7 3.6–7.1 85.3 79.8 83.3 80.6–90.1 74.8–84.8 79.4–87.2 299 254 553 232 289 521 n % highend (≥60g) 11.2 12.9 11.8 (≥40g) 6.9 15.9 10.3 2.8–11.1 9.3–22.5 6.4–14.2 6.3–16.1 7.7–18.1 7.9–15.7 95% CI % inter­ mediate (40–59.9g) 4.2 6.9 5.2 (20–39.9g) 6.2 5.0 5.7 3.3–9.1 2.1–7.8 3.6–7.8 1.4–7.0 3.5–10.4 3.0–7.4 95% CI % lowerend (<40g) 84.6 80.1 83.0 (<20g) 86.9 79.2 83.9 81.5–92.2 72.2–86.1 79.1–88.8 78.4–90.8 73.9–86.4 78.2–87.8 95% CI

Table 5.8: Mean maximum number of standard drinks consumed on one occasion in the past 30 days Age Group (years) 18–39 40–69 Total Men n 233 283 516 Mean 9.1 9.3 9.2 95% CI 7.7–10.6 7.7–10.9 8.0–10.4 n 290 251 541 Women Mean 5.3 7.3 6.1 95% CI 4.4–6.3 6.0–8.6 5.2–7.0 n 523 534 1057 Both Sexes Mean 7.9 8.6 8.2 95% CI 6.9–9.0 7.3–9.9 7.3–9.1

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Table 5.9: Six or more drinks on a single occasion at least once during the past 30 days among total population Age Group (years) 18–39 40–69 Residence Rural Urban Total 775 297 1072 30.0 26.6 29.0 24.6–35.3 21.1–32.1 24.9–33.1 1176 571 1747 16.2 9.8 14.1 12.6–19.8 5.6–14.0 11.3–16.9 1951 868 2819 24.1 18.7 22.4 20.3–27.9 14.7–22.7 19.5–25.3 Men n 500 572 % 28.2 30.3 95% CI 22.9–33.6 25.3–35.4 n 969 778 Women % 11.0 19.8 95% CI 8.3–13.7 15.2–24.4 n 1469 1350 Both Sexes % 20.7 25.7 95% CI 17.3–24.0 21.8–29.6

Table 5.10: Mean number of times with six or more drinks during a single occasion in the past 30 days among current drinkers Age Group (years) 18–39 40–69 Total Men n 225 284 509 Mean 4.1 4.6 4.3 95% CI 2.7–5.5 3.4–5.7 3.2–5.3 n 291 242 533 Women Mean 2.0 3.6 2.6 95% CI 1.2–2.7 2.6–4.7 1.9–3.3 n 516 526 1042 Both Sexes Mean 3.4 4.3 3.7 95% CI 2.4–4.4 3.3–5.2 2.9–4.5

Table 5.11: Frequency of alcohol consumption in the past 7 days Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 494 492 986 13.3 31.8 19.9 8.5–18.0 26.1–37.4 15.7–24.1 5.9 12.6 8.3 3.4–8.4 8.4–16.7 6.0–10.6 16.5 14.3 15.7 12.5–20.5 10.8–17.8 12.9–18.6 47.6 29.6 41.1 42.4–52.9 23.7–35.5 36.7–45.6 16.7 11.8 14.9 12.7–20.7 7.8–15.7 11.8–18.0 276 221 497 6.5 20.9 11.8 2.4–10.6 14.2–27.7 7.9–15.7 6.1 9.9 7.5 2.7–9.5 4.8–14.9 4.4–10.5 10.8 19.8 14.1 6.3–15.2 13.5–26.2 10.3–17.9 54.5 32.0 46.1 46.7–62.2 24.5–39.5 39.7–52.6 22.3 17.4 20.5 16.0–28.6 10.4–24.5 15.5–25.5 218 271 489 16.5 37.3 23.9 9.7–23.3 30.3–44.4 18.2–29.7 5.8 13.9 8.7 2.6–9.1 8.6–19.2 5.8–11.6 19.3 11.5 16.5 13.6–25.1 7.8–15.2 12.5–20.5 44.4 28.4 38.7 37.1–51.6 21.0–35.8 33.1–44.3 14.0 8.9 12.2 8.7–19.2 4.6–13.1 8.3–16.0 n % Daily 95% CI % 5–6 days 95% CI % 3–4 days 95% CI % 1–2 days 95% CI %0 days 95% CI

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Table 5.12: Mean number of standard drinks and unrecorded alcohol consumed on average per day in the past 7 days among current drinkers Age Group (years) Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Standard drinks consumed 18–39 40–69 Total 18–39 40–69 Total 218 271 489 99 154 253 2.2 3.8 2.8 1.5 1.6 1.5 1.5–2.8 2.8–4.9 2.1–3.4 1.1–1.8 1.3–1.9 1.3–1.8 276 221 497 125 135 260 1.1 2.7 1.7 1.0 1.6 1.3 0.8–1.4 1.9–3.5 1.3–2.1 0.7–1.3 1.2–2.0 1.0–1.5 494 492 986 224 289 513 1.8 3.4 2.4 1.3 1.6 1.4 1.3–2.3 2.6–4.3 1.9–2.9 1.0–1.6 1.4–1.9 1.2–1.6

standard drinks of unrecorded alcohol

Table 5.13: Consumption of unrecorded alcohol by sex, age and residence of respondents* Age Group (years) 18–39 40–69 Residence Rural Urban Total 405 136 541 64.6 42.6 58.4 58.4-70.7 33.1-52.2 53.0-63.9 404 175 579 63.5 42.1 56.8 55.9-71.2 31.6-52.6 50.4-63.2 809 311 1120 64.2 42.4 57.9 59.1-69.4 35.2-49.7 53.4-62.3 Men n 236 305 % 57.8 59.5 95% CI 50.6–65.0 52.5–66.5 n 310 269 Women % 53.5 62.0 95% CI 45.6–61.3 53.9–70.2 n 546 574 Both Sexes % 56.4 60.4 95% CI 50.8–61.9 54.7–66.0

*Percentage of respondents that consumed unrecorded alcohol (homebrewed alcohol, alcohol brought over the border, not intended for drinking or other untaxed alcohol) during the past 7 days among current (past 30 days) drinkers.

Table 5.14: Percentage of unrecorded alcohol from all alcohol consumed during past 7 days Age Group (years) 18–39 40–69 Total Men n 150 204 354 % 48.6 36.6 41.7 n 169 143 312 Women % 57.3 50.8 54.3 n 319 347 666 Both Sexes % 53.2 42.5 47.6

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Table 5.15: Unrecorded alcohol consumption during the past 7 days by type* Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 184 233 417 44 54.9 50.1 50.5 38.6 43.9 4.3 6.0 5.3 1.1 0.4 0.7 98 100 198 48.6 48 48.5 43 39.3 40.9 7.1 12.4 9.6 1.3 0.3 0.5 86 133 219 38.5 59.8 51.6 59.3 38 46.6 1.0 1.5 1.4 1.2 0.7 0.9 n % homebrewed spirits % homebrewed beer/ wine % brought over border % other

*Percentage of each type of unrecorded alcohol of all unrecorded alcohol consumed in the past 7 days among current (past 30 days) drinkers.

Table 5.16: Frequency of not being able to stop drinking once started during the past 12 months among past 12 month drinkers Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 706 654 1360 21.7 27.6 23.8 17.2–26.1 23.0–32.1 20.1–27.5 13.3 15.9 14.2 9.2–17.5 12.3–19.5 11.1–17.4 65.0 56.5 62.0 59.4–70.5 51.1–62.0 57.5–66.5 421 321 742 14.6 22.4 17.4 10.5–18.6 17.2–27.6 14.1–20.7 9.7 17.3 12.4 6.1–13.4 12.2–22.4 9.3–15.6 75.7 60.3 70.1 70.4–81.1 53.6–67.0 65.7–74.6 285 333 618 25.6 30.6 27.3 19.5–31.7 24.9–36.4 22.4–32.2 15.3 15.1 15.2 9.9–20.8 10.7–19.5 11.2–19.3 59.1 54.3 57.4 51.9–66.3 47.2–61.3 51.7–63.1 n % monthly or more frequently 95% CI % less than monthly 95% CI % never 95% CI

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Table 5.17: Frequency of failing to do what was normally expected from you during the past 12 months among past 12 month drinkers Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 706 654 1360 5.3 5.8 5.5 3.1–7.6 3.5–8.0 3.8–7.2 9.5 11.5 10.2 6.3–12.7 8.4–14.6 7.8–12.6 85.2 82.7 84.3 81.3–89.1 78.8–86.6 81.3–87.3 421 321 742 2.9 5.3 3.8 1.1–4.6 2.5–8.1 2.2–5.3 7.4 7.7 7.5 4.3–10.6 4.2–11.2 5.2–9.9 89.7 87.0 88.7 86.1–93.3 82.4–91.6 85.8–91.6 285 333 618 6.7 6.1 6.5 3.2–10.1 3.1–9.1 4.0–9.0 10.6 13.7 11.7 5.9–15.3 9.3–18.2 8.2–15.2 82.7 80.2 81.9 76.9–88.6 75.0–85.4 77.5–86.2 n % monthly or more frequently 95% CI % less than monthly 95% CI % never 95% CI

Table 5.18: Frequency of needing a first drink in the morning to get going during the past 12 months among past 12 month drinkers Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 706 654 1360 4.9 10.2 6.7 2.5–7.3 7.2–13.1 4.6–8.8 5.0 5.8 5.3 2.9–7.1 3.2–8.5 3.6–7.0 90.1 84.0 87.9 87.1–93.2 80.1–87.9 85.3–90.6 421 321 742 2.8 4.7 3.5 0.2–5.5 2.3–7.0 1.3–5.7 4.5 5.0 4.7 1.4–7.5 1.7–8.4 2.4–6.9 92.7 90.3 91.8 88.9–96.5 85.7–95.0 88.8–94.9 285 333 618 6.0 13.4 8.6 2.6–9.3 9.1–17.8 5.6–11.5 5.3 6.3 5.7 2.5–8.2 3.0–9.6 3.5–7.8 88.7 80.3 85.8 84.4–93.0 75.0–85.6 82.3–89.3 n % monthly or more frequently 95% CI % less than monthly 95% CI % never 95% CI

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Table 5.19: Frequency of family/partner problems due to someone else’s drinking during the past 12 months among all respondents Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1469 1350 2819 0.9 0.4 0.7 0.3–1.4 0.1–0.7 0.3–1.1 6.4 5.4 6.0 4.4–8.3 3.8–7.1 4.5–7.6 92.8 94.2 93.3 90.7–94.9 92.5–95.9 91.6–94.9 969 778 1747 1.2 0.8 1.0 0.4–2.1 0.1–1.4 0.5–1.6 7.1 3.9 6.0 4.0–10.1 1.9–5.9 3.8–8.1 91.7 95.4 93.0 88.6–94.8 93.3–97.4 90.7–95.2 500 572 1072 0.6 0.1 0.4 0.0–1.3 0.0–0.3 0.0–0.9 5.8 6.6 6.1 3.6–8.1 4.0–9.2 4.5–7.7 93.6 93.3 93.5 91.2–96.0 90.6–95.9 91.7–95.2 n % monthly or more frequently 95% CI % less than monthly 95% CI % never 95% CI

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Dietary habits Table 6.1: Mean number of days fruit and vegetables consumed in a typical week Age Group (years) Fruit 18–39 40–69 Residence Rural Urban Total Vegetables 18–39 40–69 Residence Rural Urban Total 774 297 1071 5.6 5.9 5.6 5.3–5.8 5.5–6.2 5.5–5.8 1174 571 1745 5.3 5.9 5.5 5.1–5.5 5.6–6.2 5.3–5.7 1948 868 2816 5.4 5.9 5.6 5.3–5.6 5.6–6.2 5.4–5.7 500 571 5.7 5.6 5.4–5.9 5.4–5.8 969 776 5.5 5.5 5.3–5.7 5.3–5.7 1469 1347 5.6 5.6 5.4–5.8 5.4–5.7 735 296 1031 1.2 2.4 1.6 1.0–1.5 2.0–2.9 1.4–1.8 1117 570 1687 1.6 2.6 1.9 1.3–1.8 2.3–2.9 1.7–2.1 1852 866 2718 1.4 2.5 1.7 1.2–1.6 2.2–2.8 1.5–1.9 487 544 1.7 1.4 1.4–2.0 1.2–1.6 942 745 2.0 1.7 1.8–2.3 1.4–2.0 1429 1289 1.8 1.5 1.6–2.0 1.3–1.7 Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Table 6.2: Mean number of servings of fruit and/or vegetables on average per day by sex, age and residence of respondents Age Group (years) Fruit 18–39 40–69 Residence Rural Urban Total Vegetables 18–39 40–69 774 297 4.2 3.4 3.7–4.8 2.9–4.0 1173 571 3.3 3.7 2.9–3.7 3.1–4.4 1947 868 3.9 3.6 3.4–4.3 3.0–4.1 735 296 1031 0.5 1.0 0.7 0.4–0.7 0.7–1.3 0.5–0.8 1114 569 1683 0.6 1.1 0.8 0.5–0.8 0.8–1.3 0.7–0.9 1849 865 2714 0.6 1.0 0.7 0.4–0.7 0.8–1.2 0.6–0.8 487 544 0.7 0.6 0.5–0.9 0.4–0.7 940 743 0.8 0.7 0.7–1.0 0.5–0.9 1427 1287 0.8 0.6 0.6–0.9 0.5–0.8 Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

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Age Group (years) Residence Rural Urban Total 18–39 40–69 Total Rural Urban Total

