PR E V 2017 ALENCE OF NONCOMM U NI C ABLE DI …...PR E V ALENCE OF NONCOMM U NI C ABLE DI S E A S E...
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NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY PREVALENCE OF NONCOMM
UNICABLE DISEASE RISK FACTORS, 2017
NATIONALHOUSEHOLD HEALTHSURVEY IN TURKEYPREVALENCE OF NONCOMMUNICABLEDISEASE RISK FACTORS2017
Republic of TurkeyMinistry of Health
World Health Organization Regional Office for EuropeUN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark
Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01Email: [email protected]
Website: www.euro.who.int
The WHO Regional Office for EuropeThe World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves.
Member StatesAlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzechiaDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandIsraelItalyKazakhstanKyrgyzstanLatviaLithuaniaLuxembourgMaltaMonacoMontenegroNetherlandsNorwayPolandPortugalRepublic of MoldovaRomaniaRussian FederationSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTajikistanThe former Yugoslav Republic of MacedoniaTurkeyTurkmenistanUkraineUnited KingdomUzbekistan
NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY: PREVALENCE OF NONCOMMUNICABLE DISEASE RISK FACTORS, 2017
Republic of TurkeyMinistry of Health
ii National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ABSTRACT
This publication reports the results of the National Household Health Survey – Prevalence of Noncommunicable Disease Risk Factors in Turkey, conducted in 2017 using the WHO-approved STEPwise survey method. The main objectives of the survey were: to determine the prevalence of the most common behavioural and biological risk factors for noncommunicable diseases (NCDs) in the general population aged ≥ 15 years; and to determine differences in the prevalence of risk factors between the sexes, across five age groups and across 12 regions described by level-1 Nomenclature of Territorial Units for Statistics. The risk conditions were grouped into behavioural factors understood as modifiable (tobacco use, harmful alcohol consumption, low consumption of fruits and vegetables, and physical inactivity etc.) and biological factors considered controllable (hypertension, overweight and obesity, high blood sugar and increased total cholesterol etc.). The results obtained in the study show the current prevalence of NCD risk factors among the Turkish population.
In addition to obtaining valuable information on NCD risk factors for people of five different age groups, both sexes and 12 regions, the results of the survey provide a significant input for policy-makers.
Keywords NONCOMMUNICABLE DISEASES PREVENTION AND CONTROL RISK FACTORS TURKEY STEPWISE APPROACH
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ISBN 9789289053136
Suggested citation: National Household Health Survey – Prevalence of Noncommunicable Disease Risk Factors in Turkey 2017 (STEPS). Üner S, Balcılar M, Ergüder T editors. World Health Organization Country Office in Turkey, Ankara, 2018.
© World Health Organization 2018
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Data source: Ministry of Environment and Urbanization, Republic of Turkey
Map production: WHO Country Office in Turkey
iii
CONT
ENTS
CONTENTS iii
TABLES vi
FIGURES viii
ABBREVIATIONS x
FOREWORD xi
PREFACE xiv
ACKNOWLEDGEMENTS xvi
CONTRIBUTORS xviii
EXECUTIVE SUMMARY xx
1. BACKGROUND OF THE SURVEY 2
1.1. Noncommunicable diseases 2
1.2. Risk factors 3
1.3. NCDs and risk factors in Turkey 4
1.4. STEPwise approach 5
2. SURVEY GOAL AND OBJECTIVES 8
2.1. Survey goal 8
2.2. Survey objectives 8
2.3. Rationale for the survey 8
3. SURVEY METHODOLOGY 10
3.1. Inclusion criteria 10
3.2. Exclusion criteria 10
3.3. Sample size 11
3.4. Effective sample 11
3.5. Sampling frame 11
3.6. Sampling design 11
3.7. Selection of individuals 16
3.8. Survey design 16
3.9. Weighting of the survey 17
3.10. Data collection 19
3.11. Training of the field survey staff 20
3.12. Field work 21
3.13. Data management and consolidation 21
3.14. Measurement and determination of risk factors 21
3.14.1. Step 1 21
3.14.1.1. Tobacco use 21
3.14.1.2.Consumptionofalcohol 21
3.14.1.3.Consumptionoffruitsandvegetables 22
iv National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
CONTENTS
3.14.1.4.Physicalactivity 22
3.14.2. Step 2 22
3.14.2.1.Bloodpressure 23
3.14.2.2. BMI 23
3.14.2.3.Waistandhipcircumference 23
3.14.3. Step 3 24
3.14.3.1.Glycaemia 24
3.14.3.2. HbA1c 24
3.14.3.3.Totalcholesterol 25
3.14.3.4.Triglycerides 25
3.14.3.5.HDLcholesterol 25
3.14.3.6.Urinarysodiumandcreatinine 25
4. SURVEY RESULTS 28
4.1. Sampling and participation 28
4.2. Demographic indicators 28
4.2.1.Ageandsexcharacteristics 29
4.2.2.Maritalstatus 30
4.2.3.Education 32
4.2.4.Employment 36
4.2.5. Income 37
4.3. Tobacco use 39
4.3.1.Conclusions 46
4.4. Alcohol consumption 46
4.4.1.Conclusions 49
4.5. Use of addictive drugs (substances) 49
4.5.1.Conclusions 51
4.6. Diet: fruit and vegetable consumption 51
4.6.1.Conclusions 53
4.7. Dietary salt 53
4.7.1.Conclusions 55
4.8. Physical activity 55
4.8.1.Conclusions 58
4.9. History of raised blood pressure 58
4.9.1.Conclusions 60
4.10. History of diabetes 60
4.10.1.Conclusions 61
4.11. History of raised total cholesterol 61
4.11.1.Conclusions 62
4.12. History of CVD 63
4.12.1.Conclusions 64
v
4.13. Family history of chronic diseases 64
4.13.1.Conclusions 65
4.14. History of asthma, chronic obstructive pulmonary disease or cancer 65
4.14.1.Conclusions 67
4.15. Lifestyle advice 67
4.15.1.Conclusions 69
4.16. Awareness of harm to health from selected risk factors for NCDs 69
4.16.1.Conclusions 71
4.17. Cancer screening tests 71
4.17.1.Conclusions 72
4.18. Accidents and injuries 72
4.18.1.Conclusions 73
4.19. Ambulatory or inpatient care 73
4.19.1.Conclusions 74
4.20. Ambulatory diagnosis, treatment and home care 74
4.20.1.Conclusions 76
4.21. Physical measurements 76
4.21.1.Conclusions 80
4.22. Biochemical measurements 80
4.22.1.Conclusions 86
4.23. CVD risk 86
4.23.1. Conclusions 88
4.24. Summary of combined risk factors 88
4.24.1.Conclusions 90
4.25. Health perception 90
4.25.1.Conclusions 90
CONCLUSION 92
REFERENCES 94
ANNEX 1. FIELD TEAMS BY REGION 98
ANNEX 2. NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY – PREVALENCE OF
NONCOMMUNICABLE DISEASE RISK FACTORS, 2017 FACT SHEET 100
ANNEX 3. WHO STEPS INSTRUMENT FOR NATIONAL HOUSEHOLD HEALTH SURVEY IN
TURKEY: PREVALENCE OF NONCOMMUNICABLE DISEASE RISK FACTORS, 2017
(SURVEY INFORMATION QUESTIONNAIRE) 107
vi National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
TABLES
Table 1. NUTSregionsinTurkey 12
Table 2. SampleclustersandhouseholdsbyNUTS-1regions 15
Table 3. Distributionofnonrespondinghouseholdnumbersbyclustersand
NUTSregions 17
Table 4. Datafortwo-waysex–agepoststratification 18
Table 5. Datafortwo-waysex-educationpoststratification 18
Table 6. DataforNUTS-1regionpoststratification 19
Table 7. Equipmentandsuppliesusedforthefieldimplementation 19
Table 8. WHOcut-offpointsandriskofmetaboliccomplications 24
Table 9 Overallresponseproportions 28
Table 10. Ageandsexdistributionofrespondents 29
Table 11. NUTS-1distributionofrespondents 30
Table 12. Maritalstatusofrespondentsbysexandagegroup 30
Table 13. MaritalstatusofrespondentsbyNUTS-1regions 31
Table 14. Respondents’highestlevelofeducationbysexandagegroup 33
Table 15. Respondents’levelsofeducationbyNUTS-1regions,bothsexes 34
Table 16. Respondents’meannumberofyearsofeducationbysexandagegroup 34
Table 17. Respondents’meannumberofyearsofeducationbyNUTS-1regions 35
Table 18. Respondents’paidemploymentstatusbysexandagegroup 36
Table 19. Respondents’unpaidemploymentstatusbysexandagegroup 37
Table 20. Respondents’meanannualpercapitahouseholdincomebyNUTS-1regions 38
Table 21. Percentageofcurrentsmokersamongrespondentsbysexandagegroup 39
Table 22. PercentageofcurrentsmokersamongrespondentsbyNUTS-1regions 40
Table 23. Smokingstatusofrespondentsbysexandagegroup 42
Table 24. Meanageatwhichcurrentdailysmokersamongrespondents
startedsmoking,bysexandagegroup 43
Table 25. Meanamountoftobaccousedbydailysmokersbytypeandagegroup 44
Table 26. Currentusersofsmokelesstobaccobysexandagegroup 45
Table 27. Alcoholconsumptionamongrespondentsbysexandagegroup 47
Table 28. Meannumberofepisodesinwhichcurrentdrinkersdrank≥ 6drinkson
asingleoccasionintheprevious30days,bysexandagegroup 48
Table 29. Proportionoftotalrespondentswhodrank≥ 6drinksonasingleoccasion
intheprevious30days,bysexandagegroup 49
Table 30. Respondentswhoneverusedaddictivedrugsbysexandagegroup 50
Table 31. Respondentswhocurrentlyuseaddictivedrugsbysexandagegroup 50
Table 32. Respondentswhotriedaddictivedrugsbysexandagegroup 50
Table 33. Meannumberofdaysinatypicalweekinwhichrespondentsconsumed
fruitbysexandagegroup 51
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Table 34. Meannumberofdaysinatypicalweekinwhichrespondentsconsumed
vegetablesbysexandage 51
Table 35. Meannumberofdaysinatypicalweekinwhichrespondentsofbothsexes
consumedfruitandvegetablesbyNUTS-1regions 52
Table 36. Meannumberofservingsoffruitconsumedperdaybysexandagegroup 52
Table 37. Meannumberofservingsofvegetablesonaverageperdaybysexandagegroup 53
Table 38. Proportionofrespondentsconsumingfewerthanfiveservingsoffruit
and/orvegetablesonaverageperdaybysexandagegroup 53
Table 39 Respondents’useofdietarysaltbysexandagegroup 54
Table 40. Respondents’levelsoftotalphysicalactivityasdefinedbyWHObysex
andagegroup 56
Table 41. Respondents’meanminutesofwork-relatedphysicalactivityonaverage
perdaybysexandagegroup 56
Table 42. Respondents’meanminutesoftransport-relatedphysicalactivityon
averageperdaybysexandagegroup 57
Table 43. Respondents’meanminutesofrecreation-relatedphysicalactivity
onaverageperdaybysexandagegroup 57
Table 44. ProportionsofrespondentsnotmeetingtheWHOrecommendations
onphysicalactivityforhealthbysexandagegroup 58
Table 45. Respondents’activitiestomanagehypertensionbysex 59
Table 46. Respondents’activitiestomanagediabetesbysex 61
Table 47. Respondents’activitiestomanagetotalcholesterolbysex 62
Table 48. Proportionsofrespondentsthatcouldstatetwoormorenegative
healtheffectsofdifferentriskfactors,byagegroup 70
Table 49. Percentagesofrespondentswhohadvisitedahospitalforthetreatment
ofhypertension,CVD,diabetes,cancer,COPDorasthmaintheprevious
12months,bysexandagegroup 73
Table 50. Proportionofallhypertensivepeoplewithcontrolledbloodpressure
inthepopulation 78
Table 51. ProportionsofrespondentswithmeanHbA1c,bysexandagegroup 82
Table 52. ProportionofrespondentswithraisedHbA1C(≥6.5%)orwhowere
currentlyonmedicationfordiabetes 82
Table 53. Meantotalcholesterol,bysexandagegroup 83
Table 54. Respondents’meanHDLcholesterollevels,bysexandagegroup 84
Table 55. Respondents’meanfastingtriglyceridesbysexandagegroup 85
Table 56. Percentageofrespondentswhohadaten-yearCVDrisk≥ 30%or
alreadyhadCVD,bysexandagegroup 87
Table 57. Proportionofeligiblepersonsreceivingdrugtherapyandcounselingto
preventheartattacksandstrokes 88
Table 58. Healthstatusperceptionofindividuals,byagegroup 91
viii National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
FIGURES
Fig. 1. GeographicalbordersofNUTS-1regions 14
Fig. 2. SamplesizesbyNUTS-3provinces 15
Fig. 3. Geographicallocationofsampleclusters 16
Fig. 4. Respondents’levelsofeducationbysex 32
Fig. 5. Respondents’meannumberofyearsofeducationbyNUTSregions 35
Fig. 6. MeanannualpercapitahouseholdincomebyNUTS-1regions 38
Fig. 7. Percentageofcurrentsmokersbysexandagegroup 39
Fig. 8. Prevalenceofdailysmokingamongcurrenttobaccousersbysex
andagegroup 40
Fig. 9. PrevalenceofdailysmokinginrespondentsbyNUTS-1regions 43
Fig. 10. Dailysmokersusingmanufacturedcigarettesbysexandagegroup 44
Fig. 11. Currentsmokerswhohadtriedtoquitduringtheprevious12months 45
Fig. 12. Currentsmokersadvisedbyadoctortostopsmokingintheprevious
12months 46
Fig. 13. Respondents’alcoholconsumptionstatusbyNUTS-1regions 48
Fig. 14. Respondentswhothinkloweringsaltindietisveryimportant 55
Fig. 15. Proportionsofrespondentsnotengaginginavigorous
physicalactivitybysexandagegroup 58
Fig. 16. Bloodpressuremeasurementandhypertension
diagnosisamongrespondentsbysex 59
Fig. 17. Bloodsugarmeasurementanddiabetesdiagnosisamongrespondentsbysex 60
Fig. 18. Percentagesofrespondentswithraisedbloodglucosewhoare
currentlytakingmedicationorinsulin,bysex 61
Fig. 19. Cholesterolmeasurementandraised-cholesterol
diagnosisamongrespondentsbysex 62
Fig. 20. Respondentswhoeverhadaheartattackorchestpainfromheart
disease,orastroke,bysexandagegroup 63
Fig. 21. Percentagesofrespondentswhoarecurrentlytakingaspirinorstatins
regularlytopreventortreatheartdiseasebysex 64
Fig. 22. Typesofdiagnosedchronicdiseaserequiringmedication
forrespondents’parentsorsiblings 65
Fig. 23. Proportionsofrespondentswithanasthmadiagnosis,bysexandagegroup 66
Fig. 24. ProportionsofrespondentswithCOPDdiagnoses,bysexandagegroup 66
Fig. 25. Respondents’perceptionoftheirweightbysex 67
Fig. 26. Percentageofrespondentswhoreceivedlifestyleadvicefromadoctor
orhealthworkerduringtheprevious12monthsbyagegroup 68
Fig. 27. Percentageofrespondentswhocouldnametwoormorenegative
healtheffectsofanyoftheselectedNCDriskfactors 70
Fig. 28. Percentagesofrespondentswhohaveheardthatthecancerscreeningsare
availablefreeinFHCandCEDSTC,bysexandagegroup 71
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Fig. 29. Typesofaccidentscausinginjuriessufferedbytherespondentsin
theprevious12months,bysex 72
Fig. 30. Percentagesofrespondentsinjuredasaresultofanaccidentintheprevious
12monthswhoreceivedambulatoryorinpatientcare,byagegroup 73
Fig. 31. Typeandlengthofcarereceivedbyrespondentswhohadvisitedahospitalfor
thetreatmentofhypertension,CVD,diabetes,cancer,COPDorasthmainthe
previous12months 74
Fig. 32. Percentagesofrespondentswhohadvisitedhealthpersonnel,bysex 75
Fig. 33. Percentagesofrespondentswhohadvisitedhealthpersonnelwithinthe
previousmonth,byagegroup 75
Fig. 34. Percentagesofrespondentswhohadreceivedmedicalcareathomeinthe
previous12months 76
Fig. 35. Respondents’meanSBPandDBP(mmHg)bysexandagegroup 77
Fig. 36. Percentagesofrespondentswithraisedbloodpressureorcurrentlyon
medicationforraisedbloodpressure,bysex 77
Fig. 37. Percentagesofrespondentswithraisedbloodpressure,excludingthoseon
medicationforraisedbloodpressure,byagegroup 78
Fig. 38. Respondents’meanBMI,bysexandagegroup 79
Fig. 39. DistributionbyBMIcategory,bysex 79
Fig. 40. Meanfastingbloodglucose,bysexandagegroup 80
Fig. 41. Prevalenceofimpairedfastingglycaemiabysexandagegroup 81
Fig. 42. Proportionsofrespondentswhohadraisedbloodglucoseorwere
currentlyonmedicationfordiabetes,bysexandagegroup 81
Fig. 43. PercentageofrespondentswithraisedHbA1c≥ 6.5%,bysexandagegroup 82
Fig. 44. ProportionsofrespondentswithraisedHbA1corraisedbloodglucoseorwere
currentlyonmedication,bysexandagegroup 83
Fig. 45. Percentagesofrespondentswithtotalcholesterollevels≥ 190mg/dlincluding
≥ 240mg/dlorcurrentlyonmedicationforraisedcholesterol,bysex 84
Fig. 46. PercentagesofrespondentswithlowHDLcholesterol,bysexandagegroup
(< 50mg/dlforwomenand< 40mg/dlformen) 85
Fig. 47. Percentagesofrespondentswithfastingtriglycerides
levels≥ 150mg/dland≥ 180mg/dl,bysex 86
Fig. 48. Percentageofrespondentswithaten-yearCVDrisk≥30%oralreadywith
CVDandreceivingdrugtherapyandcounsellingtopreventheartattacks
andstrokes,bysexandagegroup 87
Fig. 49. Summaryofcombinedriskfactorsinrespondents
aged18–69bysexandagegroup 89
Fig. 50. Summaryofallrespondents’combinedriskfactorsbysexandagegroup 89
Fig. 51. Respondents’perceptionsoftheirhealthstatusbysex 90
x National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ABBREVIATIONS
BMI bodymassindexCEDSTC cancerearlydiagnosisscreeningandtrainingcentres(inTurkey)CHD coronaryheartdiseaseCI confidenceintervalCOPD chronicobstructivepulmonarydiseaseCVD cardiovasculardiseasesDALYs disability-adjustedlife-yearsDBP diastolicbloodpressureFAO FoodandAgricultureOrganizationoftheUnitedNationsFHC familyhealthcentres(inTurkey)GP generalpractitionerHbA1ctest haemoglobinA1corglycatedhaemoglobintestHDLcholesterol high-densitylipoproteincholesterolHPV humanpapillomavirusMET metabolicequivalentsNCDs noncommunicablediseasesNHHST NationalHouseholdHealthSurveyinTurkey– PrevalenceofNoncommunicableDiseaseRiskFactorsNUTS-1 level-1NomenclatureofTerritorialUnitsforStatisticsPCs personalcomputersPSUs primarysamplingunitsSBP systolicbloodpressureSSUs secondarysamplingunitsSTEPS (WHO)STEPwiseapproachtosurveillanceTL TurkishLiraTURKSTAT TurkishStatisticalInstituteWHR waist–hipratio
xi
The prevalence of, and mortality from, noncommunicable diseases (NCDs) have increased in Turkey, as they have around the world, even though life expectancy is rising and the burden of disease is changing. NCDs are the leading cause of death globally and account for a significant share of disability-adjusted life-years; they therefore place a substantial burden on health systems, as well as negatively affecting one’s quality of life.
