A study of the profile of behavioral risk factors of non communicable diseases in an urban setting using the WHO steps 1 approach


India is in the grip of an epidemic posed by non communicable diseases and a rising trend is even being witnessed in low socio-economic urban areas. A total of 531 adults residing in an urban settlement area participated and were interviewed with regard to the presence of behavioral risk factors using the World Health Organization (WHO) STEPS 1 questionnaire on various parameters. Smoking prevalence was found to be 18.4%, out of which more than three-fourths of the adults smoked more than one packet of cigarettes per day. Almost one-third of known hypertensive patients were not on any treatment regimen. A total of 40.3% did not participate in any kind of physical activity; 43% consumed only one serving of green vegetables a day while 58% of the patients included fruits as a part of their diet only once or twice a week. There is a need to develop strong community-based intervention programs that adopt comprehensive preventive and promotive strategies.

Keywords: Non communicable disease, risk factors, urban, WHO STEPS

How to cite this article:
Nath A, Garg S, Deb S, Ray A, Kaur R. A study of the profile of behavioral risk factors of non communicable diseases in an urban setting using the WHO steps 1 approach. Ann Trop Med Public Health 2009;2:15-9


How to cite this URL:
Nath A, Garg S, Deb S, Ray A, Kaur R. A study of the profile of behavioral risk factors of non communicable diseases in an urban setting using the WHO steps 1 approach. Ann Trop Med Public Health [serial online] 2009 [cited 2020 Dec 5];2:15-9. Available from: https://www.atmph.org/text.asp?2009/2/1/15/64268



According to a WHO report from 2005, non communicable diseases (NCDs), especially cardiovascular disease, cancer, and Type II diabetes mellitus account for 53% of all deaths and 44% of Disability Adjusted Life Years (DALYs) in India. [1] Whereas unhealthy diet and a lack of physical exercise are leading causes of NCDs, there exists a number of risk factors such as high blood pressure, high serum cholesterol, inadequate intake of fruits and vegetables, excess weight, physical inactivity, and alcohol and tobacco use. It has been projected that in the next 10 years, India would be losing an estimated $237 billion in the national income as a result of NCDs due to reduced economic productivity. [1] The growing urbanization, poor dietary habits and low awareness regarding the predominant risk factors are contributing towards this rising epidemic. Studies conducted across India and other Asian countries report a higher prevalence of coronary artery disease in urban areas as compared with rural areas. [2],[3] It has been observed that although the burden posed by communicable diseases is still in existence in low socio-economic urban areas, a rising trend in NCDs is being encountered. [4] However, NCDs are largely preventable. The WHO STEPS approach focuses on obtaining core data on the established risk factors that determine the major non communicable disease burden by covering three different levels of steps of risk factor assessment, which includes a questionnaire (STEP 1), simple physical measurements (STEP 2), and Biochemical Measurements (STEP 3). [5] In this study, we will be presenting the preliminary findings of the STEP 1 approach, which is a part on an ongoing surveillance study that is being conducted in the urban field practice area of our institution.

Materials and Methods

This was a cross-sectional study conducted on Mata Sundari Road, which is a low-income housing settlement, and the urban field practice area of the Department of Community Medicine at Maulana Azad Medical College in New Delhi. Out of the total adult population of 2234, a total of 531 adults who gave voluntary consent were included in the study. Information on behavioral risk factors was collected by interviews using the WHO STEPS-1 questionnaire. [5] This included information pertaining to demographic details, tobacco and alcohol intake, diet, physical activity, and health seeking behavior. An inquiry for any history of hypertension was also made. With regard to diet, the total fruit and vegetable intake per day was calculated by considering one serving of fruits/vegetables to be 100 grams. For assessment of physical activity, the respondents were asked whether they undertook any kind of specific physical activity for at least 30 minutes during the day. Using the CDC guidelines, those who undertook moderate physical activity such as walking/sports for 30 minutes a day for at least 5 days a week were considered to be physically active. [6] The data so collected was compiled and analyzed using SPSS, Version 16.0.


Socio-demographic characteristics [Table 1]: Out of the total 2,234 adult participants, 270 (51%) were females. Most of the participants (23.9%) were in the age range of 20 to 27 years old followed by 23.1% who were in the 28 to 35 years old age range. The majority (334; 62.9%) were married. As many as 93 males (35.6%) were skilled workers while 95 of the women (35%) were housewives. The majority (198; 37.2%) had completed secondary education and 64.4% belonged to the lower-middle income group according to Kuppuswamy’s classification. [7]

Tobacco intake: Out of 261 adult males, 94 (17.7%) claimed they had smoked at least 100 cigarettes during their lifetime. Only 6.5% admitted to tobacco chewing. About 18.4% were current smokers out of whom the majority (86.7%) smoked more than one packet of cigarettes every day. As many as 14.2% took their first cigarette puff within 5 minutes of waking up. Only 28.5% had ever considered quitting smoking. The majority (349; 69.5%) agreed that smoking/tobacco consumption is bad for their health.

Alcohol intake: Only 23 of the males (8.9%) admitted to alcohol consumption. All claimed to be social drinkers.

Hypertension: As many as 48.5% of the respondents stated that their blood pressure had been checked by a health professional. About 73 (13.7%) were known hypertensives out of whom 20 (27.3%) were not on any kind of medication/dietary restriction/ weight reduction program.