Men n Mean 95% CI n

Women Mean 95% CI n

Both Sexes Mean 95% CI

774 297 1071 500 571 1071 774 297 1071

4.2 3.4 4.0 4.6 4.7 4.6 4.7 4.4 4.6

3.7–4.8 2.9–4.0 3.5–4.4 4.0–5.1 4.2–5.3 4.1–5.1 4.1–5.3 3.7–5.1 4.1–5.1

1173 571 1744 969 777 1746 1175 571 1746

3.3 3.7 3.5 4.3 4.1 4.2 4.0 4.8 4.2

2.9–3.7 3.1–4.4 3.1–3.8 3.9–4.7 3.6–4.5 3.8–4.6 3.5–4.4 4.0–5.5 3.8–4.6

1947 868 2815 1469 1348 2817 1949 868 2817

3.9 3.6 3.8 4.5 4.4 4.5 4.4 4.6 4.5

3.4–4.3 3.0–4.1 3.4–4.1 4.0–4.9 4.0–4.9 4.1–4.8 3.9–4.9 4.0–5.2 4.1–4.8

Fruit and/or vegetables

Residence – Fruit and/or vegetables

Table 6.3: Number of servings of fruit and/or vegetables on average per day Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total 18–39 40–69 Total Both Sexes 1469 1348 2817 6.6 7.9 7.1 4.7–8.6 5.6–10.2 5.3–8.9 28.1 32.1 29.5 23.1–33.1 27.2–37.0 25.0–34.0 32.0 27.2 30.3 27.9–36.1 23.7–30.7 26.8–33.8 33.3 32.8 33.1 27.6–39.0 27.3–38.3 28.0–38.3 969 777 1746 5.9 10.7 7.6 3.6–8.3 7.3–14.1 5.4–9.7 30.9 34.4 32.1 25.7–36.1 29.3–39.5 27.8–36.5 32.0 25.8 29.9 28.0–36.0 22.1–29.6 26.5–33.2 31.2 29.1 30.4 25.3–37.1 23.5–34.7 25.3–35.6 500 571 1071 7.2 5.7 6.7 4.2–10.2 3.4–8.0 4.4–8.9 25.9 30.3 27.4 19.4–32.4 24.2–36.5 21.8–33.1 32.0 28.2 30.7 25.4–38.5 23.2–33.3 25.4–35.9 35.0 35.7 35.2 27.7–42.3 28.9–42.6 28.8–41.7 % no fruit and/or vegetables % 1–2 servings % 3–4 servings % ≥5 servings

n

95% CI

95% CI

95% CI

95% CI

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Table 6.4: Less than five servings of fruit and/or vegetables on average per day Age Group (years) 18–39 40–69 Residence Rural Urban Total 774 297 1071 63.1 68.8 64.8 54.8–71.3 59.8–77.7 58.3–71.2 1175 571 1746 71.3 66.1 69.6 65.3–77.3 56.6–75.7 64.4–74.7 1949 868 2817 66.6 67.5 66.9 59.9–73.2 59.8–75.3 61.7–72.0 Men n 500 571 % 65.0 64.3 95% CI 57.7–72.3 57.4–71.1 n 969 777 Women % 68.8 70.9 95% CI 62.9–74.7 65.3–76.5 n 1469 1348 Both Sexes % 66.7 67.2 95% CI 61.0–72.4 61.7–72.7

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Dietary salt Table 7.1: Salt consumption habits Age Group (years) 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Total 18–39 40–69 Rural Urban Total 769 297 1066 499 566 1065 497 567 769 295 1064 8.2 5.5 7.4 40.8 43.8 41.8 12.5 8.1 7.2 20.1 11.0 4.2–12.2 1.9–9.1 4.4–10.5 34.6–47.0 37.0–50.5 36.6–47.1 9.0–16.0 5.4–10.9 4.7-9.6 14.2-26.0 8.4-13.6 1169 570 1739 965 774 1739 961 771 1161 571 1732 7.8 9.2 8.3 43.9 36.6 41.4 15.0 4.1 8.0 17.4 11.2 5.2–10.4 5.7–12.7 6.2–10.4 38.1–49.8 31.4–41.8 36.6–46.2 12.2–17.7 2.0–6.2 5.4-10.7 14.1-20.7 9.1-13.3 1938 867 2805 1464 1340 2804 1458 1338 1930 866 2796 8.0 7.2 7.8 42.2 40.6 41.6 13.6 6.4 7.5 18.8 11.1 4.9–11.2 4.2–10.3 5.4–10.2 37.1–47.2 35.6–45.6 37.2–46.1 11.2–16.0 4.6–8.1 5.6-9.5 15.1-22.6 9.3-12.9 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Add salt always or often before eating or when eating 499 567 7.9 6.6 3.3–12.4 4.0–9.2 967 7h72 9.0 6.9 6.3–11.7 4.5–9.3 1466 1339 8.4 6.7 4.9–11.8 4.8–8.7

Add salt always or often when cooking or preparing food at home

Always or often consume processed food high in salt

Always or often consume processed food high in salt by Residence

Table 7.2: Percentage of people who think they consume far too much or too much salt Age Group (years) 18–39 40–69 Total Men n 496 565 1061 % 16.8 17.6 17.1 95% CI 13.5–20.2 13.6–21.5 14.5–19.7 n 956 764 1720 Women % 19.0 10.9 16.2 95% CI 15.7–22.2 7.9–13.9 13.8–18.5 n 1452 1329 2781 Both Sexes % 17.8 14.6 16.7 95% CI 15.4–20.1 12.0–17.3 14.9–18.5

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Table 7.3: Self-reported quantity of salt consumed Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1452 1329 2781 0.7 0.6 0.7 0.3–1.2 0.0–1.1 0.3–1.0 17.1 14.1 16.0 14.7–19.4 11.5–16.6 14.2–17.8 70.8 68.2 69.9 67.6–74.0 64.3–72.0 67.4–72.3 10.9 16.3 12.8 8.6–13.2 13.6–18.9 11.0–14.5 0.5 1.0 0.7 0.2–0.9 0.3–1.6 0.3–1.0 956 764 1720 0.8 0.4 0.7 0.3–1.4 0.0–1.1 0.2–1.1 18.2 10.4 15.5 15.0–21.4 7.7–13.2 13.2–17.8 69.4 69.4 69.4 65.1–73.7 64.8–73.9 66.1–72.6 10.9 18.6 13.6 8.6–13.2 14.9–22.3 11.5–15.7 0.8 1.2 0.9 0.2–1.3 0.3–2.2 0.4–1.4 496 565 1061 0.6 0.6 0.6 0.0–1.3 0.0–1.4 0.1–1.1 16.2 16.9 16.4 12.8–19.6 13.1–20.7 13.9–19.0 71.9 67.2 70.3 67.6–76.2 61.8–72.7 66.9–73.7 10.9 14.5 12.1 7.6–14.2 11.0–17.9 9.7–14.6 0.4 0.8 0.5 0.0–0.9 0.0–1.5 0.1–0.9 n % Far too much 95% CI % Too much 95% CI % Just the right amount 95% CI % Too little 95% CI % Far too little 95% CI

Table 7.4: Percentage of respondents who agree with the importance of lowering salt in diet Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1344 1226 2570 65.8 62.9 64.8 62.0–69.6 58.1–67.6 61.4–68.2 30.1 33.0 31.1 26.5–33.7 28.5–37.5 27.8–34.4 4.1 4.2 4.1 2.8–5.3 2.4–5.9 3.2–5.1 881 710 1591 63.0 62.7 62.9 58.5–67.5 56.9–68.4 59.0–66.8 32.3 33.2 32.6 28.1–36.5 28.1–38.4 29.1–36.2 4.7 4.1 4.5 2.9–6.4 2.1–6.1 3.1–5.8 463 516 979 67.9 63.0 66.2 62.7–73.1 57.0–69.0 61.7–70.8 28.5 32.8 29.9 23.6–33.4 26.7–38.9 25.4–34.5 3.6 4.2 3.8 1.8–5.5 1.8–6.7 2.4–5.3 n % Very important 95% CI % Somewhat important 95% CI % Not at all important 95% CI

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Table 7.5: Percentage of respondents who think that consuming too much salt could cause serious health problems Age Group (years) 18–39 40–69 Total Men n 455 506 961 % 91.6 92.5 91.9 95% CI 88.5–94.7 89.3–95.6 89.6–94.2 n 890 710 1600 Women % 93.6 89.7 92.3 95% CI 91.3–95.9 86.6–92.8 90.4–94.1 n 1345 1216 2561 Both Sexes % 92.5 91.2 92.1 95% CI 90.4–94.5 88.8–93.7 90.4–93.7

Table 7.6: Mean salt intake (g/day) by age, sex and residence Age Group (years) 18–39 40–69 Residence Rural Urban Total 736 282 1018 9.6 9.8 9.6 9.3-9.8 9.5-10.1 9.4-9.8 1084 516 1600 8.0 8.2 8.0 7.8-8.1 8.0-8.3 7.9-8.2 1820 798 2618 8.9 9.0 9.0 8.7-9.1 8.8-9.3 8.8-9.1 Men n 472 546 Mean 9.5 9.9 95% CI 9.2–9.8 9.7– 10.1 n 857 743 Women Mean 8.3 7.6 95% CI 8.1–8.4 7.4–7.8 n 1329 1289 Both Sexes Mean 9.0 8.9 95% CI 8.8–9.2 8.7–9.1

Table 7.7: Techniques used on a regular basis to reduce salt intake Age Group (years) 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Limit consumption of processed foods 500 572 1072 500 572 1072 500 572 1072 40.4 39.9 40.2 12.5 9.2 11.3 8.1 5.3 7.1 34.7–46.1 34.6–45.1 35.6–44.8 8.5–16.4 6.0–12.3 8.2–14.4 4.4–11.8 3.1–7.4 4.4–9.8 969 778 1747 969 778 1747 969 778 1747 39.6 41.9 40.4 9.0 3.8 7.2 8.4 6.3 7.7 35.3–43.9 36.4–47.4 36.6–44.2 6.6–11.4 2.2–5.3 5.5–8.9 5.7–11.2 3.8–8.9 5.6–9.8 1469 1350 2819 1469 1350 2819 1469 1350 2819 40.1 40.8 40.3 11.0 6.8 9.5 8.3 5.7 7.4 36.1–44.0 36.6–44.9 36.9–43.7 8.4–13.5 4.7–8.8 7.5–11.5 5.8–10.7 3.9–7.6 5.4–9.4

Look at the salt or sodium content on food labels

Buy low salt/sodium alternatives

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Age Group (years) 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total

Men n % 95% CI n

Women % 95% CI n

Both Sexes % 95% CI

Use spices other than salt when cooking 500 572 1072 500 572 1072 500 572 1072 13.2 10.9 12.4 28.0 26.2 27.4 8.9 12.7 10.3 8.8–17.7 7.4–14.4 8.9–16.0 22.2–33.9 21.8–30.7 23.0–31.8 5.1–12.8 8.7–16.8 7.1–13.4 969 778 1747 969 778 1747 969 778 1747 14.2 9.5 12.6 30.4 26.4 29.0 9.6 10.5 9.9 10.7–17.7 6.5–12.5 9.8–15.3 25.8–35.0 22.0–30.8 25.1–32.9 6.6–12.5 7.5–13.6 7.6–12.2 1469 1350 2819 1469 1350 2819 1469 1350 2819 13.6 10.3 12.5 29.1 26.3 28.1 9.2 11.7 10.1 10.1–17.2 7.6–13.0 9.6–15.3 24.9–33.3 22.8–29.9 24.7–31.6 6.5–12.0 8.8–14.6 7.7–12.5

Avoid eating foods prepared outside of a home

Do other things specifically to control your salt intake

Table 7.8: Type of oil or fat most often used for meal preparation in household n (households) 2819 % Vege­ table oil 97.1 95% CI 95.9–98.3 % Lard 0.0 95% CI 0.0–0.1 % Butter 2.3 95% CI 1.2–3.4 % Other 0.1 95% CI 0.0–0.3 % none in parti­ cular 0.4 95% CI 0.0–0.9

Table 7.9: Mean number of meals eaten outside a home Age Group (years) 18–39 40–69 Total Men n 494 555 1049 mean 1.0 1.0 1.0 95% CI 0.9–1.2 0.7–1.2 0.9–1.1 n 950 752 1702 Women mean 0.6 0.7 0.7 95% CI 0.5–0.8 0.5–0.9 0.5–0.8 n 1444 1307 2751 Both Sexes mean 0.9 0.8 0.9 95% CI 0.8–1.0 0.7–1.0 0.8–1.0

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Physical inactivity Table 8.1: Metabolic equivalent (MET) Domain Work Transport Recreation MET value Moderate MET value = 4.0 Vigorous MET value = 8.0 Cycling and walking MET value = 4.0 Moderate MET value = 4.0 Vigorous MET value = 8.0

Table 8.2: Not meeting WHO recommendations on physical activity for health Men n Age Group (years) 18–39 40–69 Residence Rural Urban Total 737 287 1024 1.9 8.4 3.8 0.9-2.9 5.0-11.8 2.5-5.0 1127 561 1688 4.9 18.6 9.6 2.8-7.0 12.4-24.8 6.8-12.4 1864 848 2712 3.2 13.2 6.4 2.2-4.2 9.0-17.4 4.7-8.0 486 538 3.5 4.5 2.0–5.0 2.6–6.5 938 750 10.1 8.7 7.0–13.1 5.4–11.9 1424 1288 6.4 6.4 4.6–8.1 4.4–8.3 % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Table 8.3: Level of total physical activity according to former recommendations Age Group (years) Men 18–39 40–69 Residence Rural Urban Total Women 18–39 40–69 Residence Rural Urban Total 1127 561 1688 12.8 24.1 16.6 9.8–15.8 17.2–31.0 13.4–19.9 9.9 17.3 12.4 7.5–12.4 13.3–21.4 10.2–14.7 77.3 58.6 70.9 72.9–81.7 50.0–67.1 66.5–75.4 938 750 16.8 16.3 13.1–20.5 12.4–20.1 13.9 9.7 11.0–16.8 7.0–12.5 69.3 74.0 64.3–74.3 68.8–79.1 737 287 1024 5.5 13.1 7.7 3.1–7.8 8.0–18.1 5.4–10.0 5.6 17.1 9.0 3.6–7.6 11.7–22.5 6.7–11.4 89.0 69.8 83.2 85.5–92.4 62.4–77.3 79.6–86.8 486 538 7.3 8.7 4.5–10.0 5.7–11.6 7.6 11.8 4.9–10.4 8.3–15.4 85.1 79.5 81.3–88.9 74.5–84.5 n % Low 95% CI % Moderate 95% CI % High 95% CI

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Age Group (years) Both Sexes 18–39 40–69 Residence Rural Urban Total

n

% Low

95% CI

% Moderate 10.4 10.9 7.4 17.2 10.5

95% CI

% High

95% CI

1424 1288 1864 848 2712

11.5 12.1 8.6 18.3 11.7

8.9–14.0 9.6–14.5 6.5–10.7 13.1–23.4 9.4–13.9

8.2–12.5 8.5–13.3 5.9–9.0 13.2–21.2 8.7–12.4

78.2 77.0 84.0 64.5 77.8

74.9–81.5 73.1–81.0 81.0–87.0 57.7–71.3 74.5–81.1

Table 8.4: Mean and median minutes of total physical activity on average per day Age Group (years) Men 18–39 40–69 Residence Rural Urban Total Women 18–39 40–69 Residence Rural Urban Total Both Sexes 18–39 40–69 Residence Rural Urban Total 1864 848 2712 – – 350.5 – – 330.0–371.0 390 180 330.0 344.3 312.9 377.1 1424 1288 346.9 357.5 322.0–371.8 335.5–379.4 312.9 351.4 377.1 374.3 1127 561 1688 – – 308.3 – – 283.9–332.8 347 180 274.3 360 325.7 377.1 938 750 294.4 334.8 265.9–323.0 306.0–363.6 250.7 317.1 360 361.4 737 287 1024 – – 383.7 – – 357.3–410.2 445.7 197.1 367.1 327.1 307.9 362.1 486 538 387.8 375.8 355.0–420.6 346.2–405.3 368.6 360.0 360.0 378.6 n Mean 95% CI Median Inter-quartile range (P25-P75)