The majority of NCDs are considered preventable as they are predominantly caused by modifiable risk factors. Current information and experience show that appropriate intervention programmes for societies or individuals can prevent NCDs. Feasible and evidence-based policies, suitable for each country’s infrastructure, are needed for the planning and implementation of intervention programmes.
Leading risks to health, based on one’s lifestyle, such as tobacco use, insufficient physical activity, raised cholesterol, raised blood pressure and alcohol consumption – increase the risk of NCDs. Reducing NCDs requires focusing on reducing their risk factors. Evidence-based public health intervention programmes should be developed at a national level on the basis of the most prevalent risk factors identified. Community-wide representative data is required to plan the activities to be implemented within this framework and to evaluate their effects.
In cooperation with WHO, the Ministry of Health of Turkey therefore conducted the National Household Health Survey – Prevalence of Noncommunicable Disease Risk Factors in Turkey to collect data on prevalent NCDs and respective risk factors based on individual statements and physical and biological measurements. This survey is important because it is countrywide and representative, and provides an opportunity for international comparisons and highlighting needs in the country.
I would like to use this opportunity to extend my gratitude to all who have contributed to this survey, which will provide valuable information for programmes to prevent and control NCDs in our country.
Dr Fahrettin KocaMinister of Health, Republic of Turkey
FOREWORD
xii National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
FOREWORD
Noncommunicable diseases (NCDs) are the leading cause of death globally. The growing number of people living with one or more NCDs, as well as the increasing number of premature deaths resulting from them, places a heavy strain on health systems and negatively impacts both economic development and well-being. We can see that efforts to control NCDs do yield results: in the WHO European Region, premature deaths from NCDs clearly declined in 2000–2010. Nonetheless, these conditions still account for nearly 80% of all deaths in the Region. Globally, NCDs represent one of the most pressing challenges to sustainable development in the 21st century. Action to mitigate, prevent and control them will be vital – across all sectors and settings – if the world hopes to achieve the ambitious targets of the Sustainable Development Goals (SDGs).
In accordance with the political declaration on NCD prevention and control adopted by the United Nations General Assembly in 2011, WHO developed its global action plan for NCD prevention and control for 2013–2020. To assess the actions taken to implement this plan, WHO also established a global monitoring framework, which includes nine voluntary targets and 25 indicators on health status, risk factors and health systems’ capacity and response. The action plan and monitoring framework provide a solid basis for all activities to prevent and control NCDs, and it is important for all countries to actively participate in these efforts.
After all, no country is left untouched by the epidemic of chronic diseases, including Turkey. The impact of NCDs in the coming year will be defined by whether and how countries respond to this growing threat to the health and well-being of their people and societies. Turkey is a country that has taken major steps to prevent and control NCDs, to reduce the additional burden on health systems and to provide comprehensive health care for the sick. In 2017, the Ministry of Health endorsed the country’s multisectoral action plan on NCDs for 2017–2025, to improve the health sector’s response to NCDs, to facilitate multisectoral cooperation, to ensure that all institutions implement health policy and to develop a common perspective on the subject. WHO’s nine voluntary global targets for NCD prevention and control were reviewed and adapted to the country context, with the participation of representatives of civil society organizations, academia and the WHO Country Office in Turkey. An additional 25 country-specific indicators were identified and target-specific priority areas were discussed.
FOREWORD
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Turkey also hosted the United Nations Interagency Task Force on NCDs in April 2016 and has hosted several missions to assess health systems barriers for better NCDs outcomes. The country implemented a comprehensive analysis of NCDs and their risk factors, using the WHO STEPwise approach to surveillance (STEPS), which focuses on obtaining core data on the established risk factors that determine the major disease burden. I would like to extend my gratitude to the Minister of Health of Turkey, Dr Fahrettin Koca, for the Ministry’s remarkable leadership of and support for these achievements. These actions, along with future activities, will play a pivotal role in helping Turkey face the NCDs epidemic.
The WHO Regional Office for Europe aims to be a partner in fighting NCDs alongside countries of the Region. Establishing a process to monitor and assess the implementation of action to prevent and control NCDs in a country involves a number of challenges related to the availability, comparability and quality of data. Thus, the Regional Office aims to enhance the availability and quality of NCD-related information and to orient health policy in Europe to address the major challenges to health and development, in line with European Health 2020 policy framework and the SDGs.
This report is an important step in setting the baseline for the prevalence of NCDs and their risk factors in Turkey. I hope that this publication will be useful not only in helping decision-makers in Turkey to sustain their commitment but also in saving the lives of citizens at risk of premature mortality from NCDs.
Dr Zsuzsanna Jakab WHORegionalDirectorforEurope
xiv National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
PREFACE
Noncommunicablediseases (NCDs)arethe leadingcauseofdeathat theglobal,regionalandnational levels.NCDskill40millionpeopleeachyear,equivalentto70%ofalldeathsglobally.Eachyear,15millionpeopleaged30–69yearsdiefromanNCD;over80%oftheseprematuredeathsoccurin low- and middle-income countries. NCDs threaten progress towardsthe 2030 Agenda for Sustainable Development, which includes a targetof reducing premature deaths from NCDs by one third by 2030. PovertyiscloselylinkedwithNCDs.TherapidriseinNCDsispredictedtoimpedepoverty reduction initiatives in low-income countries, particularly byincreasinghouseholdcostsassociatedwithhealthcare.
NCD death rates in Turkey are similar to those in the rest of the WHOEuropean Region. NCDs are responsible for 87.5% of all deaths in thecountry. The probability of premature death from one of the fourmajorNCDsforapersonlivinginTurkeywasaroundoneinsix(16.8%)in2015.TheNCDburden isundermining thesocialandeconomicdevelopmentof thecountry.NCDshavesignificantandgrowinghealthandfinancialcosts toindividuals,families,thehealthsystemandtheeconomy.WithoutadequatepreventionofthecommonriskfactorsandearlyidentificationofNCDs,thecostsforTurkishsocietywillincrease.
TorespondtothegrowingburdenofNCDs,headsofstateandgovernmentendorsedtheUnitedNations’PoliticalDeclarationoftheHigh-levelMeetingoftheGeneralAssemblyonthePreventionandControlofNon-communicableDiseases inMay 2011, and theWorldHealthAssembly endorsed theWHOglobalactionplanforNCDpreventionandcontrol2013–2020.
TheGovernmentofTurkeyrecognizedtheimpactofNCDsandreaffirmedits commitment to tackling them and their risk factors. To realize thesecommitments, Turkey published a multisectoral action plan for NCDscoveringtheperiod2017–2025.Inaddition,Turkeydevelopedaninvestmentcase for NCD prevention and control, with contributions from WHO, toprovide evidence that NCDs reduce economic output and to discusspotentialoptionsforresponse,inordertodetermineasetofinterventionsthataremostsuitedtothecountry.
Thedevelopmentandimplementationofhealthpoliciesrequirehigh-qualityanddisaggregateddataatthenational leveltounderstandtheproblems,toinformtheneedforinterventions,todevelopappropriateinterventions
PREFACE
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toreducetheburdenofdiseaseandaddresshealthinequalities,andtomonitorprogressinachievingthetargetsset.
Theprimaryobjectiveof thesurvey inTurkey,usingaWHOapproachtosurveillance,wastoevaluatethebaselinesituationofthemainNCDriskfactors,bothbehaviouralandmetabolic/physiological,andtoinformallnationalandinternationalstakeholdersofthesituation.
ThesurveydatawillserveasbaselineinformationfornewNCDpoliciesandastartingpointformonitoringtheprevalenceof riskfactors.Theeffectivenessof interventionstoreducetheburdenofNCDsandtheirrisk factorswillalsobeanalysed.The resultsof thesurveywillenablecomparisonof theprevalenceanddistributionofNCDriskfactorsovertimeandacrosscountries.
ThispublicationreportstheresultsoftheNationalHouseholdHealthSurvey–PrevalenceofNoncommunicableDiseaseRiskFactorsinTurkey,conductedin2017usingtheWHO-approvedSTEPwisesurveymethod(STEPS).The survey’s main objectives were: to determine the prevalence of the most common behavioural andbiologicalriskfactorsforNCDsinthegeneralpopulationaged≥15years;andtodeterminedifferencesintheprevalenceofriskfactorsbetweenthesexes,acrossfiveagegroupsandacross12regionsdescribedbylevel-1NomenclatureofTerritorialUnitsforStatistics.Theriskconditionsweregroupedintomodifiablebehaviouralfactors(tobaccoconsumption,harmfulalcoholconsumption,lowconsumptionoffruitsandvegetables,andphysicalinactivity)andcontrollablebiologicalfactors(hypertension,overweightandobesity,highbloodsugarandincreasedtotalcholesterol).TheresultsobtainedfromthestudyshowthecurrentprevalenceofNCDriskfactorsamongtheTurkishpopulation.
WHOprovides continuouspolicy advice, technical assistanceandcapacity building to theGovernmentofTurkey,aimingtoimprovepopulationhealthandtoreducehealthinequalitiesthroughwhole-of-governmentand-societyapproaches.Inthisway,WHOofferssupporttothecountryinensuringitsengagementintheimplementationatnational levelof theEuropeanstrategyforhealthandwell-being,Health2020,andtheWHOglobalandEuropeanactionplansforNCDpreventionandcontrol.
BoththeGovernmentofTurkeyandWHOareverygratefultotheirpartners:especiallytheInternationalBankfor Reconstruction and Development (World Bank), for the guidance provided under the “Health SystemsStrengtheningandSupportProject”,whichwassignedby theGovernmentofTurkeyand theWorldBank,to providefinancial support to implement thefirst STEPS survey in Turkey; and to other partners at theinternationalandnationallevelswhoprovidedtechnicalassistanceincarryingoutthesurvey.
TheWHOCountryOffice,TurkeyisgratefulfortheexcellentcollaborationwiththeMinistryofHealthofTurkeyandlooksforwardtocontinuedjointworktodisseminateTurkey’sachievementsinothercountries.
Dr Pavel Ursu WHORepresentativeinTurkey
xvi National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ACKNOWLEDGEMENTS
The members of the “National Household Health Survey in Turkey – Prevalence of Noncommunicable Disease Risk Factors (STEPwise approach to Surveillance (STEPS)” working group would like to express their sincere gratitude to the Ministry of Health of Turkey for the implementation of this survey, and particularly to Emine Alp Meşe, Deputy Health Minister; Eyüp Gümüş, Undersecretary, Elif Güler Kazancı, Deputy Undersecretary; Alper Cihan, Director-General of Health Services; Muhammed Ertuğrul Eğin, Deputy Director-General of Health Services; Oğuzhan Özkan, Head of the Department of Health Research, Directorate-General of Health Services, Tufan Nayır, Adviser to Deputy Health Minister, for their commitment to this report. Special thanks go to Mehmet Rıfat Köse, former Director-General of Health Research of the Ministry of Health, for initiating this process, and continuous commitment to and leadership and guidance throughout the entire STEPS survey process.
The specific contributions of Banu Ayar, Ayşegül Gençoğlu, Abdullah Akünal, Ayşegül Doğan Sönmez at the Department of Health Research, Directorate-General of Health Services, Ministry of Health – in convening the national scientific advisory board, organizing workshops, providing national materials and providing coordination and support in the development of methodology, the survey instrument, sampling, training the research team, data analysis and drafting this STEPS survey report – are particularly acknowledged.
Special thanks to the national scientific advisory board for their valuable contribution to planning, implementing and reviewing the findings of the survey.
This survey was conducted under the overall guidance of Leanne Margaret Riley, Team Leader, Surveillance and Population based-Prevention of Noncommunicable Diseases, WHO headquarters; Pavel Ursu, WHO Representative and Head of the WHO Country Office, Turkey; Gauden Galea, former Director of the Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe and Bente Mikkelsen, Director Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe. Members of the working group also express their sincere gratitude to Enrique Gerardo Loyola Elizondo, Coordinator, Integrated Prevention and Control of Noncommunicable Diseases, WHO Regional Office for Europe; Lubna Bhatti and Stefan Savin, Department of Surveillance and Population-based Prevention of Noncommunicable Diseases, WHO headquarters; and Toker Ergüder, National Professional Officer, Noncommunicable Diseases and Life-Course, WHO Country Office, Turkey, for their continuous technical support in the development of methodology, the survey instrument, sampling, training the research team and data analysis.
Members of the working group would also like to thank Enis Barış, Practice Manager, Health Nutrition Population; and Ahmet Levent Yener, Senior Human Development Specialist, Health Nutrition Population at the International Bank for Reconstruction and Development (World Bank) for the guidance that they provided under the “Health Systems Strengthening and Support Project” which was signed between Government of the Turkish Republic and the World Bank.
In addition, members of the working group would like to thank the WHO implementing partner, PGlobal Global Advisory and Training Services Inc., for the field implementation of the survey, particularly to Ertan Yülek and Alpaslan Girayalp and all the technical and field
ACKNOWLEDGEMENTS
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teamsfortheirremarkablepartnership,wellasSarpÜner,MehmetBalcılar,UfukYüzüncü,SelçukDinç,AhmetGül,SüzülayHazarandGökhanKoçtürkfortheirtechnicalsupportinthedevelopmentofmethodology,surveyinstrument,sampling,trainingtheresearchteam,dataanalysisanddraftingthisSTEPSsurveyreport.
Thestatisticalanalysis teamcomprised:MehmetBalcılar,SarpÜner,StefanSavin,LubnaBhatti,TokerErgüder,AhmetGül,SüzülayHazarandGökhanKoçtürk;andthereportwasdrafted by Sarp Üner, Mehmet Balcılar, Toker Ergüder, Alpaslan Girayalp , Ufuk Yüzüncü,SelçukDinçandCansuSaraç.
ThanksarealsoextendedGülMenetandSılaSaadetToker for translationand readingoftheTurkishlanguageversionofthisreport,andMehtiAtlıforlayoutandtypesettingofthereport.ThankstoRezinJasimandAyşeÖzlemTorunoğluforprovidingsupportfordraftingofthereport.SpecialthankstoGülMenetformakingthearrangementsforthewholeSTEPSprocess.
Technicalassistance for thesurveyand reportwasprovidedbyWHOandcoordinatedbytheWHORegionalOfficeforEuropeandWHOCountryOffice,Turkeythroughthebiennialcollaborativeagreementcovering2016/2017betweentheMinistryofHealthofTurkeyandWHO.