Physical exercise: A majority of the adults (214; 40.3%) did not partake in any kind of specific physical activity [Figure 1]. Only 150 adults (28.2%) had ever received advice from health personnel to undertake physical activity.

Body weight: The body weight of only 179 respondents (33.7%) had been measured over the past 1 year. Only 45 adults (8.5%) stated that they were keen on maintaining an optimum body weight.

Diet: A majority (309; 58%) consumed fruits only once or twice per week even though most (410; 77.2%) said that they had enough money to buy fruits [Figure 3]. As many as 227 adults (43%) consumed only one serving of green vegetables per day [Figure 2]. About 93% stated that they had adequate money to purchase vegetables. Almost all (97.2%) said that fruits and vegetables were readily available in their area. A maximum number of respondents (339; 63.8%) used refined vegetable oil for cooking followed by the use of mustard oil by (112; 21%). About 287 of the respondents (54%) added salt to their food before serving.


Our study reports a prevalent smoking rate of 18.4%, which is in agreement with the finding obtained from an analysis of the National Family Health Survey -2 results.[8],[9],[10],[11] However, it is less as compared with observations made in other studies in similar settings. Also, a majority of these smokers would smoke more than one packet of cigarettes per day, which is in contrast to a study report from Baroda but in consonance with the findings of a multicentric study. [11],[12] The prevalence rate of 6.5% for tobacco chewing was seen to be much less than the figure reported in other studies. [8],[13] None of the women in this study reported tobacco use unlike the observation made in various other studies. [8],[10],[14] Even though a majority of the respondents agreed that tobacco consumption is injurious to their health, only 28.5% of the smokers had ever considered quitting smoking. This finding calls for not only an intensification of Information, Education, and Communication (IEC) efforts against the use of tobacco, but also for the development and strengthening of programs emphasizing quitting tobacco in such urban communities.

In our study, only 8.9% of the males admitted to indulging in social drinking. This is much less than the prevalence of alcoholic consumption as observed in other studies. [10],[15] The prevalence of alcohol use in India varies from as low as 7% in Gujarat to as high as 75% in Arunachal Pradesh. [16] A disturbing observation of the prevalence of physical inactivity to be as high as 80.6% was also made. This is slightly higher than other research findings made in analogous studies. [10],[17],[18] This could be attributed to factors such as the lack of open spaces/parks in such housing settlements, recreation/sports facilities and awareness of the benefits of physical exercise. The latter is evident from the fact that only 28.2% had ever received advice from health personnel about the advantages of physical activity. These findings re-iterate the need to introduce physical activity programs for both genders and all age groups in such communities. Inter-sectoral co-ordination of the health sector with other sectors will play an important role in the introduction of such programs in the community.

With regard to general physical examination, about 48.5% of the respondents had their blood pressure measured while 33.7% had their body weight measured by a trained health personnel over the past 1 year. This is in agreement with the study findings reported among a group of urban dwellers in the city of Baroda wherein a large percentage of the study subjects never had a health check-up. [11] Therefore, it is imperative that routine general physical examinations be incorporated as a part of community intervention programs to detect an early emergence of risk factors. As many as 13.7% of the respondents had known episodes of hypertension; of these, almost one-fourth were not undertaking any kind of treatment/lifestyle modification measures. The prevalence of hypertension in India is higher in urban areas ranging from 20 to 40% as compared with 12 to 17% in rural areas. [19],[20]

The majority (58%) of the study participants consumed fruit only one to two times per week, while 43% had only one serving of vegetables per day. This is much less than the WHO recommended intake of 400 to 500 grams per day. [21] A higher level of fruit and vegetable intake of 2 to 3 servings per day have been observed amongst urban slum dwellers of Ballabhgarh in the state of Haryana. [10] A national level survey conducted by the ICMR revealed that out of 39,388 respondents surveyed across the country, only 54 people consumed five or more servings of fruits and vegetables per day. [22] The low intake in our study occurred despite the ease of availability and affordability of fruits and vegetables in the residential colony. A number of studies conducted across India have shown a significant association with a low intake of fruits and vegetables and the risk of non communicable diseases. [23],[24],[25] It has been estimated that 2.7 million lives could be potentially saved if the consumption of fruits and vegetables were sufficiently increased. [26] Also, 54% of the participants agreed to the addition of salt in the food prior to serving thus increasing the risk of hypertension as evident from research findings in other reports. [27],[28] A maximum number of the respondents (63.8%) used refined vegetable oil for cooking followed by mustard oil usage by 21%. These contain significant levels of poly unsaturated fatty acids shown to be protective against coronary artery disease. [29],[30]

Hence, the findings observed in the present study point toward an urgent need of developing strong community-based intervention programs that adopt comprehensive preventive and promotive strategies. This also requires a holistic multi-sectoral and multi-disciplinary approach and designing as well as exploring cost-effective and acceptable models and methods to be advocated in such programs. The involvement of the private sector through a public-private mix will also strengthen surveillance of risk factors of non communicable diseases in urban settings. Community involvement and community empowerment will go a long way in contributing to the success of prevention and control programs.



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Source of Support: None, Conflict of Interest: None


[Figure 1], [Figure 2], [Figure 3]


[Table 1]

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