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Table 8.5: Mean minutes spent in work-, transport- and recreation-related physical activity on average per day. Age Group (years) Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Work-related 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total 486 538 1024 486 538 1024 486 538 1024 287.7 304.6 293.4 63.1 59.4 61.8 37.1 11.7 28.5 255.1–320.2 275.2–334.1 266.7–320.1 51.2–74.9 41.8–77.0 49.9–73.7 29.6–44.5 7.7–15.7 22.9–34.1 938 750 1688 938 750 1688 938 750 1688 237.4 275.6 250.6 48.4 54.7 50.6 8.7 4.5 7.2 214.1–260.7 1424 251.4–299.7 1288 230.4–270.7 2712 37.3–59.4 42.9–66.5 41.1–60.0 5.5–11.9 1.8–7.3 5.0–9.5 1424 1288 2712 1424 1288 2712 265.7 291.7 274.5 56.6 57.3 56.9 24.6 8.5 19.1 242.1–289.2 270.5–312.8 255.0–294.1 47.4–65.8 45.2–69.4 47.8–65.9 20.0–29.2 5.7–11.3 15.6–22.7

Transport-related

Recreation-related

Table 8.6: Median minutes spent on average per day in work-, transport- and recreation-related physical activity Men Age Group (years) n Median Interquartile range (P25-P75) 394.3 394.3 411.4 85.7 68.6 77.1 51.4 0.0 39.3 n Women Median Interquartile range (P25-P75) 347.1 347.1 351.4 60.0 64.3 60.0 0.0 0.0 0.0 n Both Sexes Median Interquartile range (P25-P75) 368.6 394.3 385.7 60.0 64.3 60.0 25.7 0.0 8.6

Work-related 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total 486 538 1024 486 538 1024 486 538 1024 257.1 300.0 274.3 25.7 20.0 25.7 0.0 0.0 0.0 938 750 1688 938 750 1688 938 750 1688 180.0 257.1 210 17.1 17.1 17.1 0.0 0.0 0.0 1424 1288 2712 1424 1288 2712 1424 1288 2712 231.4 278.6 240.0 20.0 17.1 20.0 0.0 0.0 0.0

Transport-related

Recreation-related

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Table 8.7: Percentage of respondents classified as doing no work-, transport- or recreational-related physical activity. Age Group (years) Men n 486 538 1024 486 538 1024 486 538 1024 % 12.4 11.4 12.1 35.7 38.6 36.6 52.7 78.7 61.5 95% CI 8.5–16.3 7.1–15.6 9.0–15.2 28.6–42.7 31.8–45.3 30.5–42.7 45.2–60.2 73.0–84.4 55.1–67.8 n 938 750 1688 938 750 1688 938 750 1688 Women % 16.9 14.5 16.0 39.8 41.2 40.3 86.3 94.1 89.0 95% CI 12.9–20.8 10.4–18.5 12.7–19.4 33.9–45.7 35.1–47.4 35.2–45.4 82.9–89.7 91.8–96.4 86.5–91.5 n 1424 1288 2712 1424 1288 2712 1424 1288 2712 Both Sexes % 14.4 12.7 13.8 37.5 39.8 38.3 67.4 85.6 73.6 95% CI 11.6–17.1 9.7–15.8 11.5–16.1 31.9–43.1 34.1–45.4 33.2–43.4 62.6–72.3 81.9–89.2 69.5–77.7

No work-related physical activity 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total

No transport-related physical activity

No recreation-related physical activity

Table 8.8: Percentage of work, transport and recreational activity contributing to total activity. Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1355 1231 2586 68.4 75.5 70.8 64.7–72.1 71.9–79.2 67.6–74.1 20.7 19.6 20.3 17.8–23.6 16.5–22.7 17.9–22.8 10.9 4.9 8.9 8.5–13.3 3.3–6.5 6.9–10.8 877 710 1587 72.8 77.3 74.3 68.7–76.8 73.8–80.7 71.1–77.6 23.2 21.3 22.5 19.3–27.1 17.8–24.7 19.4–25.6 4.1 1.4 3.2 2.8–5.3 0.6–2.3 2.3–4.0 478 521 999 65.2 74.2 68.2 60.5–69.9 69.2–79.2 63.9–72.5 18.9 18.3 18.7 15.6–22.1 14.3–22.3 15.7–21.6 16.0 7.5 13.1 12.3–19.7 4.9–10.1 10.1–16.2 % Activity from work % Activity for transport % Activity during leisure time

n

95% CI

95% CI

95% CI

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Table 8.9: Percentage of respondents not engaging in vigorous physical activity. Age Group (years) 18–39 40–69 Residence Rural Urban Total 737 287 1024 27.9 52.4 35.2 22.4–33.4 44.6–60.3 30.3–40.2 1127 561 1688 54.5 88.5 66.0 49.0–60.1 84.0–92.9 61.2–70.9 1864 848 2712 39.2 69.4 48.8 34.8–43.7 63.2–75.6 44.6–53.1 Men n 486 538 % 31.2 43.3 95% CI 25.8–36.6 36.8–49.8 n 938 750 Women % 68.1 62.0 95% CI 63.3–73.0 56.7–67.3 n 1424 1288 Both Sexes % 47.4 51.6 95% CI 42.9–51.9 46.9–56.3

Table 8.10: Minutes spent in sedentary activities on average per day Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total 1469 1350 2819 153.9 136.9 148.0 142.8–165.0 128.9–144.8 139.3–156.6 120.0 120.0 120.0 120.0 120.0 120.0 969 778 1747 173.5 140.0 161.9 158.2–188.9 130.8–149.3 150.3–173.5 120.0 120.0 120.0 140.0 120.0 120.0 500 572 1072 138.4 134.4 137.0 127.0–149.9 123.4–145.4 127.8–146.3 120.0 120.0 120.0 120.0 120.0 120.0 n Mean minutes 95% CI Median minutes Inter-quartile range (P25-P75)

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Blood pressure Table 9.1: Blood pressure measurement and diagnosis % measu­ red, not diag­ nosed 51.8 45.9 49.7 61.6 43.5 55.3 56.1 44.9 52.2 % diag­ nosed, but not within past 12 months 2.5 6.6 3.9 5.6 7.0 6.1 3.9 6.8 4.9 % diag­ nosed within past 12 months

Age Group (years)

n

% Never measured

95% CI

95% CI

95% CI

95% CI

Men 18–39 40–69 Total Women 18–39 40–69 Total Both sexes 18–39 40–69 Total 1469 1350 2819 32.8 28.5 31.3 28.2–37.3 24.4–32.5 27.7–34.8 51.7–60.4 40.9–48.8 48.6–55.7 2.8–5.0 4.7–8.8 3.8–6.0 7.3 19.9 11.7 5.6–9.0 16.9–22.9 10.1–13.3 969 778 1747 23.7 23.7 23.7 19.6–27.9 19.2–28.3 20.6–26.9 57.3–65.8 38.8–48.2 51.8–58.8 4.0–7.3 3.9–10.1 4.6–7.6 9.1 25.8 14.9 6.7–11.4 21.5–30.0 12.7–17.1 500 572 1072 39.9 32.2 37.2 33.3–46.5 26.7–37.6 32.0–42.4 45.1–58.4 40.4–51.5 44.5–55.0 1.0–4.1 3.9–9.3 2.4–5.5 5.9 15.3 9.1 3.4–8.4 11.5–19.1 7.1–11.2

Table 9.2: Currently taking drugs (medication) for raised blood pressure prescribed by doctor or health worker among those diagnosed Age Group (years) 18–39 40–69 Total Men n 52 122 174 % 13.5 38.0 27.8 95% CI 2.1–24.9 26.7–49.3 18.8–36.8 n 152 240 392 Women % 8.8 46.5 29.3 95% CI 4.4–13.3 38.0–55.0 23.7–34.9 n 204 362 566 Both Sexes % 10.8 42.6 28.6 95% CI 5.3–16.2 35.5–49.7 23.5–33.8

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Table 9.3: Percentage of previously diagnosed hypertensive respondents who have visited or received treatment from a traditional healer Age Group (years) 18–39 40–69 Total 18–39 40–69 Total Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Seen a traditional healer 52 122 174 52 122 174 2.5 12.9 8.6 0.3 8.6 5.1 0.0–6.0 6.1–19.7 4.3–12.8 0.0–1.0 1.8–15.4 1.0–9.3 152 240 392 152 240 392 3.6 15.4 10.0 1.3 4.8 3.2 0.4–6.8 7.3–23.5 5.2–14.9 0.0–3.3 1.4–8.2 1.1–5.3 204 362 566 204 362 566 3.2 14.3 9.4 0.9 6.5 4.1 0.9–5.5 9.1–19.4 6.3–12.5 0.0–2.1 2.6–10.4 1.7–6.4

Currently taking herbal or traditional remedy for raised blood pressure

Physical Measurements Table 9.4: Mean blood pressure among all respondents, including those currently on medication for raised blood pressure. Age Group (years) 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total 774 297 1071 84.8 84.2 84.6 83.3–86.3 82.0–86.3 83.4–85.9 1176 569 1745 86.3 83.7 85.4 85.1–87.4 82.3–85.1 84.5–86.3 1950 866 2816 85.4 84.0 85.0 84.2–86.6 82.7–85.2 84.0–85.9 774 297 1071 499 572 128.1 127.7 128.0 82.5 88.7 126.5–129.8 125.0–130.3 126.6–129.4 81.1–83.9 87.2–90.2 1176 569 1745 968 777 125.5 120.6 123.8 82.3 91.2 123.8–127.1 118.6–122.5 122.5–125.1 81.4–83.2 89.8–92.5 1950 866 2816 1467 1349 127.0 124.3 126.2 82.4 89.8 125.6–128.4 122.9–125.8 125.1–127.2 81.5–83.4 88.6–90.9 Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Mean systolic blood pressure (mmHg) 499 572 125.1 133.4 123.7–126.5 131.1–135.6 968 777 117.9 135.0 116.8–118.9 132.8–137.2 1467 1349 121.9 134.1 120.9–122.9 132.4–135.8

Mean diastolic blood pressure (mmHg)

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Table 9.5: Percentage of respondents with raised blood pressure. Age Group (years) 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total 774 297 1071 13.7 12.3 13.3 10.1–17.3 7.7–16.8 10.4–16.2 1176 569 1745 16.8 13.8 15.8 13.8–19.7 9.7–17.8 13.4–18.2 1950 866 2816 15.0 13.0 14.4 12.3–17.8 10.1–15.8 12.3–16.5 747 286 1033 499 572 11.2 9.4 10.6 7.9 23.4 7.9–14.4 5.0–13.7 8.0–13.3 4.6–11.2 19.2–27.5 1096 531 1627 968 777 11.8 8.0 10.5 6.9 32.3 9.2–14.4 5.1–10.9 8.5–12.5 5.2–8.7 27.7–37.0 1843 817 2660 1467 1349 11.4 8.7 10.6 7.5 27.3 9.0–13.8 6.1–11.4 8.7–12.4 5.4–9.6 24.1–30.5 774 297 1071 494 539 33.5 40.4 35.5 7.2 17.5 29.0–37.9 32.0–48.9 31.5–39.6 4.0–10.3 13.6–21.5 1176 569 1745 952 675 39.1 29.7 35.9 5.8 20.8 34.5–43.6 25.2–34.2 32.5–39.4 4.2–7.4 16.7–24.9 1950 866 2816 1446 1214 35.9 35.4 35.7 6.6 18.9 32.2–39.5 30.7–40.0 32.8–38.6 4.6–8.6 15.9–21.9 747 286 1033 499 572 31.5 38.4 33.6 28.8 48.1 27.0–35.9 29.9–47.0 29.5–37.6 24.1–33.6 43.1–53.2 1096 531 1627 968 777 35.4 25.0 32.0 23.2 59.8 31.0–39.9 20.7–29.2 28.6–35.4 19.5–26.8 55.1–64.5 1843 817 2660 1467 1349 33.1 32.2 32.9 26.3 53.3 29.6–36.7 27.2–37.3 30.0–35.8 23.0–29.7 49.6–56.9 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

SBP >140 and/or DBP > 90 mmHg, excluding those on medication for raised blood pressure 494 539 28.3 44.2 23.5–33.0 39.0–49.4 952 675 22.3 53.0 18.7–25.9 47.9–58.1 1446 1214 25.6 47.9 22.3–29.0 44.0–51.7

SBP >140 and/or DBP > 90 mmHg or currently on medication for raised blood pressure

SBP >160 and/or DBP > 100 mmHg, excluding those on medication for raised blood pressure

SBP >160 and/or DBP > 100 mmHg or currently on medication for raised blood pressure

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Table 9.6: Percentage of respondents with treated and/or controlled of raised blood pressure among those with raised blood pressure(SBP >140 and/or DBP > 90 mmHg) or currently on medication for raised blood pressure. % On medication and SBP<140 and DBP<90 % On medication and SBP>140 and/or DBP>90 % Not on medication and SBP>140 and/or DBP>90 97.2 85.3 91.6 94.9 75.6 83.7 96.3 80.5 88.1

Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both Sexes 18–39 40–69 Total

n

95% CI

95% CI

95% CI

147 276 423 234 444 678 381 720 1101

1.5 3.3 2.3 0.5 4.8 3.0 1.1 4.0 2.6

0.0–3.5 1.2–5.4 0.9–3.8 0.0–1.3 2.3–7.3 1.5–4.5 0.0–2.4 2.5–5.6 1.6–3.7

1.3 11.4 6.1 4.5 19.6 13.3 2.5 15.5 9.2

0.0–3.0 6.5–16.4 3.5–8.6 1.8–7.2 14.9–24.3 10.2–16.3 1.1–4.0 12.1–18.8 7.4–11.1

94.6–99.9 79.9–90.7 88.7–94.5 92.2–97.7 69.8–81.4 80.0–87.5 94.4–98.3 76.6–84.4 85.9–90.4