ThefulllistofexpertswhocontributedtothisreportisgiveninAnnex1.
xviii National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
CONTRIBUTORS
Participating organizationsMinistryofHealthoftheRepublicofTurkeyanditsDirectorate-GeneralforHealthResearchTurkishStatisticalInstituteWorldHealthOrganizationWorldBankPGlobalGlobalAdvisoryandTrainingServicesInc.InternationalconsultantsDr Lubna Bhatti, Department of Surveillance and Population-based Prevention ofNoncommunicableDiseases,WHOheadquartersDrEnriqueLoyola,Coordinator,NCDSurveillance,WHORegionalOfficeforEuropeDrLeanneMargaretRiley,TeamLeader,SurveillanceandPopulationbased-PreventionofNoncommunicableDiseasesDr Stefan Savin, Department of Surveillance and Population-based Prevention ofNoncommunicableDiseases,WHOheadquarters
WHO Country Office, TurkeyDrPavelUrsu,WHORepresentativeinTurkeyDrTokerErgüder,NationalProfessionalOfficer,NoncommunicableDiseasesandLife-CourseMsGülMenet,ProgrammeAssistantMsSılaSaadetToker,Interpreter/Translator
Ministry of Health Scientific Advisory CommitteeProfessorDrDenizÇalışkan,PublicHealthDepartment,AnkaraUniversityMedicalFacultyProfessorDrPeyamiCinaz,PaediatricEndocrinologyDepartment,GaziUniversityMedicalFacultyProfessorDrYaseminErten,NephrologyDepartment,GaziUniversityMedicalFacultyProfessorDrBerrinİmgeErgüder,BiochemistryDepartment,AnkaraUniversityMedicalFacultyProfessorDrAhmetKaya,EndocrinologyDepartment,NecmettinErbakanUniversityMedicalFacultyProfessorDrMeralKayıkçıoğlu,CardiologyDepartment,EgeUniversityMedicalFacultyProfessorDrAytekinOğuz,InternalMedicineDepartment,İstanbulMedeniyetUniversityMedicalFacultyProfessorDrSeçilÖzkan,PublicHealthDepartment,GaziUniversityMedicalFacultyProfessorDrNevinŞanlıer,FacultyofHealthSciences,GaziUniversityMedicalFacultySpecialistDrÇiğdemSönmez,PublicHospitalUnionofTurkeyProfessorDrEbruÜnsal,PulmonologyDepartment,YıldırımBeyazıtUniversityMedicalFacultyProfessorDrS.LaleTokgözoğlu,CardiologyDepartment,HacettepeUniversityMedicalFacultyProfessorDrM.TemelYılmaz,EndocrinologyandMetabolismDepartment,İstanbulUniversityMedicalFaculty
Staff of the Ministry of Health of TurkeyDrMehmetRıfatKöse,formerDirectorGeneralofHealthResearchMrOğuzhanÖzkan,HeadofDepartmentofDirectorate-GeneralforHealthServicesSpecialistDrBanuAyar,Directorate-GeneralforHealthServicesDrAyşegülGençoğlu,Directorate-GeneralforHealthServicesMrAbdullahAkünal,Directorate-GeneralforHealthServicesMsAyşegülDoğanSönmez,Directorate-GeneralforHealthServices
CONTRIBUTORS
xix
Project team (PGlobal Global Advisory and Training Services Inc.)MrAlpaslanGirayalp,ProjectGeneralCoordinator,PGlobalProfessorDrSarpÜner,ProjectManager/TeamLeader,Collaboration,ImplementationandResearchCentreforPreventionofNoncommunicableDiseases,HacettepeUniversityProfessorDrMehmetBalcılar,ProjectChiefConsultant,FacultyofBusinessandEconomics,EasternMediterraneanUniversityDrUfukYüzüncü,ProjectCoordinator,PGlobalMrSelçukDinç,ChiefAnalyst,PGlobalMrMustafaReşitBulut,Analyst,PGlobalMsCansuSaraç,AssistantAnalyst,PGlobalMsGülcanDemirÖzdenk,AssistanttotheTeamLeader,Lecturer,HealthOccupationHighSchool,AhiEvranUniversityAssistantProfessorDrGürcanGünaydın,AssistanttotheTeamLeader,InstituteofCancer,HacettepeUniversityDrM.EminKeleş,AssistanttotheTeamLeader,FacultyofMedicine,HacettepeUniversity
Advisory board (PGlobal Global Advisory and Training Services Inc)ProfessorDrMuratYülek,Consultant,EconomicsandFinance,PGlobalDrErtanYülek,Consultant,OrganizationandPlanning,PGlobalProfessorDrZelihaGünnurDikmen,Consultant,Biochemistry,HacettepeUniversityFacultyofMedicineDrSüleymanCanNumanoğlu,Consultant,PublicHealth,PGlobal
Field survey staff (SeeAnnex1foralistoffieldteamsbyregion.)MrAhmetGül,FieldSurveyGeneralManagerMsSüzülayHazar,FieldCoordinatorMsİlaydaUrvaylioğlu,AssistantFieldCoordinatorMrTolgaÇomak,AssistantFieldCoordinatorMrGökhanKoçtürk,TechnicalCoordinatorMsYeşimUzun,HealthCoordinator
The statistical analysis team ProfessorDrMehmetBalcılar,ProjectChiefConsultant,FacultyofBusinessandEconomics,EasternMediterraneanUniversityProfessorDrSarpÜner,ProjectManager/TeamLeader,Collaboration,ImplementationandResearchCentreforPreventionofNoncommunicableDiseases,HacettepeUniversityDrTokerErgüder,NationalProfessionalOfficer,NoncommunicableDiseasesandLife-CourseMrAhmetGül,FieldSurveyGeneralManagerMsSüzülayHazar,FieldCoordinatorMrGökhanKoçtürk,TechnicalCoordinatorDrStefanSavin,DepartmentofSurveillanceandPopulation-basedPreventionofNoncommunicableDiseases,WHOheadquartersDrLubnaBhatti,DepartmentofSurveillanceandPopulation-basedPreventionofNoncommunicableDiseases,WHOheadquarters
Report drafting team ProfessorDrSarpÜnerProfessorDrMehmetBalcılarAssociateProfessorDrTokerErgüderMrAlpaslanGirayalpDrUfukYüzüncüMrSelçukDinçMsCansuSaraçMsGülMenetMsSılaSaadetToker
xx National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
EXECUTIVE SUMMARY
The National Household Health Survey – Prevalence of Noncommunicable Disease RiskFactorsinTurkeywasorganizedwithfinancialsupportprovidedbytheMinistryofHealthoftheRepublicofTurkeyunderthe“HealthSystemsStrengtheningandSupportProject”loanagreementsignedbetweentheGovernmentoftheTurkishRepublicandInternationalBankforReconstructionandDevelopment(WorldBank).TechnicalassistanceforthesurveywasprovidedbyWHOtotheMinistryofHealthoftheRepublicofTurkeywithinthescopeoftheAgreementsignedon10November2016betweenWHOandtheGovernmentoftheRepublicofTurkey.FieldimplementationoftheNationalHouseholdHealthSurveywasconductedbyPGlobalGlobalAdvisoryandTrainingServicesInc.contractedbyWHOCountryOffice,Turkey.Thefieldsurveyteamsweretrainedon10–14April2017inAnkara(seeAnnex1).Therequisitemedicalequipmentwasdeployedto14logisticalcentresserving79provincesinTurkey,andthefieldsurveyteamsweremobilizedon16–28April2017.Thefirststageofthefieldsurveywasconductedfrom28Aprilto26May.AfterapostponementforRamadan,thesurveywasresumedon3July2017,andcompletedon15September2017,owingtonationalandreligiousholidays,andunforeseencircumstancesthathinderedprogress.
The general goal of the survey was to determine the prevalence of major risk factorsfor noncommunicable diseases using the WHO-approved STEPwise survey method,so as to enable more efficient planning of activities for the prevention and control ofnoncommunicablediseases.
Themainobjectivesofthesurveywere:
todeterminetheprevalenceofthemostcommonbehaviouralandbiologicalriskfactorsfornoncommunicablediseasesinthegeneralpopulationaged≥15years;and
todeterminedifferencesintheprevalenceofriskfactorsbetweenthesexes,acrossfiveagegroupsandacross12regionsdescribedbylevel-1NomenclatureofTerritorialUnitsforStatistics.
Based on multistage cluster sampling methodology for surveillance of noncommunicablediseases,8644subjectswererandomlyselected,toensureequaldistributionoftheparticipantsaccordingtoageandsex,andincludinganestimated20%non-responserate.Atotalof6053subjectsaged≥15yearsparticipatedinthesurveyandtheresponseratewas70.0%.
Ofthetotalnumberofrespondents(N=6053),31.5%reportedbeingcurrentsmokersand29.2%dailysmokers.Mensmokedmorethanwomen(43.4%versus19.7%).Themeanageofstartingsmokingwas18.1yearsforbothsexes(17.2yearsformenand20.2yearsforwomen).Manufacturedcigaretteswereusedbydailysmokersin97.3%ofcases.Themeannumberofcigarettessmokedamongdailysmokerswas15.5.
More than four out of five respondents (83.6%) were lifetime abstainers from alcohol,and 4.3%had abstained for the previous 12months. Only 8.0%of respondents reporteddrinkingalcoholintheprevious30days,andonlyoneinevery20respondents(5.2%)wasanepisodicallyheavydrinker,althoughtheratesofepisodicheavydrinkinginmen(8.7%)wasfourtimesthatinwomen(1.8%).
Fruit and vegetable consumption was in general low: 87.8% of respondents reportedconsumingfewerthanfiveservingsoffruitandvegetablesperday,andthusbeingathigher
EXECUTIVE SUMMARY
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riskfornoncommunicablediseases.Theproportionsweresimilarformen(87.8%)andwomen(87.9%).
Almosthalfoftherespondents(43.6%)didnotmeetWHOrecommendationsonphysicalactivityforhealth,witha significantdifferencebetweenmen (33.1%)andwomen (53.9%).The totalmediantimespentinphysicalactivitywas30.0minutesperday,althoughhigheramongmen(51.4minutes)thanwomen(17.1minutes).Further,81.3%(70.1%ofmalesand92.2%offemales)didnotparticipateinanyeffectivephysicalactivity.Morethantwoinfiverespondentsreportedreceivingadviceonahealthylifestylefromadoctororotherhealthworkerduringtheprevious12months.Inaddition,87.3%ofrespondents(89.1%ofmenand85.5%ofwomen)couldstatetwoormorenegativehealtheffectsofanyoftheselectedriskfactors
Oneinfourofrespondentsaged50–70yearshadhadafaecaloccultbloodtest.Whilemorethanhalfofwomenaged30–65years (54.2%)reportedhavingbeenscreenedforcervicalcancer,threeinfiveofthoseaged40–69yearshadhadamammography.
Asaresultofphysicalmeasurements,themeanbodymassindexrecordedwas26.6kg/m2formenand28.3kg/m2forwomen.Twoineverythreerespondentswereoverweight(bodymassindex≥25kg/m2).Threein10ofrespondents(28.8%)wereobese(bodymassindex≥30kg/m2),andtheproportionofobesewomen(35.9%)was1.6timesthatofmen(21.6%).Meanwaistcircumferencewas87.9cmandhipcircumferencewas102.5forwomen,and91.3cmand98.7cmformen,respectively.
Mean systolic and diastolic blood pressure (including in people taking medication forhypertension)was 123.0mmHg and 78.4mmHg, respectively,with no substantial differencebetweenmenandwomen.Threeoutof10respondentshadhypertensionandwithoutsignificantdifferencesbetweenthesexes.
Mean fasting blood glucose was 97.8 mg/dl (96.2 mg/dl for men and 99.3 mg/dl for women).Accordingtotheresultsofthesurvey,theproportionofrespondentswithimpairedfastingbloodglycaemia (≥ 110mg/dl and< 126mg/dl)was 7.9%and thisproportionwashigheramongmen(8.1%) thanwomen (7.7%).One in 10 respondents (11.1%)haddiabetesor reduced tolerance toglucose(fastingbloodglucose≥126mg/dlortakingantidiabeticmedication),withoutsignificantdifferencesbetweenmenandwomen.TheproportionsofrespondentswithhaemoglobinA1corglycatedhaemoglobin≥6.5%wassimilarformen(11.9%)andwomen(12.2%)andincreasedwithage.
Further,oneinfourrespondents(24.7%)hadaraisedtotalcholesterollevel(≥190mg/dlortakingmedicationforhypercholesterolemia),withtheproportionbeinghigherinwomen(28.5%)thanmen(20.9%).Suboptimallevelsofhigh-densitylipoproteincholesterolwerefoundin55.6%ofmen(<40mg/dl)and49.1%ofwomen(<50mg/dl).Meansaltintakeperdaywashigh:9.9gperday(11.0gperdayformenand8.7gperdayforwomen).
The survey showed that half of the respondents (51.2%) had three ormore risk factors fornoncommunicablediseases,andthisfigureincreasedproportionallywithage.Only1.3%ofthepopulationstudiedhadnoneofthefiveriskfactors.AfactsheetdescribingtheresultsofthesurveycomprisesAnnex2ofthisreport.Annex3presentsthesurveyinstrument.
BACKGROUND OF THE SURVEY
1
2 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
1. BACKGROUND OF THE SURVEY
1. BACKGROUND OF THE SURVEY
1.1. Noncommunicable diseases
Chronicconditionsthatarenotcausedbyaninfectiousprocess,arenontransmissible,haveprolongedcourses,arenotresolvedreadilyandforwhichacompletecureismostlynotavailablearecallednoncommunicablediseases.AccordingtoAllenandFeigl,theuseofthetermnoncommunicablefortheworld’sbiggestkillermightcauseconfusion(1)andtheyproposedthetermsociallytransmittedtoreplaceit(2).Despiteseveralattemptstorenamenoncommunicablediseases(NCDs),however,awidelyacceptedalternativetermisnotyetavailable(1).
NCDsusuallyhavecomplexetiology.Severalriskfactorshavebeenimplicatedinthem.Theyusuallyhaveanoncommunicableoriginandalonglatencyperiod.Aprolongedcourseoftheillnessisfrequentlyfollowedby functional impairment or disability.NCDsare oneof themost important health problems today, sincetheyaretheleadingcausesofdeathanddiseaseburdenallaroundtheworld (3).TheglobaltrendinNCDscloselyresemblespandemicsofinfectiousdiseases(4).NCDshaveverydramaticconsequences:theyaffectbothhumanbeingsandthesocioeconomicparametersofsocieties.Theirimpactismoreprominentforlow-andmiddle-incomecountriesandwillevidentlycontinuetogrow.Mortalityduetocardiovasculardiseases(CVD),stomachandcervicalcancerseemstohavedeclinedbetween1980and2012,whilemortalityduetodiabetes,livercancerand(infemales)chronicrespiratorydiseaseandlungcancerincreasedonaverage.Inaddition,high-andlow-incomecountriesshowimportantdifferencesinNCDs.Forinstance,CVDandcancermortalitydeclined inhigh-incomecountries. Inmany low-andmiddle-incomecountries,deathsfromCVDandchronicrespiratorydiseasewererelativelyflat,whilemortalityfrombreastandcoloncancerincreased(5).Nevertheless,NCDsseemtobethemostsignificantpublichealthissueofthe21stcenturyworldwide(6).
TheumbrellaofNCDscoversCVD(48%ofthetotal),cancer (21%),chronicrespiratorydiseases(12%)anddiabetes(3.5%).Thesediseasesareconsideredtobeamongthebiggestkillersintheworld.Morethan36millionpeoplediedfromNCDs(63%ofglobaldeaths)in2008.Approximately14millionpeopledieyoung(at30–70yearsofage)duetoNCDs.Middle-andlow-incomecountriescarrythelargestshareoftheburdenoftheseprematuredeaths.Asresult,NCDshavebeenclaimedtocauseatotaleconomiclossofUS$ 7trillioninfifteenyears (7).Targetingseveralbehavioural riskfactorsforNCDs– includingtobaccouse,unhealthydiet, physical inactivity and the harmful use of alcohol – could preventmany deaths. The annual cost ofimplementingeffectiveinterventionstodecreasetheburdenofNCDsisestimatedtobeaboutUS$ 11.2billion(7). In low-incomecountries,thestrongerconcentrationoncommunicablediseases,maternal/childhealthandothertraditionalhealthconcernsovershadowsfundingforNCDs(8).
NCDswereestimatedtoaccountforover36milliondeathsin2008:63%ofthe57milliondeathsthatoccurredworldwide(9).About80%ofalldeathsfromNCDs(29million)occurredinmiddle-andlow-incomecountries.EventhoughmorbidityandmortalityfromNCDsmostlyoccurinadulthood,exposuretoriskfactorsbeginsearlyinlife.InlinewithresearchdemonstratingthatproperactioncanvastlydecreasetheburdenofNCDs,WHOadoptedanewhealthgoalin2012:toreduceavoidablemortalityfromNCDsby25%by2025(the25by25goal)(10).
During2012,56milliondeathsoccurredworldwide,ofwhich38millionwereduetoNCDs(11).About28millionoftheseNCDdeathsoccurredinmiddle-andlow-incomecountries(12).DeathsduetoNCDshaveincreasedworldwidesince2000.Whilethedeathsfrominfectiousdiseasesareestimatedtodecrease,theannualtotalnumberofdeathsduetoNCDs isestimatedto increaseto52millionby2030 (13).MortalityduetoCVD is
3
projectedtorisefrom17.5millionin2012to22.2millionby2030,anddeathsduetocancer,from8.2millionto12.6million.ThefourmajorNCDsaccountforabout82%ofNCDdeaths(13).
PrematuredeathisoneofthebiggestconcernsinevaluatingtheimportanceofNCDsinasociety.Approximately42%ofthepeoplewhodiedfromNCDdeathsin2012werelessthan70yearsold.Mostprematuredeaths(82%)occurinlow-andmiddle-incomecountries.CVD(37%),cancer(27%),chronicrespiratorydiseases(8%)anddiabetes(4%)wereresponsibleforthemajorityofprematureNCDdeaths.
1.2. Risk factors
Alcoholisimplicatedinincreasedriskofcancerofthemouth,oropharynx,nasopharynx,larynx,oesophagus,colon, rectum, liverandfemalebreast (14),aswellasof livercirrhosisandpancreatitis (15,16). Inaddition,alcohol consumption is associatedwith hypertensive disease, atrial fibrillation and haemorrhagic stroke.AccordingtoWHO,48%oftheglobaladultpopulationhasneverconsumedalcoholicbeverages,althoughmiddle-andhigh-incomecountrieshavethehighestalcoholconsumption(17).
Physicalinactivityisoneofthemostimportantriskfactorsformortalityworldwideandisassociatedwith3.2milliondeathsand69.3millionDALYsannually(18).Regularphysicalactivitydecreasestheriskofischaemicheartdisease,stroke,breastandcoloncancer,anddiabetes.Italsoaidsweightcontrolandthepreventionofobesity(19).
ExcessdietaryconsumptionofsodiummaycauseahigherriskofhypertensionandCVD(20,21). Thesourceofsaltinthedietvariesamongcountries.Saltmaybeusedmoreofteninready-mademealsorprocessedfoodsinsomecountries,andinfoodpreparationorconsumptionathomeinothers.Asexpected,highersodiumintake(over3.5gperday)maycauseCVD(22,23).
Tobaccouseisthoughttokillapproximately6millionpeopleeachyear,andsecond-handsmoke,600 000(170 000ofwhomarechildren) (24,25). Inaddition,tobaccousecausesamajoreconomicburden,since itresultsinhighermedicalcostsandlossofproductivity.Thedefinitionoftobaccouseincludesthecurrentuseoftobaccoinbothsmokedandsmokelessforms(26).
Amongadults,theworldwideprevalenceofcurrenttobaccosmokingwasapproximately22%in2012,althoughitdiffersbetweencountriesandishigherinmen(37%)thanwomen(7%)(7).
Highbloodpressureisthoughttoberesponsibleforapproximately9.4milliondeathsand7%ofthediseaseburden in terms of DALYs in 2010 (18). Hypertensionmay cause renal failure, dementia, stroke,myocardialinfarction,cardiacfailureandblindness,whichhaveahugeimpactonhealthsystems(27,28).Severalmodifiablefactorsareimplicatedinhypertension,suchassocioeconomicdeterminants,highfatandsaltconsumption,psychologicalstress,physicalinactivity,overweightorobesity,reducedvegetableorfruitconsumption,alcoholandinadequateaccesstohealthcare.Bothageingandgeneticfactorsareassociatedwithhypertension.
Law,Morris&Wald(29) reportedthatdecreasingsystolicbloodpressureby10mmHgisrelatedtoreductionsof22%incoronaryhearddiseases(CHD)and41%instroke.Similarly,DiCesareetal.(30)showedthatitisalsoassociatedwitha41–46%reductionincardiometabolicmortality.Hypertension,CHD,stroke,diabetes,certaintypesofcancer,obstructivesleepapnoeaandosteoarthritisareassociatedwithobesity.Theidealmedianbodymassindex(BMI)foradultsisacceptedas21–23kg/m2andthetargetedBMIrangeis18.5−24.9kg/m2.OverweightisdefinedashavingaBMI≥ 25kg/m2,whileobesityisconsideredashavingaBMI≥ 30kg/m2.Bothoftheseconditionsmayresultinanincreasedriskforseveralconditions(31).Combined,theycauseabout3.4milliondeathsand93.6millionDALYseachyear(18).Obesityiswellknowntoresultinworsehealthoutcomesandhighermortality.
4 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
1. BACKGROUND OF THE SURVEY
Globalobesityprevalencehasincreaseddramaticallyoverthelast30years.Womenusuallyhaveagreatertendencytowardsobesitythanmen:11%ofmenand15%ofwomen(≥ 18years)werereportedtobeobesein2014,whilethegeneralprevalencewasabout9%.Morethan5millionadultsintheworldareobese.Inaddition,38%ofmenand40%ofwomen(≥ 18)werereportedtobeoverweightin2014.Overweightisalsoanimportantproblemforchildrenagedunder5years,affectingapproximately42millionofthem.Bothoverweightandobesityareassociatedwithincome,sincetheirprevalenceishigherinbothsexesinhigh-andupper-middle-incomecountries.IntheNetherlandsandSwitzerland,however,obesityprevalenceinchildrenseemstohavebeenstabilized(32,33).
Diabetesisalsoaveryimportantcauseofprematuremortality,withaprevalenceofapproximately9%in2014anddiabetescausesabout1.5milliondeathsand89millionDALYseachyear(7).CVD,kidneyfailure,blindnessand lower-limbamputationareassociatedwithdiabetes (34), and impairedglucose toleranceand fastingglycaemiaareclearlyknowntocarryahigherriskofdiabetesandCVD.Aswithobesity,diabeteshasshowninincreasedglobalprevalenceoverrecentyears,especiallyinlow-andmiddle-incomecountries.Unhealthydiet,physicalinactivity,obesity/overweight,increasedbloodpressure,highcholesterolareamongthemajormodifiableriskfactorsofdiabetes.DiabetesasariskfactorforNCDwasassessedbymeansofbloodglucosemeasurement.Bothobesityanddiabetescanbepreventedbyseveraltypesofinterventionsrelatedtothefoodsectorandthepromotionofphysicalactivityinbothindividualsandpopulations.Similarly,weightlossandroutinephysicalactivitycandecreasetheriskofdiabetes.
1.3. NCDs and risk factors in Turkey
TheissueofNCDsisveryimportantforTurkey,aswellastherestoftheWHOEuropeanRegion.TheWHORegionalOfficeforEuropeestimatedthatthecumulativepercentageofNCD-relateddeathsintheRegionwas86%(35).Of430 459deathsinTurkeyin2000,305 467wereduetoNCDs,andCVDaccountedfor205 457ofthelatter.ThethreemostcommoncausesofdeathfromdiseaseinTurkeyareischaemicheartdisease(22%),cerebrovasculardiseases(15%)andchronicobstructivepulmonarydisease(6%).ThesixthandtenthmostcommoncausesofdeathinTurkeyarehypertensiveheartdiseaseandinflammatoryheartdiseases,respectively(36).
NCDswereestimatedtoberesponsiblefor86%oftotaldeathsinTurkey(37).TheprobabilityofprematuredeathfromthefourmainNCDswasabout18%,and42%ofmalesand13%offemaleswerefoundtobecurrenttobaccosmokers(total:27%)(38,39).Totalalcoholconsumptionpercapitawas1.4Lpurealcoholin2015(12).
PrematuredeathfromNCDswillcontinuetobeamongthemostimportantobstaclestoglobaldevelopmentinthiscentury,includinginTurkey,andtheprematuredeathrateattributedtothefourmainNCDswas303per100 000in2016(40).WHO’sNoncommunicable diseases progress monitor 2017reportedthatNCDsaccountedfor88%ofdeaths(392 000)inTurkey(population:over78million)and17%oftheriskofprematuredeath(41).
TurkeyseemstohavesucceededinsettingnationalNCDtargetsandcollectingmortalitydata,althoughrisk-factorsurveyshavebeenonlypartiallyachieved.Inaddition,thenationalintegratedNCDpolicy,strategyoractionplancouldstillbeimproved.Ontheotherhand,Turkeyhasbeenverysuccessfulintakingmeasuresto reduce the demand for tobacco, including tax increases; large graphic healthwarnings on packaging;bansonadvertising,promotionandsponsorship,campaignswiththemassmedia;andsmoke-freepolicies.Turkeyhasalsotakenactionagainsttheharmfuluseofalcohol,includingadvertisingbansorcomprehensiverestrictions,andincreasedexcisetaxes.Effortstoreduceunhealthydietsincludetheadoptionofpolicieson salt/sodium and saturated and trans fats, and restrictions on food marketing. The country has alsopromotedpubliceducationandawarenesscampaignsonphysicalactivity(41).Theprovisionofdrugtherapyorcounsellingtopreventheartattacksandstrokes,however,hasnotyetbeenachieved.
5
1.4. STEPwise approach
ToaddresstheglobalhealthproblemofNCDs,in2013,theWorldHealthAssembly–WHO’sdecision-makingbody – adopted a globalmonitoring framework forNCDs (42),with 25 key indicators to track progress inpreventionandcontrol,andasetofglobalvoluntary targets, linkedto theframework, for: thepreventionandcontrolofNCDsby2025(includingatargettoreduceprematuremortalityfromthefourmainNCDsby25%), themainbehaviouralandmetabolic risk factors,andhealthsystems.Further, the2030Agenda forSustainableDevelopment recognized the importanceofaddressingNCDswith the inclusionofa similarlyambitioustargettoreducethenumberofprematuredeathsfromNCDsbyonethirdby2030(43).
Recognizing a global need for data on key NCD risk factors, WHO initiated the STEPwise approach tosurveillance(STEPS)in2002(44).Itsgoalsaretoguidetheestablishmentofrisk-factor-surveillancesystemsincountriesbyprovidingaframeworkandapproach:
tostrengthentheavailabilityofdatatohelpcountries inform,monitor,andevaluatetheirpoliciesandprogrammes;
tofacilitatethedevelopmentofpopulationprofilesofexposuretoNCDriskfactors; toenablecomparabilityacrosspopulationsandtimeframes;and tobuildhumanandinstitutionalcapacityforNCDsurveillance.
Sinceitsinception,STEPShasarguedthatsmallamountsofgood-qualitydataaremorevaluablethanlargeamountsofpoor-qualitydata.Itsupportsmonitoringafewmodifiableriskfactorsthatreflectalargepartof the futureNCDburdenand thatcan indicate the impactof interventionsconsidered tobeeffective inreducingthe leadingNCDs.BecauseSTEPSalsopromotesthecollectionofdataonanumberofdifferentriskfactors,incontrasttosurveysofsinglefactors,itallowsthecreationofanunderstandingofhowriskfactorsclusterinapopulationandoffersanopportunityforcountriestoestimatethesmallproportionofthepopulationwithhighoverallriskofacardiovascularevent,forreferralforpossibletreatment.
ThesurveillanceofNCDsconsistsofaprocessofpermanentmonitoringofthepopulation’shealthsituation,mainly risk factors for the development of disease and aspects of the social context, in such a way toensurethatinterventionsfocusonandareadjustedtothecharacteristicsofvariouspopulationgroups.Theinformationobtainedcanbeused indecision-makingatthe individualandcollective levels, toreducetherisksofmorbidityandmortality.
Against this backdrop, the study described in this publication provides valuable information onNCD riskfactorsinTurkeyandshouldallowthedifferentactorsofthehealthsystemandthecommunityingeneral,giventhepopulationrepresentativenessoftheresults,clearlytoidentifytheriskfactorsonwhichmeasuresandstrategiesshouldbeformulatedtopreventtheincreaseofnewcasesofCVD,diabetesandcancer.ThestudyusesSTEPStogatherinformationonNCDriskfactorsforthesamplerepresentingTurkeyandits12regions,asdescribedbylevel-1NomenclatureofTerritorialUnitsforStatistics(NUTS-1).
SURVEY GOAL AND OBJECTIVES
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8 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
2. SURVEY GOAL AND OBJECTIVES
2. SURVEY GOAL AND OBJECTIVES
2.1. Survey goal
ThegeneralgoalofthesurveyistodeterminetheprevalenceofmajorriskfactorsforNCDsusingtheWHO-approvedSTEPSsurveymethod(44)byusingtheNationalHouseholdHealthSurveyinTurkey–PrevalenceofNoncommunicableDiseaseRiskFactors(NHHST)toevaluatethebaselinesituationandenablemoreefficientplanningofactivitiesforthepreventionandcontrolofNCDs.
STEPSisasurveillancestrategythatconsistsofasimple,standardizedapproachtocollecting,analysinganddistributinginformationontheriskfactorsthatdeterminethemostcommonNCDs.Itsapplicationseekstohelpbuildandstrengthencountries’capabilitiestoperformsurveillanceoftheseriskfactors.Thismethodis flexible, since it can be adapted to a country or territory’s economic, logistical, human resources andinfrastructurecapacitiesandtoitsinformationneedsfortheconstructionofthebaselineofriskfactorsforNCDs.Atpresent,morethan104WHOMemberStateshaveimplementedthismethod.
TheWHOestablishedeight risk factorsconsidered tobe themost important for inclusion in surveillancestrategies,asvalidmethodologiesareavailablefortheirmeasurementandinviewofthepotentialoftheircontrol to decreasepremature death anddisability. These risk conditionswere grouped into behaviouralfactors understood as modifiable (tobacco use, harmful use of alcohol, low consumption of fruits andvegetables,andphysicalinactivity)andbiologicalfactorsconsideredcontrollable(hypertension,overweightandobesity,highbloodsugarandincreasedtotalcholesterol).
2.2. Survey objectives
TheobjectivesoftheNHHSTare:
● to determine the prevalence of the most common behavioural risk factors for NCDs in the generalpopulationaged≥ 15years,representingbothsexes;
● todeterminetheprevalenceofthemostcommonbehaviouralriskfactorsforNCDsinsamplesrepresentingthepopulationsinthe12NUTS-1regions;
● todeterminetheprevalenceofbiologicalriskfactorsforNCDsinthepopulationaged≥ 15years;and ● todeterminethedifferencesintheprevalenceofriskfactorsbetweenthesexes,areasofresidenceandfiveagegroups.
2.3. Rationale for the survey
ManyNCDsmaybereducedthroughmeasurestargetingfourormorerisk factors, includingtobaccouse,physical inactivity, harmful useof alcohol andunhealthydiet. TheMinistryofHealthofTurkeyworked tosetnationaltargetsfor2025basedonthenationalsituation(takingintoaccountthenineglobaltargetsforNCDsandWHO’seffortstocollectdataonoutcomeandprocessindicatorsin2015)andachievethesetargets(takingaccountoftheWHOGlobalNCDActionPlan2013–2020).Further,theMinistryofHealthlaunchedtheNationalMultisectoralActionPlanforNoncommunicableDiseases2017–2025(39).
ThedataontheprevalenceofriskfactorsforNCDsavailablefromprevioussurveysinTurkey,however,werelimitedandfragmented.Nationallyrepresentative,comprehensive,comparableandup-to-datedataonNCDriskfactorsareneededtoevaluatetheeffectivenessofcurrentpublichealthpoliciesandtodevelopfurtherinterventions forNCDpreventionandcontrol.TheWHO-assistedNHHSThasbeen implemented togatherthesedata.Thesurveywasplannedtobecarriedoutintwophases:abaselinestudyconductedin2017andafollow-upphasein2019.Thispublicationdescribesphase1.
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SURVEY METHODOLOGY
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10 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
3. SURVEY METHODOLOGY
3. SURVEY METHODOLOGYTheSTEPSmethodevaluatesriskfactorsthroughtheapplicationoftheSTEPSinstrument,whichallowsthecollectionofdatathrough:
1. aquestionnaire2. physicalmeasures3. biochemicalmeasures.
Eachstepcanbedeepened: theycanbebasic,extendedandoptional. In implementation, theMinistryofHealthfurtherextendedtheSTEPSinstrumentsfornation-specificmeasurements(seeAnnex3).
Step1consistsofevaluationbasedonaquestionnairethat investigatesexposuretofourbehaviouralriskfactors:tobaccoconsumption,harmfulalcoholconsumption,lowconsumptionoffruitsandvegetables,andphysicalinactivity.
Step2considersthephysicalmeasurementofvariablessuchasbloodpressure,height,weight,andwaistandhipcircumferencetoassessexposuretobiologicalriskfactorssuchashighbloodpressure,overweightandobesity.
Step3addsbiochemicalmeasurementsbytakingbloodandurinesamplesforthedetectionofhighlevelsofglycaemia,hypercholesterolemiaandsodiumintake.
DatawerecollectedinApril–September2017,usingtheinstrumentinAnnex3.
NHSSTisacross-sectionalhouseholdsurveythatcollectsinformationthroughanestablishedquestionnaire.Thisinformationisobtainedbyinterviewing,makingaphysicalexaminationofandtakingbiologicalsamplesfromsubjects.Thetargetpopulationconsistsofasampleofpeopleaged≥ 15years, living inhouseholdsrandomlyselectedaccordingtotheWHOprotocol.
Biologicalmeasurementsaremadeonwhole-bloodandurinesamples.Fastingbloodglucose,totalcholesterol,high-density lipoprotein(HDL)cholesterol,triglycerides,haemoglobinA1corglycatedhaemoglobin(HbA1c)test,urinarycreatinine,andurinarysodiumaremeasuredforallrespondentswhoagreedtoparticipateinstep3ofthesurvey.
3.1. Inclusion criteria
Householdmemberswhometthefollowingcriteriawereincludedinthesurvey.Subjects:
● werecitizensoftheRepublicofTurkeyaged≥ 15years; ● gavewritten informed consent to their participation, as demonstrated by the Directorate-General forHealthResearchoftheMinistryofHealthtotheethicscommitteethatapprovedthestudy;and
● hadnodisabilitypreventingthemfromansweringthequestionsoftheinterview.
3.2. Exclusion criteria
Householdmemberswhometatleastoneofthefollowingcriteriawereexcludedfromthestudy:
● anageof0–14years; ● residenceinaninstitution,includingmotels,hotels,hospitals,studenthostels,prisons,etc.; ● lackofstatusasapermanentresidentofTurkey; ● statusasvisitorstothehomeswherethefieldsurveywasperformed;and
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● cognitiveimpairmentatalevelthatwouldhinderthesubjectfromunderstandingthequestionsofsurveyandgivingclearandcorrectanswers.
3.3. Sample size
Forcalculating thesamplesize, theprevalenceofoverweightandobesity (P=53.6%, rounded toP=0.50),identifiedbytheTurkishStatisticalInstitute(TURKSTAT)duringthehealthsurveyof2014,wasused,assuminga95%confidenceinterval(CI)(Z=1.96),a5%acceptablemarginoferror(e),acomplexsamplingdesigneffect(D)coefficientof1.50,andequalrepresentationofthesexesineachagegroup(S)(fiveagegroupsforeachsexoratotalof10groups).Thestudyalsoaimstoobtainregional-levelestimatesfor12NUTS-1regionsinTurkey.Thus,themaximumnumberofdifferentgroupsinthesamplesizewas12.Calculationsresultedinasamplesizeof6915individuals,whichwasfurtherincreasedbyanon-responsefactorof20%(i=0.20)to8644,toaccountfornon-response.Atotalof8644subjectsaged≥ 15yearswasrequiredfollowingtheseassumptions.
3.4. Effective sample
Ofthe8650householdsvisited,16053peopleaged≥ 15yearsparticipatedinthestudy,ofwhom3352alsocompletedstep3(2701peopleoutofthe6053selecteddidnotwanttoparticipate).