Table 9.7: Mean heart rate (beats per minute) of respondents by sex and age Age Group (years) 18–39 40–69 Total Men n 499 572 1071 mean 71.4 72.5 71.8 95% CI 70.1–72.6 71.3–73.8 70.8–72.7 n 968 777 1745 Women mean 76.8 75.4 76.4 95% CI 75.9–77.8 74.2–76.6 75.5–77.2 n 1467 1349 2816 Both Sexes mean 73.8 73.8 73.8 95% CI 72.9–74.6 72.8–74.8 73.1–74.5

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Blood glucose Table 10.1: Blood sugar measurement and diagnosis Age Group (years) Men 18–39 40–69 500 572 89.3 80.5 86.1–92.4 76.8–84.2 10.4 16.0 7.3–13.5 12.6–19.4 0.0 0.9 0.0–0.0 0.1–1.6 0.3 2.6 0.0–1.0 1.1–4.2 n % Never measured 95% CI % measured, not diagnosed 95% CI % diagnosed, but not within past 12 months 95% CI % diagnosed within past 12 months 95% CI

Total Women 18–39 40–69

1072 969 778

86.2 85.6 76.6

83.7–88.8 82.5–88.6 72.2–81.0

12.3 13.7 19.1

9.8–14.9 10.7–16.8 15.2–22.9

0.3 0.1 1.1

0.0–0.6 0.0–0.4 0.0–2.3

1.1 0.6 3.2

0.4–1.8 0.0–1.2 1.5–4.9

Total 18–39 40–69

1747 1469 1350

82.4 87.6 78.8

79.9–85.0 85.5–89.8 75.7–81.8

15.6 11.9 17.4

13.1–18.1 9.7–14.0 14.7–20.0

0.5 0.1 1.0

0.0–0.9 0.0–0.2 0.3–1.6

1.5 0.4 2.9

0.8–2.2 0.0–0.9 1.7–4.0

Both sexes

Total

2819

84.6

82.7–86.4

13.8

12.0–15.6

0.4

0.1–0.6

1.3

0.8–1.8

Table 10.2: Percentage of respondents currently taking oral medication and insulin prescribed for diabetes among those previously diagnosed: Both Sexes Age Group (years) Taking oral drugs 18–69 Taking insulin 18–69 59 4.8 0.0–10.4 59 35.0 18.6–51.5 Both Sexes n % 95% CI

Table 10.3: Percentage of respondents who have sought advise or treatment from a traditional healer for diabetes among those previously diagnosed: Both Sexes Age Group (years) 18–69 Both Sexes n 59 % seen trad. healer 11.5 95% CI 0.6–22.5 % taking trad. meds 2.4 95% CI 0.0–7.2

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Table 10.4: Mean fasting blood glucose results including those currently on medication for diabetes (non–fasting recipients excluded) by sex, age and residence Age Group (years) 18–39 40–69 Total 18–39 40–69 Rural Urban Total Men n Mean 95% CI n Women Mean 95% CI n Both Sexes Mean 95% CI

Mean fasting blood glucose (mmol/L) 484 553 1037 484 553 752 285 1037 4.8 5.1 4.9 86.7 92.5 88.4 89.3 88.7 4.7–4.9 5.0–5.3 4.8–5.0 84.5–88.8 89.6–95.4 86.2-90.6 86.4-92.2 86.9-90.5 935 752 1687 935 752 1135 552 1687 4.8 5.1 4.9 87.0 92.5 88.7 89.2 88.9 4.7–4.9 5.0–5.3 4.9–5.0 85.4–88.5 90.0–95.0 87.1-90.4 86.1-92.3 87.4-90.4 1419 1305 2724 1419 1305 1887 837 2724 4.8 5.1 4.9 86.8 92.5 88.6 89.3 88.8 4.7–4.9 5.0–5.3 4.9–5.0 85.3–88.3 90.3–94.7 86.8-90.3 86.7-91.8 87.4-90.2

Mean fasting blood glucose (mg/dl)

Mean fasting blood glucose (mg/dl), by residence 

Table 10.5: Categorization of respondents into blood glucose level categories and percentage of respondents currently on medication for raised blood glucose (non–fasting recipients excluded) by sex and age Age Group (years) Men n 484 553 752 285 1037 484 553 752 285 1037 % 10.2 13.5 11.3 11.4 11.4 4.9 9.6 5.3 9.5 6.5 95% CI 6.7–13.7 9.3–17.8 7.4–15.3 6.4–16.4 8.2–14.5 2.5–7.3 6.2–13.0 3.1–7.6 5.7–13.3 4.6–8.5 n 935 752 1135 552 1687 935 752 1135 552 1687 Women % 8.5 12.7 9.7 10.5 10.0 3.4 11.7 5.7 7.5 6.3 95% CI 6.1–10.8 9.7–15.8 7.3–12.1 6.7–14.4 7.9–12.0 2.0–4.8 8.1–15.4 4.0–7.4 4.1–11.0 4.7–7.9 n 1419 1305 1887 837 2724 1419 1305 1887 837 2724 Both Sexes % 9.4 13.2 10.6 11.0 10.7 4.3 10.5 5.5 8.5 6.4 95% CI 7.1–11.8 10.3–16.1 8.0–13.3 7.7–14.3 8.6–12.9 2.7–5.8 7.9–13.1 3.9–7.1 5.8–11.3 5.0–7.8

Impaired Fasting Glycaemia* 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total

Raised blood glucose or currently on medication for diabetes**

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Age Group (years)

Men n 500 574 775 299 1074 % 0.0 1.1 0.1 0.9 0.4 95% CI 0.0–0.0 0.0–2.2 0.0–0.4 0.0–2.2 0.0–0.8 n 969 779 1177 571 1748

Women % 0.1 2.3 0.5 1.7 0.9 95% CI 0.0–0.2 1.0–3.7 0.0–0.9 0.4–2.9 0.4–1.3 n 1469 1353 1952 870 2822

Both Sexes % 0.0 1.6 0.3 1.3 0.6 95% CI 0.0–0.1 0.7–2.5 0.0–0.5 0.4–2.2 0.3–0.9

Currently on medication for diabetes 18–39 40–69 Residence Rural Urban Total

* Impaired fasting glycaemia is defined as either • plasma venous value: =6.1mmol/L (110mg/dl) and <7.0mmol/L (126mg/dl) • capillary whole blood value: =5.6mmol/L (100mg/dl) and <6.1mmol/L (110mg/dl) • plasma venous value: = 7.0 mmol/L (126 mg/dl) • capillary whole blood value: = 6.1 mmol/L (110 mg/dl)

** Raised blood glucose is defined as either

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Abnormal lipids Table 11.1: Mean total cholesterol among respondents including those currently on medication for raised cholesterol Age Group (years) Men n 489 560 1049 489 560 762 287 1049 Mean 3.6 3.9 3.7 139.8 152.2 143.8 144.9 144.1 95% CI 3.5–3.7 3.8–4.1 3.6–3.8 135.3–144.2 147.8–156.7 139.3–148.2 137.8–152.1 140.3–147.9 n 945 767 1712 945 767 1153 559 1712 Women Mean 3.7 4.2 3.8 142.1 161.0 147.8 150.5 148.7 95% CI 3.6–3.8 4.1–4.3 3.8–3.9 138.6–145.6 157.3–164.8 144.5–151.2 146.1–154.8 146.0–151.4 n 1434 1327 2761 1434 1327 1915 846 2761 Both Sexes Mean 3.6 4.0 3.8 140.8 156.1 145.5 147.6 146.1 95% CI 3.6–3.7 4.0–4.1 3.7–3.8 137.6–144.0 152.9–159.4 142.1–148.9 143.2–151.9 143.4–148.9

Mean total cholesterol (mmol/L) 18–39 40–69 Total 18–39 40–69 Residence Rural Urban Total

Mean total cholesterol (mg/dl)

Table 11.2: Percentage of respondents with raised total cholesterol or on medication for raised cholesterol by sex and age Age Group (years) Men N 489 560 762 287 1049 489 560 762 287 1049 % 9.2 16.9 11.8 12.0 11.9 0.9 2.6 1.3 1.9 1.5 95% CI 6.0–12.4 13.2–20.6 8.5–15.1 6.9–17.2 9.1–14.7 0.1–1.7 0.9–4.3 0.5–2.1 0.1–3.7 0.7–2.3 n 945 767 1153 559 1712 945 767 1153 559 1712 Women % 9.0 21.2 13.2 13.5 13.3 2.3 3.6 2.5 3.2 2.8 95% CI 6.8–11.3 17.4–25.0 10.7–15.7 10.3–16.7 11.3–15.3 0.9–3.7 1.9–5.3 1.1–3.9 1.7–4.8 1.7–3.8 n 1434 1327 1915 846 2761 1434 1327 1915 846 2761 Both Sexes % 9.1 18.8 12.4 12.7 12.5 1.5 3.0 1.8 2.5 2.0 95% CI 6.9–11.3 16.0–21.6 10.0–14.8 9.6–15.9 10.6–14.4 0.8–2.3 1.8–4.2 1.0–2.6 1.4–3.7 1.4–2.7

Total cholesterol > 5.0 mmol/L or > 190 mg/dl or currently on medication for raised cholesterol 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total

Total cholesterol > 6.2 mmol/L or > 240 mg/dl or currently on medication

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Table 11.3: Total cholesterol measurement and diagnosis among respondents in last 12 month by sex and age. Age Group (years) Men 18–39 40–69 Total Women 18–39 40–69 Total Both sexes 18–39 40–69 Total 1469 1350 2819 97.1 96.3 96.8 95.7–98.5 95.0–97.7 95.8–97.8 2.7 2.1 2.5 1.3–4.1 1.2–3.0 1.5–3.5 0.0 0.4 0.2 0.0–0.1 0.0–0.9 0.0–0.3 0.2 1.2 0.5 0.0–0.4 0.5–1.9 0.3–0.8 969 778 1747 98.0 96.2 97.4 96.9–99.1 94.6–97.9 96.5–98.3 1.6 2.1 1.8 0.6–2.7 0.9–3.2 1.0–2.6 0.1 0.6 0.2 0.0–0.2 0.0–1.5 0.0–0.6 0.3 1.1 0.6 0.0–0.7 0.1–2.1 0.1–1.0 500 572 1072 96.3 96.4 96.3 93.9–98.7 94.8–98.0 94.7–98.0 3.5 2.2 3.1 1.2–5.9 0.9–3.4 1.5–4.7 0.0 0.2 0.1 0.0–0.0 0.0–0.7 0.0–0.3 0.1 1.2 0.5 0.0–0.4 0.2–2.2 0.1–0.9 % Never measured % measured, not diagnosed % diagnosed, but not within past 12 months % diagnosed within past 12 months

n

95% CI

95% CI

95% CI

95% CI

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Combined risk factors and cardiovascular disease risk prediction

Table 12.1: Summary of Combined Risk Factors Age Group (years) Men 18–39 40–69 Residence Rural Urban Total Women 18–39 40–69 Residence Rural Urban Total Both Sexes 18–39 40–69 Residence Rural Urban Total 1819 815 2634 14.2 9.6 12.7 10.8–17.5 6.8–12.4 10.2–15.2 76.4 68.0 73.7 73.2–79.5 64.6–71.4 71.3–76.1 9.5 22.4 13.5 7.7–11.2 18.9–25.8 11.8–15.3 1358 1276 14.6 9.1 11.4–17.9 6.9–11.3 74.7 72.0 71.2–78.1 68.8–75.1 10.7 18.9 8.6–12.8 15.7–22.2 1086 529 1615 8.8 10.3 9.3 6.3–11.3 7.1–13.5 7.3–11.3 77.5 67.0 74.0 74.3–80.8 61.7–72.4 71.0–77.0 13.7 22.7 16.7 11.0–16.4 17.9–27.5 14.1–19.2 874 741 11.9 4.6 9.1–14.7 2.5–6.7 75.8 70.8 72.1–79.5 66.0–75.6 12.3 24.6 9.6–15.0 19.9–29.3 733 286 1019 18.0 9.0 15.3 13.0–23.0 4.7–13.3 11.4–19.2 75.5 68.8 73.5 70.9–80.2 63.6–74.1 69.9–77.1 6.5 22.2 11.2 4.2–8.7 17.6–26.7 8.6–13.7 484 535 16.6 12.7 11.5–21.8 9.4–15.9 73.8 72.9 68.7–79.0 69.0–76.8 9.5 14.4 6.6–12.5 10.7–18.1 n % with 0 risk factors 95% CI % with 1–2 risk factors 95% CI % with 3–5 risk factors 95% CI

Table 12.2: Percentage of respondents having ever had a heart attack or chest pain from heart disease or a stroke, by age and sex Age Group (years) 18–39 40–69 Total Men n 500 572 1072 % 0.8 0.8 0.8 95% CI 0.0–2.2 0.0–1.7 0.0–1.8 n 969 778 1747 Women % 0.9 0.8 0.9 95% CI 0.0–1.9 0.0–1.7 0.2–1.6 n 1469 1350 2819 Both Sexes % 0.8 0.8 0.8 95% CI 0.0–1.8 0.2–1.4 0.2–1.5

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Table 12.3: Percentage of respondents currently taking asprin/statins regularly to prevent or treat heart disease Age Group (years) Taking aspirin 18–39 40–69 Total Taking statins 18–39 40–69 Total 500 572 1072 0.0 0.1 0.0 0.0–0.0 0.0–0.3 0.0–0.1 778 1747 1742 0.0 0.5 0.2 0.0–0.0 0.0–1.0 0.0–0.4 1469 1350 2819 0.0 0.3 0.1 0.0–0.0 0.0–0.5 0.0–0.2 500 572 1072 0.0 0.4 0.1 0.0–0.0 0.0–0.9 0.0–0.3 969 778 1747 0.0 0.1 0.0 0.0–0.0 0.0–0.2 0.0–0.1 1469 1350 2819 0.0 0.2 0.1 0.0–0.0 0.0–0.6 0.0–0.2 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Table 12.4: Percentage of respondents aged 40–69 years with a 10–year cardiovascular disease (CVD) risk >30% or with existing CVD Age Group (years) 40–54 55–69 Residence Rural Urban Total 438 113 551 1.1 3.2 1.5 0.0–2.2 0.0–6.7 0.4–2.7 580 169 749 1.8 3.3 2.2 0.5–3.1 0.6–6.1 1.0–3.4 1018 282 1300 1.4 3.3 1.8 0.6–2.2 1.1–5.5 1.0–2.6 Men n 354 197 % 0.6 3.2 95% CI 0.0–1.5 0.4–6.0 n 509 240 Women % 1.6 3.1 95% CI 0.2–3.1 0.9–5.3 n 863 437 Both Sexes % 1.1 3.2 95% CI 0.2–1.9 1.4–5.0