The overall non-response rate (including those households whose members were not home or rejectedparticipationatthedoor)correspondsto30%ofthehouseholdsvisitedforsteps1and2and61.22%forstep3.
3.5. Sampling frame
ThesurveyofNCDsriskfactorsisconductednationwide,sothesamplingframeincludedallcitizensinTurkey(2016population:79 814 871).Administratively,Turkeyhas12NUTS-1,26NUTS-2and81NUTS-3regions.Thelevel-3NUTSregionsinTurkeycorrespondto81provinces.Turkeyhad970districtsinNovember2017.Themultistageclustersamplingframecovers865clustersdistributedoverallNUTS-3provinces.ThispublicationpresentsNUTS-1estimates,sothesamplingstrategyconsideredpopulationconcentrationsatthatlevel.TherandomselectionofclustersmayexcludesomeoftheNUTS-3provinces.
3.6. Sampling design
AsperWHOSTEPSrecommendation,amultistageclustersamplingstrategywasused.ThenationalhouseholdaddressframeupdatedinFebruary–August2016wastakenasthebasisofsampling.
(TURKSTATdetermined the 100 primary sampling units (PSUs) using the probability-proportionate-to-sizesamplingmethod.EachPSUcontained10secondarysamplingunits(SSUs).Atstep3,atleast10householdswererandomlyselectedfromeachselectedSSU.Finally,oneeligiblerespondentwasselectedfromthelistofalleligiblerespondentswithinaselectedhousehold,usingtherandomselectionmethodasdescribedintheWHOSTEPsmanual(44).Thesamplesizeforeachstagewas:
1. selectionofPSUs:865clusterswerechosen,eachcontainingapproximately100householdaddresses;2. selectionofSSUs:8644householdswerechosen,with10households(addresses)withineachselected
cluster;3. selectionofindividualsinthefield:afteralleligibleadultsintheselectedhouseholdweredocumented,
oneindividualwasrandomlyselectedbyuseofacomputerprogram.
1 ThesampleoftheTURKSTATincluded8650households,insteadof8644,owingtotheindivisibilityofclusters.
12 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
3. SURVEY METHODOLOGY
Table1presentsallNUTSregions,andtheirconstituentregionsandprovinces.
Table 1. NUTS regions in Turkey
NUTS-1 (regions) NUTS-2 (subregions) NUTS-3 (provinces)
Istanbul (TR1) Istanbul (TR10) Istanbul (TR100)
WesternMarmara (TR2) Tekirdağ (TR21) Tekirdağ (TR211)
Edirne (TR212)
Kırklareli (TR213)
Balıkesir (TR22) Balıkesir (TR221)
Çanakkale (TR222)
Aegean (TR3) Izmir (TR31) İzmir (TR310)
Aydın (TR32) Aydın (TR321)
Denizli (TR322)
Muğla (TR323)
Manisa (TR33) Manisa (TR331)
Afyonkarahisar (TR332)
Kütahya (TR333)
Uşak (TR334)
EasternMarmara (TR4) Bursa (TR41) Bursa (TR411)
Eskişehir (TR412)
Bilecik (TR413)
Kocaeli (TR42) Kocaeli (TR421)
Sakarya (TR422)
Düzce (TR423)
Bolu (TR424)
Yalova (TR425)
WesternAnatolia (TR5) Ankara (TR51) Ankara (TR510)
Konya (TR52) Konya (TR521)
Karaman (TR522)
Mediterranean (TR6) Antalya (TR61) Antalya (TR611)
Isparta (TR612)
Burdur (TR613)
Adana (TR62) Adana (TR621)
Mersin (TR622)
Hatay (TR63) Hatay (TR631)
Kahramanmaraş (TR632)
Osmaniye (TR633)
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NUTS-1 (regions) NUTS-2 (subregions) NUTS-3 (provinces)
CentralAnatolia (TR7) Kırıkkale (TR71) Kırıkkale (TR711)
Aksaray (TR712)
Niğde (TR713)
Nevşehir (TR714)
Kırşehir (TR715)
Kayseri (TR72) Kayseri (TR721)
Sivas (TR722)
Yozgat (TR723)
WesternBlackSea (TR8) Zonguldak (TR81) Zonguldak (TR811)
Karabük (TR812)
Bartın (TR813)
Kastamonu (TR82) Kastamonu (TR821)
Çankırı (TR822)
Sinop (TR823)
Samsun (TR83) Samsun (TR831)
Tokat (TR832)
Çorum (TR833)
Amasya (TR834)
EasternBlackSea (TR9) Trabzon (TR90) Trabzon (TR901)
Ordu (TR902)
Giresun (TR903)
Rize (TR904)
Artvin (TR905)
Gümüşhane (TR906)
North-eastern Anatolia (TRA)
Erzurum (TRA1) Erzurum (TRA11)
Erzincan (TRA12)
Bayburt (TRA13)
Ağrı (TRA2) Ağrı (TRA21)
Kars (TRA22)
Iğdır (TRA23)
Ardahan (TRA24)
Table 1 (contd)
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3. SURVEY METHODOLOGY
NUTS-1 (regions) NUTS-2 (subregions) NUTS-3 (provinces)
CentralEastern Anatolia (TRB)
Malatya (TRB1) Malatya (TRB11)
Elazığ (TRB12)
Bingöl (TRB13)
Tunceli (TRB14)
Van (TRB2) Van (TRB21)
Muş (TRB22)
Bitlis (TRB23)
Hakkâri (TRB24)
South-eastern Anatolia (TRC)
Gaziantep (TRC1) Gaziantep (TRC11)
Adıyaman (TRC12)
Kilis (TRC13)
Şanlıurfa (TRC2) Şanlıurfa (TRC21)
Diyarbakır (TRC22)
Mardin (TRC3) Mardin (TRC31)
Batman (TRC32)
Şırnak (TRC33)
Siirt (TRC34)
Fig.1displaysthegeographicalbordersoftheNUTS-1regionsandthe81provincestheycover.
Table 2 presents the number of clusters andnumber of households in eachNUTS-1 regions,while Fig. 2displaysthenumberofhouseholdinthesamplebyNUTS-3provinces.The865clustersarethePSUsofthestudy,whicharedisplayedinFig.3bytheirgeographicalcoordinates.
Fig. 1. Geographical borders of NUTS-1 regions
Source:MinistryofEnvironmentandUrbanization,RepublicofTurkeyandTURKSTAT.
Table 1 (contd)
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Table 2. Sample clusters and households by NUTS-1 regions
NUTS-1 regions Number of clustersNumber of sample
households
TR1 161 1610
TR2 43 430
TR3 129 1290
TR4 88 880
TR5 91 910
TR6 110 1100
TR7 44 440
TR8 53 530
TR9 31 310
TRA 19 190
TRB 32 320
TRC 64 640
Total 865 8650
Fig. 2. Sample sizes by NUTS-3 provinces
Source:MinistryofEnvironmentandUrbanization,RepublicofTurkeyandTURKSTAT.
16 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
3. SURVEY METHODOLOGY
Fig. 3. Geographical location of sample clusters
Source:MinistryofEnvironmentandUrbanization,RepublicofTurkeyandTURKSTAT.
3.7. Selection of individuals
Eachhouseholdwasvisiteduptothreetimes.Ifhouseholdconsentwasobtained,aqualifiedhouseholdmemberwasrandomlyselectedforparticipationinthesurvey.Anappointmentwasmadewiththoseselectedhouseholdmemberswhowerenotavailableduringtheinitialvisitbutcouldbeavailableinthefollowing10days.
3.8. Survey design
The survey was carried out using three consecutive steps, as per WHO STEPS, and considering localnecessitiesandresources.
Step1comprisedtheadministrationofaquestionnaireadaptedfromNHHST,theWHOSTEPSInstrumentforChronicDiseaseRiskFactorSurveillance,theEuropeanHealthExaminationSurvey,andWorldBankHealthSystemStrengtheningandSupportProjectDevelopment indicatorsselectedbytheMinistryofHealthandadditional questions recommended by the Ministry’s Directorate-General for Health Research. Face-to-face interviewswereheld,using thequestionnaire tocollectdemographicandbehavioural information ina household setting, including informationon tobaccouse, alcohol consumption, diet (including fruit andvegetable consumption, oil and fat consumption, meal consumption outside the home and dietary salt),physicalactivity,historyofhighbloodpressureand/orraisedcholesterol,historyofdiabetesandCVD,lifestylecounselling,cancerscreeningandaccesstohealthcare.
Step2comprisedaseriesofphysicalmeasurementsofoverweightandobesityusingspecifictestsanddevices(bodyweightandheight,waistandhipcircumference),bloodpressureandheartrate.Duringthehouseholdvisits,bloodpressureandheartrateweremeasuredontwoseparateoccasions,onthejointrequestofWHOandtheDirectorate-GeneralforHealthResearchoftheMinistryofHealth.Thefirstmeasurementwasmadeduringstep2andthesecond,duringthesubsequentvisittoeachhouseholdforstep3(fastingmeasures).
Step3compriseda seriesofbiochemicalmeasurements incapillaryblood,usingdrychemicalmethods,andinurine.Measurementsincludedbloodglucose,totalcholesterol,HDLcholesterol,triglycerides,HbA1Candurinarysodiumandcreatinine.Participantscollectednon-fastingurinesamplesincontainersthattheyputintozip-closableplasticbags.SamplesweresentforanalysistotheCentralLaboratoryoftheHacettepeUniversityFacultyofMedicine,Ankara,Turkey.
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3.9. Weighting of the survey
Becausethedatacoveredasampleofthetargetpopulation,theyhadtobeweighted.Thus,sampleweightingwascarriedouttocorrectdifferencesintheage,sex,areaofresidencedistribution(NUTS-1region),educationlevel of the sample versus the targetpopulationandprobabilitiesof selection.Thesampleweight foreachcaseinthesurveysampleaccountedforthenumberofcasesitrepresentedinthesamplingframe,basedonthesampleselectionprocedure.TURKSTATprovided thefirst-stagesampleweights,basedon the inclusionprobabilitiesofthecluster-levelPSUs,andtheinclusionprobabilitiesoftheSSUs.Thethirdcomponentofthesamplingweightwastheinclusionprobabilityofahouseholdmember,whichwasobtainedfromthehouseholdinformationrecords.TheproductofthethreeinclusionprobabilitiesforPSUs,SSUsandhouseholdmemberswasinvertedtoobtainthebaseweights.
Thesecondweightwas thenon-responseweight,whichwasobtainedfromthe interviewtracking forms.Investigators first adjusted inclusion probabilities at the cluster level for non-coverage, as some of theaddresses included in the sample did not exist because ofminor differences between actual addressesand the address-based population count of TURKSTAT. The non-responding households in each clusterwereobtained from the interview tracking forms. Table 3 presents thenumberof clusters by numberofnon-respondinghouseholdsforeachNUTSregion.Therewasatotalof2422non-responsesin865clusters.Therewereanadditional175non-coveredaddresses,leavingatotalof6053respondinghouseholdsoutof8650householdaddresses in thesample.2Thenoncoverageandnonresponseadjustmentswereavailableattheclusterleveland,thus,investigatorswereabletocalculatenonresponseweightsandadjustthemfornoncoverageattheclusterlevel.Theproductofthesampleweightsandnonresponsegavethebaseweights,whichwerefurtheradjustedwithpoststratificationtoaccountfordifferencesinthesex–age,sex–educationandNUTS-1proportionsfromthoseintheactualpopulation.Thenonresponseratesvariedacrossthestepsofthestudy,sodifferentnonresponseweightswerecalculatedforsteps1and2,andstep3.
Table 3. Distribution of nonresponding household numbers by clusters and NUTS regions
NUTS-1 regionsNumber of non-responding households in each cluster
0 1 2 3 4 5 6 7 8 9 10
TR1 12 15 22 27 19 20 10 15 9 7 5
TR2 8 8 8 7 5 6 1 0 0 0 0
TR3 22 19 24 19 16 13 8 6 2 0 0
TR4 23 18 26 14 5 1 0 1 0 0 0
TR5 15 21 15 16 16 5 0 1 2 0 0
TR6 19 11 16 18 14 9 10 11 1 0 1
TR7 13 10 5 6 2 2 1 3 1 1 0
TR8 13 15 6 7 5 1 3 2 0 0 1
TR9 16 7 2 0 2 0 1 1 0 1 1
TRA 9 3 2 0 2 3 0 0 0 0 0
TRB 12 5 7 2 2 1 1 1 0 0 1
TRC 22 3 3 7 7 3 5 2 2 2 8
Total 184 135 136 123 95 64 40 43 17 11 17
Total non-responses 0 135 272 369 380 320 240 301 136 99 170
2 TURKSTATprovided8650householdsinthesampleinsteadofthe8644planned,becauseitcouldnotadjustthenumberofhouseholdstobesamplesineachcluster.
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Thethirdweight(populationweight,alsoknownaspoststratification)wasusedforanydiscrepancythatmayexistbetweenthesampleandthepopulation.Byadjustingtheseweights,thesurveysamplewasessentiallyforcedtoresemblethepopulation,thusenablinginferencetotheentirepopulation,notjustthesample.Toobtainthepoststratificationweights,thesex–age,sex–educationandNUTS-1distributionofthepopulationwas taken from the 2016 estimates based on TURKSTAT’s 2015 address-based population count. As theresponseratesvariedacrosssteps1and2,andstep3,poststratificationneededtobedoneseparatelyforthem.
Table 4 presents the proportions used for two-way sex–age poststratification. It presents samplepercentages forbothsteps 1 and2, andstep3by sexandagegroups, aswell as thepopulationanalogytaken fromTURKSTAT.Analogously, Table 5 presents the sample andTURKSTATproportions for two-waypoststratificationofsex–educationlevel.Finally,Table6presentstheNUTS-regionssampleandpopulationproportionsusedforpoststratificationtomatchtheregionalpopulationdistribution.Tomatchthesampleproportions, investigators used the raking (otherwise known as iterative proportional fitting, sample-balancing, or raking ratio estimation)method (45) for adjusting the samplingweights of the sample databasedonknownpopulationcharacteristicsgiveninTables4–6.
Table 4. Data for two-way sex–age poststratification
Age group (years)
Men Women
Sample steps 1 and 2 (%)
Sample step 3 (%)
TURKSTAT (%)
Sample steps 1 and 2 (%)
Sample step 3 (%)
TURKSTAT(%)
15–29 8.21 7.43 16.12 11.12 9.46 15.47
30–44 10.77 9.87 15.28 17.35 15.72 15.00
45–59 10.61 10.44 10.92 16.09 16.71 10.79
60–69 6.29 6.77 4.55 7.65 8.56 4.90
≥ 70 4.56 5.61 2.93 7.35 9.43 4.03
Table 5. Data for two-way sex-education poststratification
Education level
Men Women
Sample steps 1 and 2 (%)
Sample step 3 (%)
TURKSTAT (%)
Sample steps 1 and 2 (%)
Sample step 3 (%)
TURKSTAT (%)
Illiterate or literate but no formal schooling
3.92 5.16 2.18 22.88 22.08 13.92
Primary school completed
13.79 14.26 10.23 16.24 13.63 21.43
Secondary, vocational secondary or high school completed
15.96 14.77 28.43 5.86 5.16 7.36
College, faculty, master’s or doctorate completed
6.77 5.94 9.00 22.88 22.08 13.92
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Table 6. Data for NUTS-1 region poststratification
NUTS-1 regionsSample steps 1 and
2 (%)Sample step 3
(%)TURKSTAT
(%)
TR1 14.59 8.11 18.74
TR2 5.42 3.73 4.67
TR3 14.85 15.87 13.59
TR4 11.99 5.52 9.89
TR5 11.23 14.17 9.90
TR6 12.06 14.80 12.55
TR7 5.60 7.70 4.97
TR8 6.66 7.70 6.03
TR9 4.20 6.09 3.53
TRA 2.63 3.52 2.59
TRB 4.25 4.62 4.44
TRC 6.53 8.17 9.10
3.10. Data collection
Total of thirty teams, each of which comprising two-person, collected the survey data, using e-STEPtabletsoftware,andthedatawerestored inacentralizedserver.Theteamsalsorecordedonthetabletsthe geographical coordinates of each household visited. Each survey team included a health specialistwhoperformedphysicalandbiochemicalmeasurements.Whentheyfoundnobodyathome,teamsvisitedhouseholdsuptothreetimes.Theyobtainedtheconsentoftheselectedparticipantforallthreestepsofthesurvey.Theteamswereequippedwithportabledevicesthatallowedthemtoperformallphysicalandbiochemicalmeasurements,andtheygaveacopyoftheresultsofthebiochemicalmeasurementstoeachparticipant.Thedatacollection tookplace fromApril toSeptember2017.Thefield implementationof thesurveyusedthemedicalequipmentandsupplieslistedinTable7.
Table 7. Equipment and supplies used for the field implementation
Equipment Usage area Pieces
SiemensDCAVantageInstrument HbA1C 33
CardioChekPAAnalyzer Glucose,triglycerides 33
OmronM7IntelliIT Bloodpressure 33
SECAStadiometer Height 33
SECAelectronicflatscale Weight 813
SECAgirth-measuringtape Girth 201
EquipmentCarryingSafetyCase Medicalequipmentandkitscarryingcase 66
SampleshipmentbagShipmentofurinetothelaboratoryforanalysis(sodiumandcreatinine)
300
CDMVITvacuumurinetube Vacuumurinetube 10 000
CDMVIBsterileurineglass Sterileurineglass 10 000
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3. SURVEY METHODOLOGY
Equipment Usage area Pieces
Lancet Bloodsample/hygiene 10 000
Gloves Bloodsample/hygiene 10 000
Alcoholicwipes Bloodsample/hygiene 10 000
Capillarytube(40ml) Bloodsample 10 000
Capillarytube(15ml) Bloodsample 10 000
Cardioglucosekit Bloodsample(glucose) 10 000
CardiotriplepanelBloodsample(measurementofcholesterol,HDLcholesterol,triglyceridevalues)
10 000
SiemensDCA2000HBA1CReagentKit(ECCN;EAR99/AL:N)
HbA1C 10 000
Forthesupplementaryrequirementsforthefieldsurvey,speciallydesignedsafetycasestotransport theinstrumentsforbiochemicalmeasurementwasmanufactured,aswellasbagstotransporttheinstrumentsanddevicesforphysicalmeasurement (seeTable7).Speciallydesignedcaseswereusedtotransporttheurinesamplesincoldchain,viaspecialcourierservicesfromdifferentpointsofthefieldsurveytotheCentralLaboratoryofHacettepeUniversityFacultyofMedicine.