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Lifestyle advice by health care provider Table 13.1: Percentage of respondents who received lifestyle advice from a doctor or health worker during the past three months among all respondents. Age Group (years) Men n % advised 95% CI n Women % advised 95% CI n Both Sexes % advised 95% CI

Advised by doctor or health worker to quit using tobacco or don’t start 18–39 40–69 Total 500 572 1072 42.9 49.8 45.3 37.0–48.7 43.5–56.1 40.2–50.3 969 778 1747 34.8 44.0 38.0 30.3–39.3 39.3–48.8 34.3–41.8 1469 1350 2819 39.3 47.3 42.1 35.2–43.4 42.9–51.7 38.5–45.6

Advised by doctor or health worker to reduce salt in the diet 18–39 40–69 Total 500 572 1072 43.1 59.1 48.7 37.3–49.0 53.5–64.8 44.0–53.4 969 778 1747 46.5 60.3 51.3 42.1–51.0 54.6–66.0 47.4–55.3 1469 1350 2819 44.6 59.6 49.8 40.4–48.9 55.2–64.0 46.4–53.3

Advised by doctor or health worker to eat at least five servings of fruit and/or vegetables each day 18–39 40–69 Total 500 572 1072 52.4 61.8 55.6 45.7–59.0 56.1–67.4 50.1–61.2 969 778 1747 57.7 55.3 56.9 53.0–62.4 50.3–60.3 53.0–60.7 1469 1350 2819 54.7 58.9 56.2 49.7–59.7 54.7–63.2 52.0–60.4

Advised by doctor or health worker to reduce fat in the diet 18–39 40–69 Total 500 572 1072 48.8 61.5 53.2 42.8–54.8 55.7–67.3 48.0–58.4 969 778 1747 49.0 58.9 52.5 44.4–53.7 53.6–64.2 48.5–56.4 1469 1350 2819 48.9 60.3 52.9 44.4–53.5 55.8–64.9 48.9–56.8

Advised by doctor or health worker to start or do more physical activity 18–39 40–69 Total 500 572 1072 43.8 46.3 44.7 36.9–50.7 40.3–52.4 38.9–50.5 969 778 1747 36.1 38.3 36.9 31.7–40.6 33.4–43.2 33.3–40.5 1469 1350 2819 40.4 42.8 41.3 35.5–45.3 38.3–47.3 37.1–45.4

Advised by doctor or health worker to maintain a healthy body weight or to lose weight 18–39 40–69 Total 500 572 1072 32.9 35.2 33.7 25.7–40.2 29.3–41.1 27.7–39.8 969 778 1747 27.6 30.7 28.7 23.9–31.3 25.8–35.5 25.4–32.0 1469 1350 2819 30.6 33.2 31.5 25.8–35.4 29.0–37.4 27.5–35.6

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Table 13.2: Percentage of female respondents who have ever had a screening test for cervical cancer among all female respondents. Age Group (years) 18–39 40–69 Residence Rural Urban Total Residence (30–49) Rural Urban Total 602 291 893 59.5 73.2 64.1 52.8–66.2 65.6–80.7 59.0–69.2 1146 567 1713 48.3 55.4 50.7 43.8–52.9 49.3–61.5 47.0–54.4 Women n 956 757 % ever tested 51.5 49.2 95% CI 47.0–56.0 43.5–54.8

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Mental health Table 14.1: Percentage of respondents who seriously considered attempting suicide in the last 12 months among all respondents. Age Group (years) 18–39 40–69 Total Men n 500 571 1071 % 1.0 0.9 0.9 95% CI 0.1–1.9 0.0–1.9 0.3–1.6 n 968 778 1746 Women % 5.0 2.7 4.2 95% CI 2.5–7.5 1.3–4.1 2.5–5.9 n 1468 1349 2817 Both Sexes % 2.7 1.7 2.4 95% CI 1.5–4.0 0.9–2.5 1.5–3.2

Table 14.2: Percentage of respondents who sought professional help among those who considered attempting suicide in the past 12 months. Age Group (years) 18–39 40–69 Total Men n 6 4 10 % 35.7 0.0 24.0 95% CI 0.0–96.9 0.0–0.0 0.0–69.0 n 35 18 53 Women % 21.4 2.9 17.5 95% CI 0.0–44.1 0.0–8.8 0.0–36.6 n 41 22 63 Both Sexes % 24.3 2.0 18.9 95% CI 4.5–44.0 0.0–6.1 2.7–35.1

Table 14.3: Percentage of respondents who made a plan about how to attempt suicide in the past 12 months. Age Group (years) 18–39 40–69 Total Men n 500 571 1071 % 0.2 0.1 0.2 95% CI 0.0–0.6 0.0–0.4 0.0–0.4 n 968 777 1745 Women % 3.5 1.1 2.7 95% CI 1.2–5.9 0.2–1.9 1.1–4.2 n 1468 1348 2816 Both Sexes % 1.7 0.5 1.3 95% CI 0.6–2.8 0.1–0.9 0.6–2.0

Table 14.4: Percentage of respondents who have ever attempted suicide among all respondents. Age Group (years) 18–39 40–69 Total Men n 499 571 1070 % 0.0 0.0 0.0 95% CI 0.0–0.0 0.0–0.0 0.0–0.0 n 968 778 1746 Women % 2.1 0.0 1.4 95% CI 0.9–3.3 0.0–0.0 0.6–2.2 n 1467 1349 2816 Both Sexes % 0.9 0.0 0.6 95% CI 0.4–1.5 0.0–0.0 0.3–1.0

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Table 14.5: Percentage of respondents who have attempted suicide in the past 12 months among those who have ever attempted suicide. Age Group (years) 18–29 60–69 Total Men n – – – % – – – 95% CI – – – n 22 – 22 Women % 37.7 – 37.7 95% CI 10.2–65.2 – 10.2–65.2 n 22 – 22 Both Sexes % 37.7 – 37.7 95% CI 10.2–65.2 – 10.2–65.2

Table 14.6: Percentage of different methods used the last time suicide was attempted among those respondents who have ever attempted suicide:Women. Age Group (years) 18–39 40–69 Total n % razor, knife or other sharp instrument 9.1 – 9.1 95% CI % overdose of medication 27.3 – 27.3 95% CI % poisoning with pesticides 28.1 – 28.1 95% CI % other poisoning 5.9 – 5.9 95% CI % other 29.7 – 29.7 95% CI

21 – 21

0.0–19.9 – 0.0–19.9

4.4–50.2 – 4.4–50.2

0.0–58.6 – 0.0–58.6

0.0–17.1 – 0.0–17.1

3.5–56.0 – 3.5–56.0

Table 14.7: Percentage of respondents who sought medical care the last time they attempted suicide among those who have ever attempted suicide. Age Group (years) 18–39 40–69 Total Men n – – – % – – – 95% CI – – – n 22 – 22 Women % 26.7 – 26.7 95% CI 1.5–51.9 – 1.5–51.9 n 22 – 22 Both Sexes % 26.7 – 26.7 95% CI 1.5–51.9 – 1.5–51.9

Table 14.8: Percentage of respondents who were admitted to the hospital due to the last time they attempted suicide among those who sought medical care for having ever attempted suicide. Age Group (years) 18–39 40–69 Total Men n – – – % – – – 95% CI – – – n 4 – 4 Women % 91.4 – 91.4 95% CI 76.7–100.0 – 76.7–100.0 n 4 – 4 Both Sexes % 91.4 – 91.4 95% CI 76.7–100.0 – 76.7–100.0

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Table 14.9: Percentage of respondents who have ever had anyone in their close family attempt suicide. Age Group (years) 18–39 40–69 Total Men n 500 571 1071 % 1.3 0.7 1.1 95% CI 0.2–2.4 0.0–1.5 0.3–1.8 n 968 778 1746 Women % 2.3 1.4 2.0 95% CI 1.2–3.3 0.4–2.4 1.2–2.7 n 1468 1349 2817 Both Sexes % 1.7 1.0 1.5 95% CI 1.0–2.5 0.4–1.6 1.0–2.0

Table 14.10: Percentage of respondents who have ever had anyone in their close family die from suicide. Age Group (years) 18–39 40–69 Total Men n 500 571 1071 % 1.2 1.6 1.4 95% CI 0.1–2.4 0.4–2.9 0.5–2.2 n 968 778 1746 Women % 2.7 1.6 2.3 95% CI 1.2–4.2 0.3–2.8 1.2–3.4 n 1468 1349 2817 Both Sexes % 1.9 1.6 1.8 95% CI 1.0–2.8 0.7–2.5 1.1–2.5

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Family history of chronic disease conditions Table 15.1: Percentage with a family member who has been diagnosed with a chronic disease condition Age Group (years) 18–39 40–69 Total 18–39 40–69 Total Stroke 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total 18–39 40–69 Total 500 572 1072 500 572 1072 500 572 1072 500 572 1072 2.4 2.9 2.6 3.8 4.3 4.0 2.8 2.1 2.5 1.0 1.4 1.1 1.0–3.7 1.1–4.8 1.5–3.6 1.8–5.9 2.6–6.1 2.5–5.5 1.2–4.4 0.6–3.6 1.4–3.7 0.1–1.8 0.1–2.7 0.4–1.8 969 778 1747 969 778 1747 969 778 1747 969 778 1747 2.3 3.3 2.7 5.6 4.2 5.1 2.1 0.9 1.7 1.1 1.9 1.4 1.3–3.3 1.6–4.9 1.8–3.5 3.8–7.4 2.8–5.7 3.8–6.4 1.0–3.3 0.3–1.6 1.0–2.5 0.3–1.9 0.7–3.1 0.7–2.0 1469 1350 2819 1469 1350 2819 1469 1350 2819 1469 1350 2819 2.4 3.1 2.6 4.6 4.3 4.5 2.5 1.6 2.2 1.0 1.6 1.2 1.4–3.3 1.8–4.4 1.9–3.3 3.2–6.0 3.1–5.5 3.5–5.5 1.5–3.5 0.7–2.5 1.5–2.9 0.4–1.6 0.6–2.6 0.7–1.7 Men n % 95% CI n Women % 95% CI n Both Sexes % 95% CI

Diabetes or high blood sugar 500 572 1072 500 572 1072 11.6 10.9 11.3 37.6 26.3 33.7 8.0–15.1 7.7–14.2 8.7–14.0 32.2–43.0 21.4–31.3 29.3–38.1 969 778 1747 969 778 1747 13.6 11.1 12.7 36.0 32.8 34.9 10.9–16.2 8.1–14.0 10.6–14.8 32.3–39.8 28.5–37.2 31.8–38.1 1469 1350 2819 1469 1350 2819 12.4 11.0 11.9 36.9 29.2 34.2 10.1–14.8 8.6–13.4 10.1–13.7 33.4–40.5 25.6–32.8 31.2–37.2

Raised blood pressure

Cancer or malignant tumor

Raised cholesterol

Early myocardial infarction

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Overweight and obesity Table 16.1: Mean height (cm) of respondents by sex and age Age Group (years) 18–39 40–69 Total Men n 499 572 1071 Mean 164.6 162.5 163.9 95% CI 163.8–165.4 161.4–163.6 163.1–164.6 n 906 772 1678 Women Mean 153.2 153.1 153.2 95% CI 152.6–153.9 152.1–154.1 152.6–153.8

Table 16.2: Mean weight (kg) of respondents by sex and age Age Group (years) 18–39 40–69 Total Men n 498 572 1070 Mean 62.9 63.6 63.2 95% CI 61.7–64.2 62.4–64.9 62.1–64.2 n 906 772 1678 Women Mean 56.9 58.3 57.4 95% CI 56.1–57.6 57.0–59.6 56.6–58.1

Table 16.3: Mean BMI (kg/m2) of respondents by sex and age Age Group (years) 18–39 40–69 Residence Rural Urban Total 771 296 1067 23.1 24.5 23.5 22.7–23.5 24.0–25.0 23.2–23.9 1134 538 1672 24.1 25.3 24.5 23.7–24.5 24.9–25.7 24.2–24.8 1905 834 2739 23.5 24.9 24.0 23.2–23.9 24.6–25.2 23.7–24.2 Men n 497 570 Mean 23.2 24.2 95% CI 22.8–23.5 23.7–24.7 n 903 769 Women Mean 24.3 25.0 95% CI 24.0–24.6 24.5–25.5 n 1400 1339 Both Sexes Mean 23.6 24.6 95% CI 23.4–23.9 24.2–24.9

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Table 16.4: BMI classifications of respondents by sex and age* Age Group (years) Men 18–39 40–69 Residence Rural Urban Total Women 18–39 40–69 Residence Rural Urban Total 18–39 40–69 Residence Rural Urban Total 1905 834 2739 3.7 2.8 3.4 2.2–5.1 1.2–4.4 2.3–4.5 68.8 52.2 63.6 65.1–72.6 48.0–56.4 60.5–66.8 22.7 35.7 26.7 19.3–26.1 31.3–40.2 23.8–29.6 4.8 9.3 6.2 3.5–6.2 7.4–11.2 5.1–7.4 1134 538 1672 1400 1339 2.9 2.6 2.8 3.7 2.9 1.6–4.2 0.7–4.5 1.7–3.9 2.1–5.3 1.5–4.2 61.8 46.6 56.8 67.2 57.1 57.3–66.3 41.6–51.6 53.1–60.4 63.5–70.9 52.9–61.2 28.6 38.6 31.9 24.5 30.9 24.1–33.1 33.6–43.6 28.4–35.5 21.2–27.8 27.2–34.6 6.7 12.2 8.5 4.6 9.2 4.8–8.6 8.9–15.4 6.8–10.2 3.2–6.0 7.0–11.3 903 769 3.6 1.4 2.0–5.1 0.5–2.3 59.0 52.8 54.7–63.3 47.4–58.2 30.9 33.7 26.5–35.3 28.7–38.8 6.5 12.1 4.9–8.1 8.7–15.4 771 296 1067 4.2 3.0 3.9 2.0–6.5 0.5–5.4 2.1–5.6 73.9 56.8 68.8 69.1–78.6 49.7–63.9 64.5–73.1 18.4 33.3 22.8 14.4–22.4 26.0–40.6 19.0–26.7 3.5 6.9 4.5 1.6–5.3 4.2–9.6 2.9–6.0 497 570 3.8 4.0 1.3–6.3 1.9–6.1 73.3 60.4 68.3–78.2 54.5–66.3 19.7 28.7 15.5–23.9 23.5–33.9 3.2 6.9 1.1–5.3 4.2–9.6 % Under– weight (<18.5) % Normal weight (18.5– 24.9) % Overweight (25.0– 29.9) % Obese (>30.0)

n

95% CI

95% CI

95% CI

95% CI

Both Sexes

*excluding pregnant women

Table 16.5: Percentage of respondents (excluding pregnant women) classified as overweight (BMI>25). Age Group (years) 18–39 40–69 Residence Rural Urban Total 771 296 1067 21.9 40.2 27.3 17.4–26.4 32.7–47.7 23.1–31.6 1134 538 1672 35.3 50.8 40.4 30.5–40.1 45.6–56.0 36.6–44.3 1905 834 2739 27.5 45.1 33.0 23.7–31.2 40.7–49.4 29.7–36.2 Men n 497 570 % 22.9 35.6 95% CI 18.3–27.5 29.9–41.3 n 903 769 Women % 37.4 45.8 95% CI 33.0–41.8 40.2–51.3 n 1400 1339 Both Sexes % 29.1 40.1 95% CI 25.6–32.6 35.8–44.3

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Table 16.6: Mean waist circumference (cm) of respondents by sex and age Age Group (years) 18–39 40–69 Residence Rural Urban Total 774 297 1071 80.8 84.6 81.9 79.8–81.9 82.9–86.2 81.0–82.9 1140 538 1678 78.5 81.7 79.5 77.3–79.6 80.7–82.8 78.7–80.4 Men n 499 572 Mean 80.5 84.6 95% CI 79.5–81.6 83.3–85.9 n 906 772 Women Mean 78.3 81.8 95% CI 77.3–79.2 80.4–83.1

Table 16.7: Mean Hip circumference (cm) of respondents by sex and age* Age Group (years) 18–39 40–69 Total *excluding pregnant women.