3.11. Training of the field survey staff
The field teams received theoretical and practical training and carried out their functions following theguidelinesoftheSTEPSmanual(44)andthespecificationsofthemanualsfortheequipmentusedtomeasureglycaemiaandcholesterol.Theteams(78fieldsurveypersonnelfrom15regionallogisticcentres,representing79provincesinTurkeydesignatedbyTURKSTATbasedon12NUTS-1regions)receivedfourdaysoftraining(10–14April 2017) inAnkara to foster their skills in communication and their knowledgeof techniques forthe development of interviews, equipment management and physical and biochemical measurements.Thetraineescomprised31interviewers/data-collectionspecialists,32healthprofessionalsand15regionalsupervisorsandcoordinatorstoconductthenationwidefieldsurveys.
Thetrainingwasconducted,underthesupervisionofthefieldteamcoordinator,bytheprogrammeleader,members of project team and representatives of themanufacturers of the equipment used tomeasurebloodglucose,glycaemia,cholesterolandHbA1c.RepresentativesoftheWHOCountryOffice,TurkeyandtheDirectorate-GeneralforHealthResearchoftheMinistryofHealthalsotookpart.
Thetrainingprogrammeforthefirsttwodaysfocusedontwomaingroups:data-collectionpersonnelandhealthprofessionals.Expertstrainedthefirstgroupinthecomprehensiveuseofthetablets,withspeciallydesignedsoftware,inadministeringthequestionnairesduringhouseholdvisits,whiledoctorsandtrainersfromsupplierfirmstrainedthesecondgroupintechniquesforintakinganthropometricmeasurements.Thegroupswerejointlyfamiliarizedwiththeproceduretobefollowedbeforeandduringthehouseholdvisits.
ThelasttwodaysoftrainingweredevotedtopilotfieldsurveyinthreedifferentregionsinAnkara(Mamak,AltındağandKeçiören):makingvisits to randomlyselectedhouseholdswhere the traineesbothcollecteddataandmadephysicalandbiochemicalmeasurementsundertheclosesupervisionofexperts.Anevaluationmeetingwasorganizedontheclosingdayofthetrainingprogrammetoelaborateontheresultsofthepilotfieldsurvey,thenecessaryclarificationsweremadeandtheprecautionsweretaken.
21
3.12. Field work
Afterthetraining,theorganizationoftheNHHSTwasfinalizedsothatitcouldbeconductedin79provinces,encompassingurbanandruralareas,andcoordinated,controlledandsupervisedfromtotalof15logisticalcentresinTurkey.Allnecessarylegalproceduresandformalitieswerecompletedfortheemploymentoftotalof30fieldsurveyteamsand15regionalsupervisorsandcoordinators.
Eachteamwasfurnishedwithseparatesurveyguidesforthedatacollectorsandthehealthstaff,andallformstobeusedduringhouseholdvisitsand/ortobepresentedtothelocalauthoritiesuponrequest.Allnecessaryofficialcorrespondenceandprocedures,aswellasthedeploymentofthemajorityofmedicalequipmentandmaterialsfromtheheadquartersinAnkara,werecompletedandthefieldsurveywasinitiatedasof21April2017.
Thefieldandzonecoordinatorssystematicallysupervisedthefieldwork,accordingtoguidelinesgivenintheSTEPSmanual(44),mainlytoensurethereliabilityofthedatacollected.Tocompletethefieldoperation,thesurveycoordinatorsvisitedandsurveyedthehousingunits,andsubsequentlyfocusedonthefinalreportofthefieldoperation.
The work of control and supervision of the surveys carried out by the field coordinator and the zonecoordinatorswasconductedsystematicallyinordertoensurethereliabilityofthedatacollection.
3.13. Data management and consolidation
Tofacilitatethecollectionandmanagementofdataandreducethetimeofapplicationofthesurvey,eSTEPSsoftwaredevelopedbyWHOforthecollectionoftheSTEPSinstrumentwasinstalledontabletpersonalcomputers(PCs).Theinterviewerstypedintothetabletsalltheinformationobtainedfromtheparticipants,andthedatawereuploadedtoacentralizeddatabaseonaserver,attheendofeachcollectiondayoraftereachsurveywascompleted.Thecoordinatorscontinuouslymonitoredtheuploading.Thecentraldatabasewasconsolidatedandthequalityofthedatawasvalidatedaccordingtocriteriaincludinginconsistency,jumperrors,absenceofdata,surplusdataandinvaliddata.Thevalidateddatabasefortheanalysisprocesswasgeneratedinthisway.
3.14. Measurement and determination of risk factors
ThemeasurementoftheriskfactorswascarriedoutfollowingalltheguidelinesandrecommendationsoftheSTEPSmethod(44).
3.14.1. Step 1
ThroughtheapplicationoftheSTEPSquestionnaire,thefieldimplementation teamsinvestigatedexposuretofourbehaviouralriskfactors:tobaccoconsumption,alcoholconsumption,lowconsumptionoffruitsandvegetables,andphysicalinactivity.
3.14.1.1. Tobacco use
Currentanddailyconsumption,theageofonsetofdailyconsumption,timeofcessationofdailyconsumptionandexposuretosecond-handsmokeinthehomeandotherspaceswereinvestigated.
3.14.1.2. Consumption of alcohol
Theconsumptionofalcoholisestablishedaccordingtoperiodicity(inthepreviousyearandmonth)andthenumberofdrinksconsumed.Theparticipantswereclassifiedas:
22 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
3. SURVEY METHODOLOGY
● non-orexdrinker:absenceofalcoholicbeveragesduringtheprevious12months; ● allrespondentsdrinkingatahighlevel:≥ 60gpurealcoholonaverageperoccasionamongmenand≥ 40gamongwomen;
● allrespondentsdrinkingatanintermediatelevel:40–59.9 gpurealcoholonaverageperoccasionamongmenand20–39.9 gpurealcoholamongwomen;and
● allrespondentsdrinkingata lower level:< 40 gpurealcoholonaverageperoccasionamongmenand< 20 gpurealcoholamongwomen)(44).
3.14.1.3. Consumption of fruits and vegetables
Teamsaskedparticipantsabouttheirconsumptionoffruitsandvegetablesinatypicalweek(numberofdaysofconsumptionanddailyportionsconsumed).Toestablishriskbehaviour,theytookaccountofthecurrentrecommendationofdailyconsumptionofatleastfiveservingsoffruitsorvegetables(44).
3.14.1.4. Physical activity
TheSTEPSquestionsonphysicalactivitywereadaptedfromtheWHOGlobalPhysicalActivityQuestionnaire,version2,whichassessesbehaviourinthreedomains:atwork(whichincludespaidandunpaidwork,inandoutsidethehome),fortransportandduringleisuretime.Toestablishthetotalandthelevelofphysicalactivityof each participant,metabolic equivalents (METs) perminutewere calculated for oneweek; for this, theweeklyminutesofvigorousphysicalactivityweremultipliedby8METsandtheminutesofmoderatephysicalactivityanddisplacements,by4METs.(Bydefinition,themovementsareconsideredasmoderate-intensityphysicalactivity.)Thephysicalactivityofthesurveyedpopulationwasdescribedusingcontinuousindicators(MET-minutesperweekandminutesperweek)andcategoryindicatorsusingthefollowingcut-offpointstoestablishthelevelofphysicalactivity(44).
Participants’physicalactivitywassaidtobehighiftheymetoneofthefollowingcriteria:
● vigorous-intensityactivityforatleastthreedays,reachingaminimumof1500MET-minutesperweek;or ● ≥ 7daysofphysicalactivityinanydomainandintensity,reachingaminimumof3000MET-minutesperweek.
Participants’physicalactivitywassaidtobemoderateiftheydidnotmeetthecriteriaforthehighlevel,butmetanyofthefollowingthreecriteria:
● vigorous-intensityphysicalactivityfor≥ 3daysforatleast20minutesaday; ● moderate-intensityphysicalactivityfor≥ 5daysforatleast30minutesaday;or ● physicalactivityofanyintensityanddomainfor≥ 5days,reachingaminimumof600MET-minutesperweek.
Participants’ physical activity was said to be low if they did notmeet the criteria stated for the high ormoderatelevels.
3.14.2. Step 2
Physicalmeasurementsofbloodpressure,height,weight,andwaistandhipcircumferenceweremadetoevaluatetheexposuretobiologicalriskfactors:hypertension,overweightandobesity.
23
3.14.2.1. Blood pressure
Bloodpressure(BP)wasmeasuredthreetimes,with15minutes’restafterthefirstmeasurementandthree
minutesbetweenthesecondandthird.ToestablishthealterationoftheBP,thefollowingcut-offpointswere
takenintoaccount:
● high:systolicbloodpressure(SBP)≥ 140mmHgordiastolicbloodpressure(DBP)≥ 90mmHg;and
● veryhigh:SBP≥ 160mmHgorDBP≥ 100mmHg.
Teamsalsoinquiredaboutanyhistoryofhypertensiondiagnosismadebyadoctororotherhealthprofessional
To establish the total prevalence of hypertension, teams took account of the figure for high BP and the
reportedcurrentuseofdrugsforthecontrolofarterialhypertension(questionaskedtotheparticipantswith
abackgroundreportofdiagnosis).Inaddition,theydeterminedtheprevalenceofhighBPwithandwithout
antihypertensivetreatment,andnormalbloodpressurewithantihypertensivetreatment.
3.14.2.2. BMI
ThecalculationofBMIisbasedonmeasurementsofheightandweightinthesurveypopulation.Theheight
measurementismadewithacrylicheight2 mlong,fixedwithadhesivetapeonsurfacesperpendicularto
thefloor,suchaswallsordoors,askingtheparticipanttostandwithoutshoes,withhisorherbodytouching
thestadiometer.Forthemeasurementofweight,anelectronicscalewasused,placedonaflat,horizontal
andfirmsurfacesuchasthefloor;theparticipantshadtostandinfrontofthescalescreen,atthecentre
ofthescalesurface,standingwiththeheelstogether,thearmsatthesidesandchinparalleltothefloor.
Beforethemeasurement,theteamverifiedthattheparticipantwasnotwearingexcessclothes,soasnotto
overestimatetheweight.
Withtheheightandweightaverages,teamscalculatedparticipants’BMI,classifyingthemusingthefollowing
categories(44):
Category BMI (kg/m2)
Underweight < 18.5
Normalweight 18.5–24.9
Overweight 25–29.9
Obesity > 30
3.14.2.3. Waist and hip circumference
For the measurement of the waist and hip circumference, the participant remained standing, with feet
togetherandhandsoneachsideofthebody.A6-mmwidefibreglassretractabletapemeasure,graduated
incentimetres,wasplaceddirectlyontheparticipant’sskinatthemidpointbetweenthelastribandtheiliac
cresttomeasurethecircumferenceofthewaistandinthemostprominentpartofthewaist.
Thecut-offpointsgiveninTable8wereusedinthemeasurementofwaistcircumferencetoestablishthe
prevalence of waist obesity and to classify the risk of CVD andmetabolic alterations related to obesity,
accordingtowaistmeasurement,bysex.
24 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
3. SURVEY METHODOLOGY
Table 8. WHO cut-off points and risk of metabolic complications
IndicatorCut-off points (cm)
Risk of metabolic complicationsMen Women
Waistcircumference > 94 > 80 Increased
Waistcircumference > 102 > 88 Substantiallyincreased
Waist–hipratio ≥ 0.90 ≥ 0.85 Substantiallyincreased
3.14.3. Step 3
Step3oftheSTEPSsurveyincludedurineandbloodtesting.Duetofastingrequirementsforglucoseandtriglyceridesmeasurements,bloodtestingwasdoneinthemorningofthedayaftersteps1and2weredone.Participantswereaskedtofastfor24hoursbeforebloodsamplesweretaken.Fastingvenouscapillarybloodsamplesweretakentoassessbloodglucose,HbA1c, triglycerideandcholesterol levelsanddeterminethepresenceofhyperglycaemiaandhypercholesterolemia.Thesebiochemicalmeasurementswereperformedby drymethod using the devices listed in Table 7, including automated instruments for the biochemicalsamplingbydrymethodrecommendedbyWHO(44)forthisstudy.Thebiochemicalmeasurementsinstep3includedthefollowing:
● glucose ● cholesterol ● triglycerides ● HDLcholesterol ● HbA1c ● urinarysodiumandurinarycreatinine
DuringtheSTEPS3implementation,measurementofBPwasrepeatedthreetimes,with15minutes’restafterthefirstmeasurementandthreeminutesbetweenthesecondandthird.
3.14.3.1. Glycaemia
Todeterminetheprevalenceofraisedbloodglucose,theteamstookintoaccountthevalueofthefastingbloodglucoseor thecurrentconsumptionof insulinorothermedications tocontroldiabetes (aquestionaskedofparticipantswhoreportedahistoryofdiagnosisofdiabetesbyahealthprofessional).Inaddition,theprevalenceofhighbloodsugarwithandwithouttreatment,andnormalglycaemiawithtreatment,wasdetermined.Thefollowingcut-offpointswereusedfordetectingglycaemia(44):
● impairedfastingglycaemia:plasmavenousvalue≥ 110mg/dland< 126mg/dl;and ● raisedfastingbloodglucose:plasmavenousvalue≥ 126mg/dlorcurrentlyonmedicationforraisedbloodglucose.
3.14.3.2. HbA1c
TheNHHSTalsoincludedmeasurementofHbA1cinstep3ofthesurvey.Thefollowingcut-offpointwasusedfordiagnosingglycaemia:
● raisedfastingbloodglucose:HbA1c≥ 6.5%.
25
ThestudyalsocombinedfastingbloodglucoseandHbA1candusedthefollowingcut-off:raisedfastingbloodglucose:
● fastingplasmavenousglucose≥ 126mg/dlorHbA1c≥ 6.5%orcurrentlyonmedicationforraisedbloodglucose.
3.14.3.3. Total cholesterol
Todeterminetheprevalenceofhypercholesterolemia,thetotalfastingcholesterolvalueorthecurrentuseofmedicationsorspecialdiet forcontrolwasconsidered,basedonaquestionaskedtoparticipantswhoreportedadiagnosisofhypercholesterolemiabyahealthprofessional.Thecut-offpointsestablishedintheSTEPSmanual(44)wereusedtoclassifytotalcholesterollevels,usingthedrymethod:
● raisedtotalcholesterol:≥ 190mg/dlorcurrentlyonmedicationforraisedcholesterol.
3.14.3.4. Triglycerides
FastingtriglycerideswerealsomeasuredfollowingtherecommendedprocedureinSTEPSandusingthecut-offrecommendedbyWHO(44):
● raisedtriglycerides:fastingtriglycerides≥ 180mg/dl.
3.14.3.5. HDL cholesterol
Toexaminelow-cholesterolprevalenceinthestudypopulation,theteamsmeasuredHDLcholesterolinSTEPS3usingthecut-offpointrecommendedbyWHO(44):
● suboptimalHDLcholesterol:HDL< 40mg/dlformenand< 50mg/dlforwomen.
3.14.3.6. Urinary sodium and creatinine
Urinary sodium and creatinine were measured to determine population levels of high salt intake, a riskfactormainly forhypertensionandCVD.Urinesamplesweresent to theCentralLaboratoryofHacettepeUniversityFacultyofMedicineinAnkaraincoldchain.Thesampleswereanalysedbylaboratorytechnicians,who recorded the resultsona tabletPCanduploaded them to thedatabaseon theserver, tohaveeachparticipant’sdatacomplete.Theidentificationnumberofeachparticipantplayedacrucialrolehere,sinceitwasthevariableusedformatchingthedata.
LevelsofsodiumandcreatinineinspoturinesamplesareusedinSTEPStoestimatepopulation24-hoursaltintake,usingthefollowingformulas(providedbytheWHORegionalOfficeforEurope):
● estimated 24-hour sodium intake for males: [39.58 + (0.45*urinary sodium (mmol/L)] – [3.09*urinarycreatinine(mmol/L)*88.4/1000)+(4.16*BMI)+(0.22*age)];and
● estimated 24-hour sodium intake for females: [17.02+ (0.33*urinary sodium (mmol/L)] – [2.44*urinarycreatinine(mmol/L)*88.4/1000)+(2.42*BMI)+(2.34*age)–(0.03*age)].
The24-hour sodiumvalues inmmolaredividedby 17.1 inorder togetgramsof salt.Asmentioned,WHOrecommendsanintakeof< 5gsaltor< 2gsodiumperpersonperday.
SURVEY RESULTS
4
28 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
4. SURVEY RESULTSTheforemostobjectiveofthestudyistoassesstheriskfactorsforNCDsinthepopulationofTurkeyusingtheSTEPSapproach.Inadditiontoinformationusedtoassesstheriskfactorsandtheprevalenceofseveralhealth characteristics, the study also collected information onmajor demographic characteristics of therespondents,astherecanbestronglinksbetweenthem.Theearliersectionsofthischapterpresentsomeinformation on the demographic characteristics of the study population in Turkey and the later sectionspresentresultsontherespondentsbehaviouralandbiologicalriskfactorsforNCDs.Allresultspresentedinthisreportarebasedonweighteddata,exceptsomedemographicsampleinformation.
4.1. Sampling and participation
Asmentioned,8650householdswereselectedin865clusters(55clusterswithvillagestatusand810withnon-villagestatus)composedof10participantsineachcluster,withatotalof6555peopleeligibleforselectionasparticipants.Ofthese,6053(92.3%)weresurveyed,withanaverageageof46.8yearsandmarginoferrorof±0.45.AsTable9shows,outof8650households,6053selectedhouseholdmembersparticipatedinsteps1and2ofthestudy,while3352ofthesealsoparticipatedinstep3.Theoverallparticipationratewas70.0%forsteps1and2and38.6%forstep3.Outof8650householdsvisited,householdmemberswereawayfromhomeorrejectedparticipationatthedoorin2095.Thefieldteamswereabletoobtaininformationandselectamember toparticipate in the study from6555households.After the successful selectionof aneligiblehouseholdmember,502rejectedparticipationinsteps1and2and3253rejectedparticipationinstep3(seeTable9).
Table 9. Overall response proportions
Age group (years)
Men Women Both sexes
Eligible Responded Eligible Responded Eligible Responded
N N % N N % N N %
15–29 539 497 92.2 730 673 92.2 1269 1170 92.2
30–44 729 652 89.4 1146 1050 91.6 1875 1702 90.8
45–59 703 642 91.3 1045 974 93.2 1748 1616 92.4
60–69 397 381 96.0 484 463 95.7 881 844 95.8
≥ 70 307 276 89.9 475 445 93.7 782 721 92.2
Total 2675 2448 91.5 3880 3605 92.9 6555 6053 92.3
4.2. Demographic indicators
Thesurveycollected informationondemographic indicatorssuchas theage,sex,education,occupation,householdincomeandmaritalstatusofrespondents.
The6053respondentswereaged≥ 15yearsandcamefrom79provincesinTurkeycollectedinto12NUTS-1regions(seeTable1).Thissubsectionpresentssomedemographicindicatorsofthestudypopulationbyageandsex.TheNUTS-1demographicindicatorsarealsogivenincaseswherethesamplecharacteristicsvarysignificantlyacrossregions.
29
4.2.1. Age and sex characteristics
Table10givestheweightedandunweighteddistributionsofthe6053samplerespondentsbyagegroupandsex, indicating thatmenmadeup40.4%andwomen, 59.6%.3 As the survey respondentswere limited topeopleaged≥ 15years, thesample’sage–sexdistribution isnotrepresentativeofthewholepopulationofTurkey.Theweightedage–sexdistributioninTable10representsactualpopulationdistributionaccordingtoTURKSTAT’s2016populationestimates.Onlytheageandsexcharacteristicsoftheunweightedsamplearediscussedinthissection,becauseweightedfiguresreportedinTables10and11exactlymatchTURKSTAT’s2016populationestimates,owingtothepoststratificationbytwo-waysexandagedistribution.
FromtheresultsgiveninTable10,theagedistributionofthesamplerespondentsforthefivegroups–15–29,30–44,45–59,60–69and≥ 70years–are19.3%,28.1%,26.7%,13.9%and11.9%,respectively.Basedonthiscategorization,47.4%oftherespondentswereinthegroupaged15–44,and40.6%inthegroupaged45–69.Thoseintheoldestagegroupmakeup11.9%oftherespondents.
Table11showsthedistributionoftherespondentsbyNUTS-1regions:14.6%forTR1,5.4%forTR2,14.9%forTR3,12.0%forTR4,11.2%forTR5,12.1%forTR6,5.6%forTR7,6.7%forTR8,4.2%forTR9,2.6%forTRA,4.2%forTRBand6.5%forTRC.Accordingtothe2016censuscountbyTURKSTAT,thedistributionoftheTurkishpopulationbyNUTS-1regionswas18.7%forTR1,4.7%forTR2,13.6%forTR3,9.9%forTR4,9.9%forTR5,12.6%forTR6,5.0%forTR7,6.0%forTR8,3.5%forTR9,2.6%forTRA,4.4%forTRBand9.1%forTRC.
AccordingtotheresultsgiveninTable10andTable11,womenwereoversampledandmenundersampled.Similarly, there was minor over- and undersampling by NUTS-1 regions, which were accounted for byappropriatesample,populationandnon-response (cluster-level)weighting,appliedusingcomplexsampledesign.
Table 10. Age and sex distribution of respondents
Age group (years)
Men Women Both sexes
NWeighted cases (%)
Unweighted cases (%)
NWeighted cases (%)
Unweighted cases (%)
NWeighted cases (%)
Unweighted cases (%)
15–29 497 51.0 42.5 673 49.0 57.5 1170 31.6 19.3
30–44 652 50.5 38.3 1050 49.5 61.7 1702 30.3 28.1
45–59 642 50.3 39.7 974 49.7 60.3 1616 21.7 26.7
60–69 381 48.1 45.1 463 51.9 54.9 844 9.5 13.9
≥ 70 276 42.2 38.3 445 57.8 61.7 721 7.0 11.9
Total 2448 49.8 40.4 3605 50.2 59.6 6053 100.0 100.0
Note. The weighted results exactly match TURKSTAT’s 2016 population estimate, owing to post-stratification by two-way sex–age and NUTS-1 population distribution.
3 Thissectiondiscussesonlytheageandsexcharacteristicsoftheunweightedsample,becausetheweightedresultsreportedinTables10and11exactlymatchTURKSTAT’s2016populationestimate,owingtopost-stratificationbytwo-waysex–ageandNUTS-1populationdistribution.
30 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Table 11. NUTS-1 distribution of respondents
NUTS-1 regions
Respondents
NWeighted cases
(%)Unweighted cases
(%)
TR1 883 18.7 14.6
TR2 328 4.7 5.4
TR3 899 13.6 14.9
TR4 726 9.9 12.0
TR5 680 9.9 11.2
TR6 730 12.6 12.1
TR7 339 5.0 5.6
TR8 403 6.0 6.7
TR9 254 3.5 4.2
TRA 159 2.6 2.6
TRB 257 4.4 4.2
TRC 395 9.1 6.5
Total 6053 100.0 100.0
Note. The weighted results exactly match TURKSTAT’s 2016 population estimate, owing to post-stratification by two-way sex–age and NUTS-1 population distribution.
4.2.2. Marital status
Table 12presents the results for themarital statusof respondentsbyagegroupandsex.More thanhalf(65.9%)statedthat theywerecurrentlymarried (65.9%ofmenand66.0%ofwomen);27.0%weresingle;1.8%,divorced;andtheremaining5.3%,widowed.Maritalstatusvariedwithage,withthepredominanceofmarriagetoapartnerstartingfromtheageof30andthestatusofasingleperson,inthoseaged15–29years.
Thepercentageofsinglewomen(22.4%)waslowerthanthatofsinglemen(31.7%),andmorepeoplewerewidowedthandivorced.Thepercentageofwidowsaged≥ 70years(39.2%)wasalmost10timesthatinthegroupaged45–59(4.0%),showingthefeminizationofoldageorexcessmalemortality.
Table 12. Marital status of respondents by sex and age group
SexAge group (years)
N
Marital status
Single (%)
Currently married (%)
Divorced (%)
Widowed (%)
Men
15–29 497 83.2 16.7 – 0.1
30–44 652 12.1 86.7 1.1 0.2
45–59 642 3.6 93.5 1.9 1.1
60–69 381 2.0 92.0 1.4 4.6
≥ 70 276 0.8 84.2 0.3 14.8
Total 2448 31.7 65.9 0.9 1.6
31
SexAge group (years)
N
Marital status
Single (%)
Currently married (%)
Divorced (%)
Widowed (%)
Women
15–29 673 62.3 36.4 1.2 0.1
30–44 1050 6.6 88.8 3.7 0.9
45–59 974 4.4 84.1 4.4 7.0
60–69 463 1.9 69.5 2.5 26.1
≥ 70 445 1.0 41.6 0.4 57.0
Total 3605 22.4 66.0 2.7 8.9
Both sexes
15–29 1170 73.0 26.3 0.6 0.1
30–44 1702 9.4 87.7 2.4 0.5
45–59 1616 4.0 88.8 3.1 4.0
60–69 844 1.9 80.3 2.0 15.7
≥ 70 721 0.9 59.6 0.3 39.2
Total 6053 27.0 65.9 1.8 5.3
Table13displaysasignificantvariationacrossNUTS-1regionsforallclassesofmaritalstatus.TheproportionofthosenevermarriedwaslowestinTR3(20.2%)andhighestinTRC(38.4%).Thepercentageofcurrentlymarried respondents was highest in TR8 (70.5%) and lowest in TRC (59.3%). The proportion of divorcedrespondents was highest in TR3 (3.8%) and lowest in TR9 and TRA (0.1%). The percentage of widowedrespondentswaslowestinTRC(1.7%)andhighestinTRA(8.4%).
Table 13. Marital status of respondents by NUTS-1 regions
NUTS-1 regions
Both sexes
NSingle
(%)Currently married
(%)Divorced
(%)Widowed
(%)
TR1 883 28.6 65.2 1.7 4.5
TR2 328 23.5 67.4 2.6 6.5
TR3 899 20.2 68.0 3.8 8.0
TR4 726 27.2 66.2 1.6 5.0
TR5 680 27.6 65.2 1.9 5.3
TR6 730 24.1 69.1 2.5 4.3
TR7 339 28.6 63.7 0.6 7.1
TR8 403 20.7 70.5 1.6 7.2
TR9 254 30.5 64.1 0.1 5.3
TRA 159 21.9 69.5 0.1 8.4
TRB 257 34.7 62.1 0.3 2.9
TRC 395 38.4 59.3 0.5 1.7
Total 6053 27.0 65.9 1.8 5.3
Table 12 (contd)
32 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
4.2.3. Education
Educationalattainment4 isgivenbysex inFig.4.Amongthefemalerespondents,24.5%were illiterateorhad no formal schooling, 38.4% had primary-level schooling; 27.3%, secondary or vocational secondaryschooling; and 9.8%, a college education. The corresponding percentages formales were: 9.7%, 34.1%,39.5%and16.7%,respectively.
Fig. 4. Respondents’ levels of education by sex
1
Fig. 1. Respondents’ levels of education by sex
9.7
34.1
39.5
16.7
24.5
38.4
27.3
9.8
18.5
36.7
32.2
12.6
0
5
10
15
20
25
30
35
40
45
Illiterate or literate but noformal schooling
Primary school completed Secondary, vocationalsecondary/high school
completed
College, faculty, master's ordoctorate completed
Perc
enta
ge
Men Women Both sexes
Table 14 shows that 18.5% of the respondents were illiterate or had no formal schooling, 36.7% of allrespondents had primary-school education; 32.2%, secondary or vocational secondary education; and12.6%, college education. Theproportion of respondentswith no education increasedwith age, and thathigherlevelsofeducationwerefoundinyoungeragegroups.Theseresultsareperfectlycompatiblewiththeaverageyearsofeducationcompleted,whichisexaminedlater(seeTable16).
Table 15 shows the highest level of educational attainment by NUTS-1 regions, with significant variationbetweenregionsineducationalattainmentatall levels.TRAhadthehighestrateof illiteracyornoformalschooling(39.6%),followedbyTRB(33.1%)andTRC(31.6%).ThelowestsuchrateswerefoundinTR4(11.4%),TR5(12.1%)andTR1 (10.1%).Theregionswiththehighestpercentagesofhigh-schooleducationwereTRC(40.8%), TR4 (37.1%) and TR5 (36.3%) while those with the lowest such percentages were TRA (22.0%),followedbyTR3(26.9%)andTR8(28.3%).
Table16andTable17showtheaverageyearsofeducationofthesurveyrespondentsbysexandagegroup,andNUTS-1regions,respectively.Themeannumberofyearsofeducationwaslow(9.1years)fortheoverallstudysample,as55.2%oftherespondentshadaneducationlevelbelowsecondaryschool.Theaverageyearsofeducationdifferedgreatlybybothsexandage.Thegroupwiththehighestnumberofaverageyearsofeducationwasthataged15–29years.Asmentioned,theaverageyearsofeducationdecreasedproportionallywithage.
4 Thissectiondiscussesonlyhighestlevelofeducationalattainmentoftheunweightedsample,becausetheweightedresultsreportedinTables14and15exactlymatchTURKSTAT’s2016populationestimates,owingtopost-stratificationbytwo-waysex–education,age–sexandNUTS-1populationdistribution.
33
Tabl
e 14
. Re
spon
dent
s’ h
ighe
st le
vel o
f edu
catio
n by
sex
and
age
gro
up
Sex
Age
grou
p (y
ears
)N
Illite
rate
or l
itera
te b
ut n
o fo
rmal
sch
oolin
g (%
)Pr
imar
y sc
hool
co
mpl
eted
(%)
Seco
ndar
y, v
ocat
iona
l se
cond
ary,
or h
igh
scho
ol
com
plet
ed (%
)
Colle
ge, f
acul
ty, m
aste
r’s o
r do
ctor
ate
com
plet
ed (%
)
Wei
ghte
d ca
ses
Unw
eigh
ted
case
sW
eigh
ted
case
sUn
wei
ghte
d ca
ses
Wei
ghte
d ca
ses
Unw
eigh
ted
case
sW
eigh
ted
case
sUn
wei
ghte
d ca
ses
Men
15–2
949
70.
81.4
4.1
4.8
75.4
68.2
19.7
25.6
30–4
465
22.
02.
619
.328
.459
.147
.519
.621
.5
45–5
964
24.
37.
331
.346
.646
.131
.818
.314
.3
60–6
938
19.
715
.043
.953
.034
.822
.611.
79.
4
≥ 70
276
28.5
39.5
41.1
45.3
20.8
9.8
9.6
5.4
Tota
l24
484.
49.
720
.534
.157
.039
.518
.116
.7
Wom
en15
–29
673
2.1
4.9
5.2
8.5
70.7
64.9
22.0
21.7
30–4
410
506.
79.
935
.347
.441
.129
.616
.913
.0
45–5
997
415
.120
.545
.255
.229
.018
.510
.75.
7
60–6
946
339
.249
.537
.138
.719
.29.
34.
62.
6
≥ 70
445
64.0
71.0
28.1
25.4
6.7
2.7
1.10.
9
Tota
l36
0514
.924
.527
.738
.442
.727
.314
.79.
8
Both
sex
es15
–29
1170
1.43.
44.
76.
973
.166
.320
.823
.3
30–4
417
024.
37.
127
.240
.150
.236
.518
.316
.3
45–5
916
169.
715
.338
.251
.837
.623
.814
.59.
2
60–6
984
425
.033
.940
.445
.126
.715
.38.
05.
7
≥ 70
721
49.0
58.9
33.6
33.0
12.7
5.4
4.7
2.6
Tota
l60
539.
618
.524
.236
.749
.932
.216
.412
.6
Note
. The
wei
ghte
d re
sults
repo
rted
exa
ctly
mat
ch T
URKS
TAT’s
201
6 po
pula
tion
estim
ates
, ow
ing
to p
ost-
stra
tifica
tion
by tw
o-w
ay s
ex–e
duca
tion,
age
–sex
and
NUT
S-1 p
opul
atio
n di
strib
utio
n.
34 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Respondents aged 15–29 received 11.3mean yearsof education, in contrast to thefigures for thegroupsaged30–44(9.6years),45–59(8.1years),60–69(6.0years)and≥ 70(3.9years).Similarlytothepatternforagegroups,theaverageyearsofeducationdifferedsignificantlybetweenthesexes:9.9yearsformenand8.2yearsforwomen(anaveragedifferenceof1.7years).
TheaverageyearsofeducationbyNUTS-1regionsshowninTable17andFig.5parallelthegeneraltrendsinTable15.TheaverageyearsofeducationwerehighestinTR5(9.9years)andlowestinTR8(8.3years).
Table 15. Respondents’ levels of education by NUTS-1 regions, both sexes
NUTS-1 regions
N
Illiterate or literate but no formal schooling (%)
Primary school completed (%)
Secondary, vocational secondary, or high
school completed (%)
College, faculty, master’s or doctorate
completed (%)
Weighted cases
Unweighted cases
Weighted cases
Unweighted cases
Weighted cases
Unweighted cases
Weighted cases
Unweighted cases
TR1 883 6.0 10.1 28.0 43.3 46.2 31.3 19.8 15.4
TR2 328 6.9 12.2 34.3 50.6 46.3 28.4 12.5 8.8
TR3 899 9.7 16.4 29.0 42.8 41.8 26.9 19.5 13.9
TR4 726 5.1 11.4 23.4 39.0 56.4 37.1 15.1 12.5
TR5 680 5.7 12.1 23.2 33.1 50.3 36.3 20.9 18.5
TR6 730 8.4 19.0 22.0 36.3 56.9 34.4 12.8 10.3
TR7 339 11.5 26.0 23.3 35.1 51.4 28.6 13.7 10.3
TR8 403 15.1 31.5 23.8 33.3 48.5 28.3 12.5 6.9
TR9 254 10.6 20.1 19.6 27.2 45.4 34.3 24.4 18.5
TRA 159 26.7 39.6 17.5 24.5 39.5 22.0 16.3 13.8
TRB 257 16.9 33.1 17.5 24.9 48.4 30.0 17.3 12.1
TRC 395 16.0 31.6 16.0 22.5 59.5 40.8 8.4 5.1
Total 6053 9.6 18.5 24.2 36.7 49.9 32.2 16.4 12.6
Note. The weighted results reported in the table exactly match TURKSTAT’s 2016 population estimates due to the post-stratification by two-way sex–age and NUTS-1 population distribution.