Men n 499 572 1071 Mean 92.0 93.5 92.5 95% CI 91.3–92.7 92.7–94.4 91.9–93.1 n 906 772 1678

Women Mean 93.1 95.7 94.0 95% CI 92.3–93.8 94.6–96.7 93.4–94.7

Table 16.8: Mean waist / hip ratio among respondents by age and sex Age Group (years) 18–39 40–69 Total Men n 499 572 1071 Mean 0.9 0.9 0.9 95% CI 0.9–0.9 0.9–0.9 0.9–0.9 n 906 772 1678 Women Mean 0.8 0.9 0.8 95% CI 0.8–0.8 0.8–0.9 0.8–0.9

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Annex 2: Survey instruments Survey Information Location and Date Gewog/EA ID Gewog/EA name Interviewer ID Date of completion of the survey Consent, Interview Language and Name Consent has been read and obtained Response └─┴─┴─┴─┴─┴─┘ Code I1 I2 I3 I4 Code 1 2 1 2 3 4 I7 I8 I9 I6 If NO, END I5

└─┴─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ dd mm year Response Yes No English

Interview Language [Insert language]

Dzongkha Tshanglakha Lhotshamkha

Time of interview (24 hour clock) Family Surname First Name Step 1 Demographic Information Demographic Information Question Sex (Record Male / Female as observed) What is your date of birth? Don't Know 77 77 7777 How old are you? In total, how many years have you spent at school and in full-time study (excluding pre-school)?

└─┴─┘: └─┴─┘ hrs mins

Response Male Female 1 2 If known, Go to C4

Code C1

└─┴─┘ └─┴─┘ └─┴─┴─┴─┘ dd mm year Years Years

C2 C3 C4

└─┴─┘ └─┴─┘

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No formal schooling Less than primary school Primary school completed What is the highest level of education you have completed? Class 10 completed Class 12 completed College/University completed Post graduate degree Refused Never married Currently married Separated What is your marital status? Divorced Widowed Cohabitating Refused Government employee Non-government employee Which of the following best describes your main work status over the past 12 months? Self-employed Non-paid Student Homemaker Retired (USE SHOWCARD) Unemployed (able to work) Unemployed (unable to work) Refused How many people older than 18 years, including yourself, live in your household? Taking the past year, can you tell me what the average earnings of the household have been? (RECORD ONLY ONE, NOT ALL 3) Step 1 Behavioural Measurements Number of people Per week OR per month OR per year Refused

1 2 3 4 5 6 7 88 1 2 3 4 5 6 88 1 2 3 4 5 6 7 8 9 88 └─┴─┘ └─┴─┴─┴─┴─┴─┴─┘ Go to T1 └─┴─┴─┴─┴─┴─┴─┘ Go to T1 └─┴─┴─┴─┴─┴─┴─┘ Go to T1 88 C9 C10a C10b C10c C10d C8 C7 C5

Tobacco Use Now I am going to ask you some questions about tobacco use. Question Do you currently smoke any tobacco products, such as cigarettes, cigars or bidis? (USE SHOWCARD) Do you currently smoke tobacco products daily? How old were you when you first started smoking? Response Yes No Yes No Age (years) Don’t know 77 └─┴─┘ If Known, go to T5a/T5aw 1 2 1 2 If No, go to T8 T2 T3 Code T1

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Do you remember how long ago it was? (RECORD ONLY 1, NOT ALL 3) Don’t know 77

In Years OR OR in Months in Weeks

└─┴─┘ If Known, go to T5a/T5aw └─┴─┘ If Known, go to T5a/T5aw └─┴─┘ DAILY↓ WEEKLY↓

T4a T4b T4c

Manufactured cigarettes On average, how many of the following products do you smoke each day/week? (IF LESS THAN DAILY, RECORD WEEKLY) (RECORD FOR EACH TYPE, USE SHOWCARD) Don’t Know 7777 Bidis Cigar, cheroots, cigarillos Other Other (please specify): During the past 12 months, have you tried to stop smoking? Yes No Yes During any visit to a doctor or other health worker in the past 12 months, were you advised to quit smoking tobacco? No No visit during the past 12 months In the past, did you eversmoke any tobacco products? (USE SHOWCARD) Yes No Yes In the past, did you ever smoke daily? No Age (years) Don’t Know 77 Years ago OR OR Yes No Yes No Months ago Weeks ago

└─┴─┴─┴─┘└─┴─┴─┴─┘

T5a/T5aw T5b/T5bw T5c/T5cw T5d/T5dw T5f/T5fw T5other/

Hand-rolled cigarette └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ If Other, go to T5other, else go to T6 └─┴─┴─┴─┴─┴─┘ 1 2 1 If T2=Yes, go to T12; if T2=No, go to T9 2 If T2=Yes, go to T12; if T2=No, go to T9 3 If T2=Yes, go to T12; if T2=No, go to T9 1 2 If No, go to T12 1 If T1=Yes, go to T12, else go to T10 2 If T1=Yes, go to T12, else go to T10

T5otherw T6

T7

T8

T9

How old were you when you stopped smoking? How long ago did you stop smoking? RECORD ONLY 1, NOT ALL 3) Don’t Know 77 Do you currently use any smokeless tobacco products such as snuff, chewing tobacco, betel? (USE SHOWCARD) Do you currently use smokeless tobacco products daily?

└─┴─┘ If Known, go to T12 └─┴─┘ If Known, go to T12 └─┴─┘ If Known, go to T12 └─┴─┘ 1 2 1 2 If No, go to T14aw If No, go to T15

T10 T11a T11b T11c T12

T13

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DAILY↓ Snuff, by mouth On average, how many times a day/week do you use …. (IF LESS THAN DAILY, RECORD WEEKLY) (RECORD FOR EACH TYPE, USE SHOWCARD) Don’t Know 7777 Chewing tobacco Snuff, by nose Chewing tobacco Betel, quid

WEEKLY↓ T14a/T14aw T14b/T14bw T14c/T14cw T14d/T14dw T14e/T14ew T14other/ T14otherw T15

└─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ └─┴─┴─┴─┘└─┴─┴─┴─┘ If other, go to T14 other, if T13=No, go to T16, else go to T17 └─┴─┴─┴─┴─┴─┘ If T13=No, go to T16, else go to T17 1 2 1 2 1 2 1 2 3 If No, go to T17

Other (please specify): In the past, did you ever use smokeless tobacco products such as snuff, chewing tobacco, or betel? In the past, did you ever use smokeless tobacco products such snuff, chewing tobacco, or betel daily? During the past 30 days, did someone smoke in your home? During the past 30 days, did someone smoke in closed areas in your workplace (in the building, in a work area or a specific office)? Yes No Yes No Yes No Yes No Don't work in a closed area

T16

T17

T18

The next questions ask about tobacco control policies. They include questions on your exposure to the media and advertisements, health warnings and cigarette purchase. During the past 30 days, have you noticed information about the dangers of smoking cigarettes or that encourages quitting through the following media? (RECORD FOR EACH) Yes Newspapers or magazines No Don't know Yes Television No Don't know Yes Radio No Don't know Yes Posters or Banners No Don't know 1 2 77 1 2 77 1 2 77 1 2 77 TP1d TP1c TP1b TP1a

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The next questions TP4 - TP7 are administered to current smokers only. Yes During the past 30 days, did you notice any health warnings on cigarette packages? No Did not see any cigarette packages Don't know Yes During the past 30 days, have warning labels on cigarette packages led you to think about quitting? No Don't know Number of cigarettes The last time you bought manufactured cigarettes for yourself, how many cigarettes did you buy in total? Don't know or Don't smoke or purchase manuf. cigarettes 7777 Amount Don't know Refused Alcohol Consumption The next questions ask about the consumption of alcohol. Have you ever consumed any alcohol such as beer, wine, hard drinks, ara, changkoe, or Bangchang? (USE SHOWCARD OR SHOW EXAMPLES) Have you consumed any alcohol within the past 12 months? Have you stopped drinking due to health reasons, such as a negative impact on your health or on the advice of your doctor or other health worker? Yes No Yes No Yes No Daily During the past 12 months, how frequently have you had at least one standard alcoholic drink? (READ RESPONSES, USE SHOWCARD) 5-6 days per week 3-4 days per week 1-2 days per week 1-3 days per month Less than once a month Have you consumed any alcohol within the past 30 days? During the past 30 days, on how many occasions did you have at least one standard alcoholic drink? Yes No Number Don't know 77 └─┴─┘ 1 2 If No, go to A16 1 If Yes, go to A4 2 1 If Yes, go to A16 2 If No, go to A16 1 2 3 4 5 6 1 2 If No, go to A13 A5 A4 A1 1 2 If no, go to TP6 3 If "did not see any cigarette packages", go to TP6 77 If Don't know, go to TP6 1 2 77 └─┴─┴─┴─┘ If "Don't know or don't smoke or purchase manuf. cig.", go to A1 └─┴─┴─┴─┘ 7777 8888 TP7 TP6 TP5 TP4

In total, how much money did you pay for this purchase? (DIGITS TO BE ADAPTED TO COUNTRY NEEDS)

A2

A3

A6

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During the past 30 days, when you drank alcohol, how many standard drinks on average did you have during one drinking occasion? (USE SHOWCARD) During the past 30 days, what was the largest number of standard drinks you had on a single occasion, counting all types of alcoholic drinks together? During the past 30 days, how many times did you have six or more standard drinks in a single drinking occasion?

Number Don't know 77 Largest number Don't Know 77 Number of times Don't Know 77 Monday Tuesday └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘ └─┴─┘

A7

A8

A9 A10a A10b A10c A10d A10e A10f A10g

During each of the past 7 days, how many standard drinks did you have each day? (USE SHOWCARD) Don't Know 77

Wednesday Thursday Friday Saturday Sunday

I have just asked you about your consumption of alcohol during the past 7 days. The questions were about alcohol in general, while the next questions refer to your consumption of homebrewed alcohol, alcohol brought over the border/from another country, any alcohol not intended for drinking or other untaxed alcohol. Please only think about these types of alcohol when answering the next questions. During the past 7 days, did you consume any Yes homebrewed alcohol, any alcohol brought over the border/from another country, any alcohol not intended for drinking or other untaxed alcohol? [AMEND ACCORDING TO LOCAL CONTEXT] (USE SHOWCARD) Homebrewed spirits, e.g. ara On average, how many standard drinks of the following did you consume during the past 7 days? [INSERT COUNTRY-SPECIFIC EXAMPLES] (USE SHOWCARD) Don't Know 77 Homebrewed beer or wine, e.g. beer, palm or fruit wine Alcohol brought over the border/from another country Alcohol not intended for drinking, e.g. alcohol-based medicines, perfumes, after shaves Other untaxed alcohol in the country Daily or almost daily During the past 12 months, how often have you found that you were not able to stop drinking once you had started? Weekly Monthly Less than monthly Never └─┴─┘ └─┴─┘ └─┴─┘ A12a A12b A12c A12d └─┴─┘ └─┴─┘ 1 2 3 4 5 A13 A12e No 1 A11 2 If No, go to A13

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Daily or almost daily During the past 12 months, how often have you failed to do what was normally expected from you because of drinking? Weekly Monthly Less than monthly Never Daily or almost daily During the past 12 months, how often have you needed a first drink in the morning to get yourself going after a heavy drinking session? Weekly Monthly Less than monthly Never Yes, more than monthly During the past 12 months, have you had family problems or problems with your partner due to someone else’s drinking? Yes, monthly Yes, several times but less than monthly Yes, once or twice No Diet

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 A16 A15 A14

The next questions ask about the fruits and vegetables that you usually eat. I have a nutrition card here that shows you some examples of local fruits and vegetables. Each picture represents the size of a serving. As you answer these questions please think of a typical week in the last year. Question In a typical week, on how many days do you eat fruit? (USE SHOWCARD) How many servings of fruit do you eat on one of those days? (USE SHOWCARD) In a typical week, on how many days do you eat vegetables? (USE SHOWCARD) How many servings of vegetables do you eat on one of those days? (USE SHOWCARD) Dietary salt With the next questions, we would like to learn more about salt in your diet. Dietary salt includes ordinary table salt, unrefined salt such as sea salt, iodized salt, salty stock cubes and powders, and salty sauces such as soya sauce or fish sauce (see showcard). The following questions are on adding salt to the food right before you eat it, on how food is prepared in your home, on eating processed foods and other foods that are high in salt such as Ezay and questions on controlling your salt intake. Please answer the questions even if you consider yourself to eat a diet low on salt. How often do you add salt or a salty sauce such as soya sauce to your food right before you eat it or as you are eating it? (SELECT ONLY ONE) (USE SHOWCARD) Always Often Sometimes Rarely Never Don't know 1 2 3 4 5 77 D5 Response Number of days Don't Know 77 Number of servings Don't Know 77 Number of days Don't Know 77 Number of servings Don’t know 77 └─┴─┘ └─┴─┘ If Zero days, go to D5 └─┴─┘ D3 └─┴─┘ If Zero days, go to D3 Code D1

D2

D4

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Always Often How often is salt, salty seasoning or a salty sauce added in Sometimes cooking or preparing foods in your household? Rarely Never Don't know How often do you eat processed food high in salt? By processed food high in salt, I mean foods that have been altered from their natural state, such as packaged salty snacks, canned salty food including pickles and preserves, salty foods prepared at a fast food restaurant, cheese, bacon and processed meat and dried fish. Other foods high in salt include Ezay, potato chips, [INSERT EXAMPLES] (USE SHOWCARD) Always Often How often do you drink Suja? Sometimes Rarely Never Don't know Far too much Too much How much salt or salty sauce do you think you consume? Just the right amount Too little Far too little Don't know Very important How important to you is lowering the salt in your diet? Somewhat important Not at all important Don't know Yes Do you think that too much salt or salty sauce in your diet could cause a health problem? No Don't know Do you do anything of the following on a regular basis to control your salt intake? (RECORD FOR EACH) Limit consumption of processed foods and other salty foods Look at the salt or sodium content on food labels Buy low salt/sodium alternatives Use spices other than salt when cooking Yes No Yes No Yes No Yes No Always Often Sometimes Rarely Never Don't know

1 2 3 4 5 77 1 2 3 4 5 77 1 2 3 4 5 77 1 2 3 4 5 77 1 2 3 77 1 2 77 D8 D10 D9 X1 D7 D6

1 2 1 2 1 2 1 2

D11a D11b D11c D11d

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Avoid eating foods prepared outside of a home Do other things specifically to control your salt intake Other (please specify)

Yes No Yes No └─┴─┴─┴─┴─┴─┴─┘

1 2 1 If Yes, go to D11other 2

D11e D11f D11other

The next questions ask about the oil or fat that is most often used for meal preparation in your household, and about meals that you eat outside a home. Vegetable oil Lard or suet What type of oil or fat is most often used for meal preparation in your household? Butter or ghee Margarine Other None in particular (USE SHOWCARD) (SELECT ONLY ONE) None used Don’t know Other On average, how many meals per week do you eat that were not prepared at a home? By meal, I mean breakfast, lunch and dinner. Physical Activity Next I am going to ask you about the time you spend doing different types of physical activity in a typical week. Please answer these questions even if you do not consider yourself to be a physically active person. Think first about the time you spend doing work. Think of work as the things that you have to do such as paid or unpaid work, study/training, household chores, harvesting food/crops, fishing or hunting for food, seeking employment. [Insert other examples if needed]. In answering the following questions '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. Work Does your work involve vigorous-intensity activity that causes large increases in breathing or heart rate like carrying or lifting heavy loads, digging or construction work for at least 10 minutes continuously? (USE SHOWCARD) Yes No 1 2 If No, go to P 4 P2 P3 (a-b) P1 Number Don’t know 77 └─┴─┘ 1 2 3 4 5 6 7 77 └─┴─┴─┴─┴─┴─┴─┘ D12other If Other, go to D12 other D12

D13

In a typical week, on how many days do you do vigorous-intensity Number of days activities as part of your work? How much time do you spend doing vigorous-intensity activities at work on a typical day? Does your work involve moderate-intensity activity, that causes small increases in breathing or heart rate such as brisk walking, [or carrying light loads] for at least 10 minutes continuously? [INSERT EXAMPLES] (USE SHOWCARD) In a typical week, on how many days do you do moderateintensity activities as part of your work? How much time do you spend doing moderate-intensity activities at work on a typical day? Hours : minutes

└─┘ └─┴─┘: └─┴─┘ hrs mins 1 2 If No, go to P 7

Yes No Number of days

P4

└─┘ └─┴─┘: └─┴─┘ hrs mins

P5 P6 (a-b)

Hours : minutes

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Travel to and from places The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way you travel to and from places. For example to work, for shopping, to market, to place of worship. [Insert other examples if needed] Do you walk or use a bicycle (pedal cycle) for at least 10 minutes continuously to get to and from places? In a typical week, on how many days do you walk or bicycle for at least 10 minutes continuously to get to and from places? How much time do you spend walking or bicycling for travel on a typical day? Recreational activities The next questions exclude the work and transport activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities (leisure), [Insert relevant terms]. Do you do any vigorous-intensity sports, fitness or recreational Yes (leisure) activities that cause large increases in breathing or heart rate like running or football, martial arts, badminton, basketball for No at least 10 minutes continuously? (USE SHOWCARD) In a typical week, on how many days do you do vigorous-intensity Number of days sports, fitness or recreational (leisure) activities? How much time do you spend doing vigorous-intensity sports, fitness or recreational activities on a typical day? Do you do any moderate-intensity sports, fitness or recreational activities that cause a small increase in breathing or heart rate such as dancing, brisk walking, cycling, swimming, khuru, or degor or archery for at least 10 minutes continuously? (USE SHOWCARD) In a typical week, on how many days do you do moderateintensity sports, fitness or recreational (leisure) activities? 1 P10 2 If No, go to P 13 P11 └─┘ P12 └─┴─┘: └─┴─┘ hrs mins 1 P13 No 2 If No, go to P16 (a-b) Yes No Number of days 1 2 If No, go to P 10 P7

└─┘ └─┴─┘: └─┴─┘ hrs mins

P8 P9 (a-b)

Hours : minutes

Hours : minutes

Yes

Number of days └─┘ Hours : minutes └─┴─┘: └─┴─┘ hrs mins

P14

How much time do you spend doing moderate-intensity sports, fitness or recreational (leisure) activities on a typical day? Sedentary Behaviour

P15 (a-b)

The following question is about sitting or reclining at work, at home, getting to and from places, or with friends including time spent sitting at a desk, sitting with friends, traveling in bus, reading, playing cards or watching television, but do not include time spent sleeping. (USE SHOWCARD) How much time do you usually spend sitting or reclining on a typical day? Hours : minutes P16 └─┴─┘: └─┴─┘ hrs mins (a-b)

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History of Raised Blood Pressure Have you ever had your blood pressure measured by a doctor or other health worker? Have you ever been told by a doctor or other health worker that you have raised blood pressure or hypertension? Have you been told in the past 12 months? In the past two weeks, have you taken any drugs (medication) for raised blood pressure prescribed by a doctor or other health worker? Have you ever seen a local healer, drungdsho or sMenpa for raised blood pressure or hypertension? Are you currently taking any herbal or traditional remedy for your raised blood pressure? History of Diabetes Have you ever had your blood sugar measured by a doctor or other health worker? Have you ever been told by a doctor or other health worker that you have raised blood sugar or diabetes? Have you been told in the past 12 months? In the past two weeks, have you taken any drugs (medication) for diabetes prescribed by a doctor or other health worker? Are you currently taking insulin for diabetes prescribed by a doctor or other health worker? Have you ever seen a local healer, drungdsho or sMenpa for diabetes or raised blood sugar? Are you currently taking any herbal or traditional remedy for your diabetes? History of Raised Total Cholesterol Have you ever had your cholesterol (fat levels in your blood) measured by a doctor or other health worker? Have you ever been told by a doctor or other health worker that you have raised cholesterol? Have you been told in the past 12 months? Yes No Yes No Yes No 1 2 1 2 If No, go to H17 1 2 If No, go to H17 H12 Yes No Yes No Yes No Yes No Yes No Yes No Yes No 1 2 1 2 1 2 1 2 1 2 1 2 1 2 If No, go to H12 If No, go to H12 H6 Yes No Yes No Yes No Yes No Yes No Yes No 1 2 1 2 1 2 1 2 1 2 1 2 If No, go to H6 If No, go to H6 H1

H2a

H2b

H3

H4

H5

H7a

H7b

H8

H9

H10

H11

H13a

H13b

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In the past two weeks, have you taken any oral treatment (medication) for raised total cholesterol prescribed by a doctor or other health worker? Have you ever seen a local healer, drungsho, or sMenpa for raised cholesterol? Are you currently taking any herbal or traditional remedy for your raised cholesterol? History of Cardiovascular Diseases Have you ever had a heart attack or chest pain from heart disease (angina) or a stroke (cerebrovascular accident or incident)? Are you currently taking aspirin regularly to prevent or treat heart disease? Are you currently taking statins (Atorvastatin) or fibrates (Fenofibrate) regularly to prevent or treat heart disease? (if D/K, interviewer to check medication) Lifestyle Advice

Yes No Yes No Yes No Yes No Yes No Yes No

1 2 1 2 1 2 1 2 1 2 1 2

H14

H15

H16

H17

H18

H19

During the past three years, has a doctor or other health worker advised you to do any of the following? (RECORD FOR EACH) Quit using tobacco or don’t start Reduce salt in your diet Eat at least five servings of fruit and/or vegetables each day Yes No Yes No Yes No Yes No Yes No Yes No 1 2 1 2 1 2 1 2 1 2 1 2 If C1=1 go to M1 H20a H20b H20c

Reduce fat in your diet

H20d

Start or do more physical activity

H20e

Maintain a healthy body weight or lose weight Cervical Cancer Screening (for women only):

H20f

The next question asks about cervical cancer prevention. A screening test for cervical cancer prevention is done by a doctor or nurse taking a swab to wipe from inside your vagina. This is sent to a laboratory where they check for abnormal cell changes. Yes Have you ever had a pap smear screening test for cervical cancer? No Don’t know 1 2 77 CX1

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Family history Have any of your blood family members (sibling, parent, grandparent, aunt or uncle) been diagnosed with the following diseases? Diabetes or raised blood sugar Raised Blood pressure Stroke Cancer or malignant tumor Raised Cholesterol Early Heart attack (below age 50 for men and below age 55 for women) Asthma or chronic lung disease (COPD) Kidney disease Mental health / Suicide The next questions ask about thoughts, plans, and attempts of suicide. Please answer the questions even if no one usually talks about these issues. During the past 12 months, have you seriously considered attempting suicide? Did you seek professional help for these thoughts? During the past 12 months, have you made a plan about how you would attempt suicide? Yes No Refused Yes No Refused Yes No Refused Yes Have you ever attempted suicide? No Refused During the past 12 months, have you attempted suicide? Yes No Refused Razor, knife or other sharp instrument Overdose of medication (e. g. prescribed, over-the-counter) Overdose of other substance (e.g. heroin, crack, alcohol) What was the main method you used the last time you attempted suicide? (SELECT ONLY ONE) Poisoning with pesticides (e.g. rat poison, insecticide, weed-killer) Other poisoning (e.g. plant/seed, household product) Poisonous gases from charcoal Other Refused Other (specify) 1 2 88 1 2 88 1 2 88 1 2 88 1 2 88 1 2 3 4 5 6 7 If Other, go to MH6other 88 └─┴─┴─┴─┴─┴─┴─┘ MH6 other MH6 MH5 If No, go to MH9 MH4 MH3 MH2 If No, go to MH3 MH1 Yes No Yes No Yes No Yes No Yes No Yes 1 2 1 2 1 2 1 2 1 2 1 F1a F1b F1c F1d F1e F1f X2 If C1=1 go to M1 If C1=1 go to M1 X3

No 2 Yes 1 No Yes No 2 1 2

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Yes Did you seek medical care for this attempt? No Refused Were you admitted to hospital overnight because of this attempt? Has anyone in your close family (mother, father, brother, sister or children) ever attempted suicide? Has anyone in your close family (mother, father, brother, sister or children) ever died from suicide? Yes No Refused Yes No Refused Yes No

1 2 88 1 2 88 1 2 88 1 2 MH10 MH9 MH8 If No, go to MH9 MH7

Step 2

Physical Measurements

Blood Pressure and Heart Rate Interviewer ID Device ID for blood pressure Reading 1 Systolic ( mmHg) Diastolic (mmHg) Systolic ( mmHg) Diastolic (mmHg) Systolic ( mmHg) Diastolic (mmHg) └─┴─┴─┘ └─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ 1 2 1 If Yes, go to M 16 2 └─┴─┴─┘ Height Weight in Centimetres (cm) in Kilograms (kg) └─┴─┘ └─┴─┘ └─┴─┴─┘. └─┘ M1 M2 M4a M4b M5a M5b M6a M6b M7

Reading 2

Reading 3

During the past two weeks, have you been treated for Yes raised blood pressure with drugs (medication) prescribed No by a doctor or other health worker? Height and Weight For women: Are you pregnant? Interviewer ID Device IDs for height and weight Height Weight If too large for scale 666.6 Yes No

M8 M9 M10a M10b M11 M12

└─┴─┴─┘.└─┘

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Waist and hip circumference Device ID for waist Waist circumference Hip circumference Heart rate Reading 1 Reading 2 Reading 3 Beats per minute Beats per minute Beats per minute └─┴─┴─┘ └─┴─┴─┘ └─┴─┴─┘ M16a M16b M16c in Centimetres (cm) in Centimetres (cm) └─┴─┘ └─┴─┴─┘.└─┘ └─┴─┴─┘.└─┘ M13 M14 M15

Step 3

Biochemical Measurements

Blood Glucose and Total Cholesterol During the past 10 hours have you had anything to eat or Yes drink, other than water? No Technician ID Device ID Time of day blood specimen taken (24 hour clock) Fasting blood glucose Hours : minutes mg/dl 1 2 └─┴─┴─┘ └─┴─┘ └─┴─┘: └─┴─┘ hrs mins └─┴─┘. └─┴─┘ 1 2 └─┴─┘. └─┴─┘ 1 2 B1 B2 B3 B4 B5 B6 B8 B9

Today, have you taken insulin or other drugs (medication) Yes that have been prescribed by a doctor or other health No worker for raised blood glucose? Total cholesterol During the past two weeks, have you been treated for raised cholesterol with drugs (medication) prescribed by a doctor or other health worker? Urinary sodium and creatinine Had you been fasting prior to the urine collection? Technician ID Time of day urine sample taken (24 hour clock) Urinary sodium Urinary creatinine mg/dl Yes No

Yes No

1 2 └─┴─┴─┘

B10 B11 B13 B14 B15

Hours : minutes mmol/l mmol/l

└─┴─┘: └─┴─┘ hrs mins └─┴─┴─┘.└─┘ └─┴─┘. └─┴─┘

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Annex 3: Fact sheet – Risk factors The STEPS survey of non-communicable disease (NCD) risk factors in Bhutan was carried out from April-June 2014. Bhutan carried out Step 1, Step 2 and Step 3. Socio demographic and behavioral information was collected in Step 1. Physical measurements such as height, weight and blood pressure were collected in Step 2. Biochemical measurements were collected to assess salt intake, blood glucose and cholesterol levels in Step 3.The survey was a population-based survey of adults aged 18-69. A multi-stage stratified cluster sampling design was used to produce representative data for that age range in Bhutan. Total of 2822 adults participated in the survey. The overall response rate was 96%. Results for adults aged 18-69 years (incl. 95% CI) Step 1: Tobacco Use Percentage who currently smoke tobacco Percentage who currently smoke tobacco daily For those who smoke tobacco daily Average age started smoking (years) Percentage of daily smokers smoking manufactured cigarettes Smokeless tobacco user Percentage who currently use smokeless tobacco Percentage who currently use smokeless tobacco daily For those who use smokeless tobacco daily Percentage of daily smokeless tobacco users using chewing tobacco/snuff by mouth Mean times per day chewing tobacco/snuff by mouth (by user of chewing tobacco/snuff by mouth) Step 1: Alcohol Consumption Percentage who are lifetime abstainers Percentage who are past 12 month abstainers Percentage who currently drink (drank alcohol in the past 30 days) Percentage who engage in heavy episodic drinking (6 or more drinks on any occasion in the past 30 days) Step 1: Diet Mean number of days fruit consumed in a typical week Mean number of servings of fruit consumed on average per day Mean number of days vegetables consumed in a typical week Mean number of servings of vegetables consumed on average per day Percentage who ate less than 5 servings of fruit and/or vegetables on average per day Percentage who always or often add salt or salty sauce to their food before eating or as they are eating Percentage who always or often eat processed foods high in salt Step 1: Physical Activity Percentage with insufficient physical activity (defined as < 150 minutes of moderate-intensity activity per week, or equivalent)* Median time spent in physical activity on average per day (minutes) (presented with inter-quartile range) Percentage not engaging in vigorous activity 39.0% (35.7–42.3) 10.8% (8.8–12.8) 42.4% (39.3–45.5) 22.4% (19.5–25.3) 1.7 (1.5–1.9) 0.7 (0.6–0.8) 5.6 (5.4–5.7) 3.8 (3.4–4.1) 66.9% (61.7–72.0) 7.8% (5.4–10.2) 11.1% (9.3–12.9) 6.4% (4.7–8.0) 330 (377.1) 48.8% (44.6–53.1) 30.6% (26.2–35.0) 12.1% (9.2–14.9) 50.0% (45.5–54.5) 29.0% (24.9–33.1)) 1.6 (1.4–1.8) 0.7 (0.5–0.8) 5.6 (5.5–5.8) 4.0 (3.5–4.4) 64.8% (58.3–71.2) 7.4% (4.4–10.5) 11.0% (8.4–13.6) 3.8% (2.5–5.0) 367.1 (362.1) 35.2% (30.3–40.2) 49.8% (45.9–53.7) 9.3% (7.0–11.6) 32.8% (29.5–36.0) 14.1% (11.3–16.9) 1.9 (1.7–2.1) 0.8 (0.7–0.9) 5.5 (5.3–5.7) 3.5 (3.1–3.8) 69.6% (64.4–74.7) 8.3% (6.2–10.4) 11.2% (9.1–13.3) 9.6% (6.8–12.4) 274.3 (377.1) 66.0% (61.2–70.9) 19.7% (16.5–22.9) 18.5% (15.3–21.7) 95.5% (93.2–97.8) 12.4 (10.6–14.2) 26.5% (22.1–31.0) 25.2% (20.7–29.7) 96.4% (93.8–99.0) 12.8 (10.6–14.9) 11.0 % (8.6–13.5) 9.9% (7.5–12.4) 92.7% (87.9–97.4) 11.3 (9.5–13.2) 18.9 (17.5–20.3) 84.1% (76.3–92.0) 19.0 (17.3–20.8) 90.1% (82.2–98.0) # # Both Sexes 7.4% (5.8–9.0) 4.3% (3.2–5.4) Men 10.8% (8.1–13.6) 6.0% (4.3–7.7) Women 3.1% (2.0–4.2) 2.1% (1.3–3.0)

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Results for adults aged 18-69 years (incl. 95% CI) Step 1: Cervical Cancer Screening Percentage of women aged 30-49 years who have ever had a screening test for cervical cancer Step 2: Physical Measurements Mean body mass index - BMI (kg/m2) Percentage who are overweight (BMI > 25 kg/m2) Percentage who are obese (BMI > 30 kg/m2) Average waist circumference (cm) Mean systolic blood pressure - SBP (mmHg), including those currently on medication for raised BP Mean diastolic blood pressure - DBP (mmHg), including those currently on medication for raised BP Percentage with raised BP (SBP > 140 and/or DBP > 90 mmHg or currently on medication for raised BP) Percentage with raised BP (SBP > 140 and/or DBP > 90 mmHg) who are not currently on medication for raised BP Step 3: Biochemical Measurement Mean fasting blood glucose, including those currently on medication for raised blood glucose (mg/dl) Percentage with impaired fasting glycaemia as defined below •• capillary whole blood value >5.6 mmol/L (100 mg/dl) and <6.1 mmol/L (110 mg/dl) Percentage with raised fasting blood glucose as defined below or currently on medication for raised blood glucose •• capillary whole blood value > 6.1 mmol/L (110 mg/dl) Mean total blood cholesterol, including those currently on medication for raised cholesterol (mg/dl) Percentage with raised total cholesterol (> 5.0 mmol/L or > 190 mg/dl or currently on medication for raised cholesterol) Mean intake of salt per day (in grams) Cardiovascular disease (CVD) risk Percentage aged 40-69 years with a 10-year CVD risk > 30%, or with existing CVD** Summary of combined risk factors •• current daily smokers •• less than 5 servings of fruits & vegetables per day •• insufficient physical activity Percentage with none of the above risk factors Percentage with three or more of the above risk factors, aged 18 to 39 years Percentage with three or more of the above risk factors, aged 40 to 69 years Percentage with three or more of the above risk factors, aged 18 to 69 years # The sample size “n” is less than 50

Both Sexes

Males

Females 64.1% (59.0–69.2)

24.0 (23.7–24.2) 26.7% (23.8–29.6) 6.2% (5.1–7.3)

23.5 (23.2–23.9) 22.8% (19.0–26.7) 4.5% (2.9–6.0) 81.9 (81.0–82.9)

24.5 (24.2–24.8) 31.9% (28.4–35.5) 8.5% (6.8–10.2) 79.5 (78.7–80.4) 123.8 (122.5–125.1) 85.4 (84.5–86.3) 35.9% (32.5–39.4) 32.0% (28.6–35.3) 88.9 (87.4–90.4) 10.0% (7.9–12.0) 6.3% (4.7–7.9) 148.7 (146.0–151.4) 13.3% (11.3–15.3) 8.0 (7.9–8.2) 2.2% (1.0–3.4)

126.2 (125.1–127.2) 85.0 (84.0–85.9) 35.7% (32.8–38.6) 32.9% (30.0–35.8) 88.8 (87.4–90.2) 10.7% (8.6–12.9) 6.4% (5.0–7.8) 146.1 (143.4–148.9) 12.5% (10.6–14.4) 9.0 (8.8–9.1) 1.8% (1.0–2.6)

128.0 (126.6–129.4) 84.6 (83.4–85.9) 35.5% (31.5–39.6) 33.6% (29.5–37.6) 88.7 (86.9–90.5) 11.4% (8.2–14.5) 6.5% (4.6–8.5) 144.1 (140.3–147.9) 11.9% (9.1–14.7) 9.6 (9.4–9.8) 1.5% (0.4–2.7)

•• overweight (BMI > 25 kg/m2) •• raised BP (SBP > 140 and/or DBP > 90 mmHg or currently on medication for raised BP) 12.7% (10.2–15.2) 10.7% (8.6–12.8) 18.9% (15.7–22.2) 13.5% (11.8–15.3) 15.3% (11.4–19.2) 9.5% (6.6–12.5) 14.4% (10.7–18.1) 11.2% (8.6–13.7) 9.3% (7.3–11.3) 12.3% (9.6–15.0) 24.6% (19.9–29.3) 16.7% (14.1–19.2)

* For complete definitions of insufficient physical activity, refer to the GPAQ Analysis Guide (http://www.who.int/chp/steps/GPAQ/en/ index.html) or to the WHO Global recommendations on physical activity for health (http://www.who.int/dietphysicalactivity/factsheet_ recommendations/en/index.html) ** A 10-year CVD risk of >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 >7.0 mmol/l (126 mg/dl).

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Annex 4: Fact sheet – Tobacco The WHO STEPwise approach to surveillance (STEPS) is a simple, standardized method for collecting, analysing and disseminating data on noncommunicable diseases (NCDs) and risk factors. Data are collected on the established risk factors and NCD conditions that determine the major NCD burden, including tobacco use, harmful use of alcohol, unhealthy diet, insufficient physical activity, overweight and obesity, raised blood pressure, raised blood glucose, and abnormal blood lipids. Data from STEPS surveys can be used by countries to help monitor progress in meeting the global voluntary targets related to specific risk factors such as tobacco, alcohol, diet and physical inactivity. The tobacco indicators from STEPS can be used to evaluate and monitor existing tobacco-control policies and programs. The STEPS survey on NCD risk factors in Bhutan was carried out from April–June 2014. It was a population-based survey of adults aged 18–69. A multi-stage stratified cluster sampling design was used to produce representative data for that age range in Bhutan. Survey information was collected electronically using handheld devices. The survey was implemented by the Ministry of Health, Bhutan. A total of 2822 adults participated in the Bhutan STEPS survey. The overall response rate was 96%.

Highlights Tobacco use ¤¤ Overall 24.8% of adults (33.6% of men and 13.6% of women) were current users of tobacco. ¤¤ Overall 7.4% of adults (10.8% of men and 3.1% of women) were current smokers of tobacco. ¤¤ Overall 19.7% of adults (26.5% of men and 11.0% of women) were current users of smokeless tobacco.

Cessation ¤¤ 7 in 10 current smokers tried to stop smoking in the last 12 months. ¤¤ 3 in 10 current smokers were advised by a health care provider to stop smoking in the last 12 months.

Secondhand smoke ¤¤ 1 in 4 adults were exposed to tobacco smoke at the workplace. ¤¤ 1 in 5 adults were exposed to tobacco smoke at home.

Media ¤¤ 3 in 5 adults noticed anti-cigarette smoking information on the television. ¤¤ 2 in 5 adults noticed anti-cigarette smoking information on the radio.

Economics ¤¤ Average amount spent on 20 manufactured cigarettes was 269.3 Bhutanese Ngultrum (Nu).

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Results for adults aged 18-69 years Tobacco Use Current tobacco users(smoked and/or smokeless)1 Current tobacco users Current daily tobacco users Current tobacco smokers Current tobacco smokers Current cigarette smokers2 (among current tobacco smokers) Current daily tobacco smokers Current daily cigarette smokers (among daily tobacco smokers) Average age started tobacco smoking (years) Average number of manufactured cigarettes smoked per day (among daily cigarette smokers) Current smokeless tobacco users3 Current smokeless tobacco users Current daily smokeless tobacco users Current tobacco non-users Former tobacco smokers4 Never Smokers Former smokeless users5 Never smokeless users Exposure to Second-hand smoke Adults exposed to second-hand smoke at home* Adults exposed to second-hand smoke in the closed areas in their workplace* Tobacco Cessation Current smokers who tried to stop smoking in past 12 months Current smokers advised by a health care provider to stop smoking in past 12 months6 Health Warnings Current smokers who thought about quitting because of a warning label* Adults who noticed anti-cigarette smoking information on the television* Adults who noticed anti-cigarette smoking information on the radio* Adults who noticed anti-cigarette smoking information in newspapers or magazines* Economics Average amount spent on 20 manufactured cigarettes

Overall %(95% CI)

Men %(95% CI)

Women %(95% CI)

24.8% (21.4–28.3) 22.0% (18.7–25.3) 7.4% (5.8–9.0) 77.6% (68.9–86.4) 4.3% (3.2–5.4) 84.1% (76.3–92.0) 18.9 (17.5–20.3) 3.5 (2.6–4.3) 19.7% (16.5–22.9) 18.5% (15.3–21.7) 19.6% (17.2–21.9) 73.0% (69.9–76.1) 12.9% (10.8–15.0) 67.4% (63.6–71.2) 20.7% (18.0–23.4) 24.6% (21.5–27.7) 69.0% (59.8–78.1) 31.8% (22.6–41.0)

33.6% (28.8–38.5) 30.0% (25.4–34.6) 10.8% (8.1–13.6) 81.5% (71.4–91.6) 6.0% (4.2–7.8) 90.1% (82.2–98.0) 19.0 (17.3–20.8) 3.7 (2.6–4.8) 26.5% (22.1–31.0) 25.2% (20.7–29.7) 26.7% (23.2–30.3) 62.5% (58.0–66.9) 13.9% (10.8–17.0) 59.5% (54.3–64.7) 20.7% (17.0–24.4) 29.0% (24.6–33.4) 66.0% (55.2–76.8) 33.2% (22.2–44.3)

13.6% (10.9–16.4) 11.8% (9.2–14.4) 3.1% (2.0–4.2) 61.2% (43.4–79.1) 2.1% (1.3–3.0) # # # 11.0% (8.6–13.5) 9.9% (7.5–12.4) 10.4% (8.2–12.7) 86.4% (83.8–89.1) 11.5% (9.6–13.5) 77.4% (74.2–80.6) 20.7% (17.8–23.6) 19.1% (15.9–22.3) 82.1% (68.6–95.7) #

84.3% (76.1–92.6) 64.3% (59.8–68.8) 44.4% (40.3–48.6) 21.0% (18.2–23.7)

83.1% (73.1–93.1) 64.3% (59.1–69.6) 45.5% (40.1–50.9) 25.2% (21.2–29.2)

# 64.3% (59.1–69.4) 43.0% (38.8–47.3) 15.4% (12.5–18.2)

Local Currency (Ngultrum) 269.3 (162.9–375.7)

1. Current use refers to daily and less than daily use. 2. Includes manufactured cigarettes and hand-rolled cigarettes. Adapted for other products as per country situation. 3. Current non-users. 4. Current non-smokers. 5. Current non smokeless users. 6. Among those who visited a health care provider in past 12 months. * During the past 30 days. # The sample size “n” is the less than 50.

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National survey for noncommunicable disease risk factors and mental health using WHO STEPS approach in Bhutan – 2014

Findings from the Bhutan STEPs Noncommunicable Disease Risk Factor Survey 2014 provide information on several key indicators in a nationally representative sample age group of 18–69 years for the first time in the country. These indicators include tobacco use, alcohol consumption, dietary habits, physical inactivity, salt intake history, history of exposure to screening for cancer cervix, body mass index and blood pressure measurement, biochemical measurements of blood glucose and cholesterol. This survey provides Bhutan an opportunity to obtain baseline information on NCD risk factors as well as to compare with other countries. In addition, the findings will help improve understanding of the effect of interventions and the formulation of nationwide strategies for better NCD control. The rich data contained in this document will be useful to programme managers, researchers, NCD control advocates and other stakeholders. The data will generate credible evidence to promote NCD control and formulate strategies for NCD control in the country.

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