Table 16. Respondents’ mean number of years of education by sex and age group
Age group (years)
Men Women Both sexes
N Mean 95% CI N Mean (95% CI) N Mean (95% CI)
15–29 497 11.4 11.2–11.7 673 11.2 11.0–11.5 1170 11.3 11.2–11.5
30–44 652 10.3 10.0–10.7 1050 8.8 8.4–9.2 1702 9.6 9.3–9.8
45–59 642 9.3 8.9–9.7 974 6.8 6.3–7.3 1616 8.1 7.7–8.4
60–69 381 7.5 7.0–7.9 463 4.6 4.0–5.2 844 6.0 5.6–6.4
≥ 70 276 5.7 5.0–6.4 445 2.5 2.1–3.0 721 3.9 3.4–4.3
Total 2448 9.9 9.7–10.1 3605 8.2 8.0–8.4 6053 9.1 8.9–9.2
35
Table 17. Respondents’ mean number of years of education by NUTS-1 regions
NUTS-1 regions
Respondents (N)Years
Mean 95% CI
TR1 883 9.7 9.3–10.1
TR2 328 8.4 7.7–9.2
TR3 899 8.8 8.3–9.3
TR4 726 9.4 9.0–9.8
TR5 680 9.9 9.3–10.5
TR6 730 8.9 8.5–9.3
TR7 339 8.8 8.1–9.6
TR8 403 8.1 7.2–8.9
TR9 254 9.5 8.7–10.3
TRA 159 8.3 6.7–9.9
TRB 257 8.6 7.6–9.5
TRC 395 8.5 7.7–9.2
Total 6053 9.1 8.9–9.2
Fig.5showsthegeographicdistributionoftheaveragenumberofyearsofeducation,whichwaslowestinthewesternBlackSearegion,followedbycentralAnatolia,easternTurkeyandsouth-easternTurkey.ThehighestnumberofyearsofeducationwasobservedintheeasternBlackSearegion,theMarmararegionandwesternAnatolia.
Fig. 5. Respondents’ mean number of years of education by NUTS regions
Source:MinistryofEnvironmentandUrbanization,RepublicofTurkeyandTURKSTAT.
36 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
4.2.4. Employment
Table18presentsthedistributionofrespondentsbypaid-employmentstatus,whileTable19presentsthedistributionofunpaidandunemployedrespondents.Ineachtable,theresultsarebrokendownbyagegroupandsex.ThegroupsdescribedinTable18andTable19aremutuallyexclusive.
During the year of the survey, the main paid employment of the respondents was employment outsidethegovernment (nongovernmental –23.5%), followedbyemploymentby thegovernment (6.0%)andself-employment (5.7%) (Table 18). Table 18 shows that 64.9% of the respondents were doing unpaid work.Occupationalstatusdifferedsignificantlyaccordingtosex,ageandareaofresidence.Intermsofpaidwork,themajorityofmen(38.9%)andwomen(8.1%)werenongovernmentalemployees.
Amongmendoingpaidwork,nongovernmentalemploymentisfollowedbyself-employmentandgovernmental(10.2%and8.6%,respectively).Thiswasobservedformeninallagegroups(Table18).
Whenunemploymentisconsidered,ratesofpeopleunemployedandabletoworkwerehigherintheyoungeragegroups:13.3%forthegroupaged15–29;7.8%forthoseaged30–44,4.2%forthoseaged45–59and2.6%forthoseaged60–69.Alargefractionofthewomenwerehomemakers(Table19).
Table 18. Respondents’ paid employment status by sex and age group
SexAge group (years)
N
Employment status (%)
Government employee
Nongovernment employee
Self-employedUnpaid including
retired
Men 15–29 496 3.6 34.6 3.8 58.0
30–44 651 13.5 62.5 18.0 6.0
45–59 642 13.8 35.0 12.1 39.1
60–69 381 2.4 7.6 7.5 82.5
≥ 70 275 – 2.9 1.0 96.1
Total 2445 8.6 38.9 10.2 42.4
Women 15–29 672 3.7 11.1 0.6 84.6
30–44 1049 5.5 12.2 2.0 80.3
45–59 973 2.7 4.8 1.9 90.6
60–69 461 0.4 0.1 – 99.5
≥ 70 445 – 0.2 – 99.8
Total 3600 3.4 8.1 1.2 87.3
Both sexes 15–29 1168 3.7 23.1 2.2 71.0
30–44 1700 9.5 37.6 10.1 42.8
45–59 1615 8.3 20.0 7.1 64.7
60–69 842 1.4 3.7 3.6 91.3
≥ 70 720 – 1.3 0.4 98.2
Total 6045 6.0 23.5 5.7 64.9
When the sexes are compared, the percentage doing paidworkwas higher inmen (57.6%) thanwomen(12.7%),aswas thepercentage thatwasunemployedbutable towork (15.0% inmenand4.1%inwomen),againbecausethemajorityofwomenhadhomemakerstatus.
37
Table 19. Respondents’ unpaid employment status by sex and age group
SexAge group (years)
N
Unpaid employment status (%) Unemployed (%)
Unpaid employee
StudentHome-maker
RetiredAble to
workNot able to work
Men 15–29 258 0.2 79.6 – 0.1 19.2 0.9
30–44 41 3.2 1.9 14.1 7.0 64.9 8.9
45–59 282 0.2 – 0.6 84.0 11.7 3.6
60–69 317 0.6 – 1.1 89.7 5.3 3.3
≥ 70 262 0.3 – 0.9 88.9 2.5 7.5
Total 1160 0.4 35.2 1.1 45.3 15.0 3.1
Women 15–29 568 – 49.1 41.5 0.1 9.2 –
30–44 860 – 0.9 95.0 0.5 3.4 0.2
45–59 899 0.2 0.2 87.5 11.1 0.9 0.1
60–69 459 – – 78.8 20.3 0.5 0.4
≥ 70 444 0.4 – 74.9 19.6 1.5 3.6
Total 3230 0.1 15.0 73.7 6.7 4.1 0.4
Both sexes 15–29 826 0.1 61.8 24.3 0.1 13.3 0.4
30–44 901 0.2 1.0 89.3 1.0 7.8 0.8
45–59 1181 0.2 0.1 61.1 33.3 4.2 1.1
60–69 776 0.2 – 45.0 50.5 2.6 1.7
≥ 70 706 0.4 – 44.4 48.1 1.9 5.2
Total 4390 0.2 21.6 50.1 19.2 7.6 1.3
4.2.5. Income
The average incomeof a household provides information on its capacities tomeet themembers’ needs,particularlyforfood.Theaverageannualpercapitaincomewascalculatedastotalannualhouseholdincomedividedbythenumberofmembersofworkingage(≥ 18years).Themajorityofhouseholds(4097or67.7%)reportedtheirapproximateincome.
Table20showshouseholds’meanpercapitaannual income.Meanannualpercapitahousehold incomeisthecombinedannualincomedividedbythenumberofhouseholdmembersage≥ 18years.Themeanannualincomereported,irrespectiveofthenumberofpeopleemployedperhousehold,is14 992.30TurkishLira(TL).AverageannualincomepercapitavariedsignificantlyacrosstheNUTS-1regions.Themeanannualpercapitaincomeinthehighest-incomeregion(TR8)is2.5timesthatinthelowest-incomeregion(TRA).TheregionswiththehighestincomewereTR8,TR5,TR1andTR9,andthosewiththelowestwereTRC,TR6,TR2andTRA.
38 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Table 20. Respondents’ mean annual per capita household income by NUTS-1 regions
NUTS-1 regionsHouseholds
N Mean income (TL)
TR1 561 17 953.2
TR2 227 10 025.8
TR3 319 12 956.6
TR4 494 14 171.4
TR5 625 20 435.0
TR6 592 10 051.6
TR7 300 13 564.6
TR8 331 22 098.5
TR9 136 17 139.2
TRA 88 8 994.7
TRB 181 10 697.5
TRC 243 10 632.5
Total 4097 14 992.3
Note. Mean annual per capita household income is the combined annual income divided by the number of household members aged ≥ 18 years. Cases are unweighted.
Fig.6showsthesignificantvariationinmeanannualpercapitaincomeacrossregions:incomewashighestinthewesternAnatoliaregion,followedbythewesternBlackSeaandIstanbulregions,andthelowestincomewasobservedinthesouth-easternandnorth-westernregions.
Fig. 6. Mean annual per capita household income by NUTS-1 regions
Source:MinistryofEnvironmentandUrbanization,RepublicofTurkeyandTURKSTAT.
39
4.3. Tobacco use
Tobaccoisusedinseveralforms,suchascigarette,cigarsandbidis,aswellasinpipesandhookahs.Theworldwide prevalence of current tobacco smoking among adults was approximately 22% in 2012. Theprevalenceoftobaccosmokingdiffersamongcountries.Men(37%)tendtosmokemorethanwomen(7%)(7).
AccordingtotheresultsgiveninTable21,theprevalenceofcurrenttobaccoconsumptionwas31.5%.Smokingprevalencewassignificantlyhigherinmen(43.4%)thanwomen(19.7%),withthedifferencebeingsignificantataP-value< 1%(P<0.01).
Theprevalenceof tobaccouse isveryclose to theprevalenceofsmoking,and31.6%of the respondentscurrentlyused(smokedorsmokeless)tobacco(males43.6%andfemales19.7%).
Inthetotalpopulation,currentsmokingstatusvariedamongagegroups(seeFig.7),peakinginthegroupaged30–44.Althoughprevalencewashigher inmen thanwomenacrossall agegroups, smokingpeakedat54.0%formenand29.3%forwomen.Prevalencefellalmostexponentiallyafterage44andreachedtheminimumintheoldestgroup.
Table 21. Percentage of current smokers among respondents by sex and age group
Age group (years)
Men Women Both sexes
NCurrent
smoker (%)95% CI N
Current smoker (%)
95% CI NCurrent
smoker (%)95% CI
15–29 497 44.6 39.6–49.6 673 15.9 12.4–19.4 1170 30.6 27.2–33.9
30–44 652 54.0 49.3–58.6 1050 29.3 25.2–33.5 1702 41.8 38.6–45.0
45–59 642 42.4 37.4–47.4 974 22.4 17.8–27.0 1616 32.4 29.1–35.7
60–69 381 26.3 20.9–31.7 463 9.3 5.0–13.5 844 17.5 14.0–20.9
≥ 70 276 12.2 6.4–18.0 445 3.7 1.1–6.3 721 7.3 4.4–10.2
Total 2448 43.4 40.8–46.0 3605 19.7 17.6–21.8 6053 31.5 29.7–33.3
Fig. 7. Percentage of current smokers by sex and age group
2
Fig. 2. Percentage of current smokers by sex and age group
Fig. 3. Prevalence of daily smoking among current tobacco users by sex and age group
44.6
54.0
42.4
26.3
12.2
15.9
29.3
22.4
9.3
3.7
30.6
41.8
32.4
17.5
7.3
0
10
20
30
40
50
60
15–29 30–44 45–59 60–69 ≥70
Perc
enta
ge
Men Women Both sexes
91.0 93
.6
94.6 98
.8
76.6
92.9
87.9 93
.3
94.5 98
.1
94.5
92.5
90.2 93
.5
94.5 98
.6
81.9
92.8
0
20
40
60
80
100
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
40 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Table22showsthattheprevalenceofcurrentsmokingvariedacrossNUTS-1regions,eventhoughnoneofthedifferenceswerestatisticallysignificantatthe5%level.Nevertheless,thehighestrateswerefoundinTR4,TR2,TR5andlowestinTRC,TR8andTRB.
Table 22. Percentage of current smokers among respondents by NUTS-1 regions
NUTS-1 regions
Respondents
NCurrent smokers
(%)95% CI
TR1 883 30.8 26.1–35.4
TR2 328 37.2 29.7–44.8
TR3 899 31.7 27.6–35.8
TR4 726 37.5 31.9–43.2
TR5 680 36.5 31.2–41.7
TR6 730 28.7 23.6–33.7
TR7 339 29.0 20.8–37.3
TR8 403 26.9 18.8–35.0
TR9 254 32.4 24.0–40.9
TRA 159 33.7 24.3–43.1
TRB 257 28.3 20.2–36.3
TRC 395 26.8 19.9–33.7
Total 6053 31.5 29.7–33.3
Fig.8showsrespondents’smokingstatusbysexandagegroup:92.8%ofcurrenttobaccouserssmokeddaily,withsimilarbehaviourinbothsexes(92.9%inmenand92.5%inwomen).
Fig. 8. Prevalence of daily smoking among current tobacco users by sex and age group
2
Fig. 2. Percentage of current smokers by sex and age group
Fig. 3. Prevalence of daily smoking among current tobacco users by sex and age group
44.6
54.0
42.4
26.3
12.2
15.9
29.3
22.4
9.3
3.7
30.6
41.8
32.4
17.5
7.3
0
10
20
30
40
50
60
15–29 30–44 45–59 60–69 ≥70
Perc
enta
ge
Men Women Both sexes
91.0 93
.6
94.6 98
.8
76.6
92.9
87.9 93
.3
94.5 98
.1
94.5
92.5
90.2 93
.5
94.5 98
.6
81.9
92.8
0
20
40
60
80
100
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
41
Consequently,theprevalenceofdailyconsumptionis29.2%(Table23).Similarlytocurrentsmoking,dailysmokinginmenwasmorethantwicethatinwomen(40.4%and18.2%,respectively,P<0.01).Dailysmokingpeakedinthegroupaged30–44(39.1%)anddecreasedafterwardsto30.7%forpeopleaged45–59,17.2%forpeopleaged60–69,and6.0%inthoseaged≥ 70(P<0.01);thedifferenceinprevalencebetweenthegroupsaged30–44and≥ 70wasparticularlygreatinwomen(7.8times).
Table23also shows theproportionsof currentnon-usersof tobaccowhowere former smokers: 10.7%of thewholestudypopulation,althoughthisratewashigherformen(14.8%)thanwomen(6.6%).Therewasasignificantdifferenceacrossagegroupsformen,butnotforwomen.
Aswithcurrentsmoking,dailysmokingshowednostatisticallysignificantdifferencebetweenNUTS-1 regions,althoughtheprevalencewashighestinTR4,TR2andTR5andlowestinTRC,TR8andTR7(Fig.9).Theregionswiththe lowestratesarepredominantlyrural.Theregionswiththehighestandlowestsmokingrates(TR4andTRC,respectively)showadifferenceof11.8percentagepoints.
42 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Tabl
e 23
. Sm
okin
g st
atus
of r
espo
nden
ts b
y se
x an
d ag
e gr
oup
Sex
Age
grou
p (y
ears
)N
Curr
ent s
mok
ers
(%)
Nons
mok
ers
(%)
Daily
sm
oker
s95
% C
INo
ndai
ly95
% C
IFo
rmer
sm
oker
s95
% C
INe
ver s
mok
er95
% C
I
Men
15–2
949
740
.635.7–45.5
4.0
2.0–6.1
4.7
1.9–7.5
50.7
45.2–56.1
30–4
465
250
.545.8–55.3
3.4
1.8–5.1
10.5
7.9–13.2
35.5
31.0–40.0
45–5
964
240
.135.2–45.0
2.3
0.9–3.7
20.0
16.0–24.1
37.6
32.8–42.4
60–6
938
126
.020.6–31.4
0.3
0.0–1.0
33.1
27.2–38.9
40.6
34.3–46.9
≥ 70
276
9.4
4.2–14.5
2.9
0.2–5.5
45.3
37.9–52.8
42.4
35.4–49.5
Tota
l24
4840
.437
.8–4
2.9
3.1
2.2–
4.0
14.8
13.1–
16.5
41.8
39.0
–44.
5
Wom
en15
–29
673
14.0
10.6–17.4
1.90.8–3.1
4.3
2.4–6.2
79.7
75.9–83.6
30–4
410
5027
.423.3–31.5
2.0
1.0–2.9
6.4
4.4–8.4
64.3
60.1–68.5
45–5
997
421
.116.6–25.7
1.20.2–2.3
9.3
6.2–12.3
68.3
63.4–73.2
60–6
946
39.
14.8–13.3
0.2
0.0–0.5
8.0
5.0–11.0
82.7
77.8–87.7
≥ 70
445
3.5
1.0–6.1
0.2
0.0–0.6
7.5
4.0–11.1
88.7
84.4–93.0
Tota
l36
0518
.216
.1–20
.31.5
0.9–
2.0
6.6
5.5–
7.8
73.7
71.4
–75.
9
Both
se
xes
15–2
9117
027
.624.4–30.8
3.0
1.8–4.2
4.5
2.8–6.2
64.9
61.2–68.6
30–4
417
0239
.135.8–42.3
2.7
1.7–3.7
8.5
6.8–10.2
49.8
46.6–53.0
45–5
916
1630
.727.4–33.9
1.80.9–2.6
14.7
12.1–17.2
52.9
49.5–56.2
60–6
984
417
.213.7–20.7
0.2
0.0–0.6
20.1
16.7–23.4
62.5
58.2–66.7
≥ 70
721
6.0
3.4–8.6
1.30.2–2.5
23.5
19.2–27.7
69.2
64.6–73.8
Tota
l60
5329
.227
.5–3
1.02.
31.7
–2.8
10.7
9.7–
11.8
57.8
55.9
–59.
7
43
Fig. 9. Prevalence of daily smoking in respondents by NUTS-1 regions
3
Fig. 4. Prevalence of daily smoking in respondents by NUTs-1 regions
Fig. 5. Daily smokers using manufactured cigarettes by sex and age group
29.7
35.3
28.8
35.9
33.5
26.225.8
25.1
30.2
26.9 26.7
24.1
29.2
20
22
24
26
28
30
32
34
36
38
TR1 TR2 TR3 TR4 TR5 TR6 TR7 TR8 TR9 TRA TRB TRC TOTAL
Perc
enta
ge
98.8
97.7
95.2
96.4
90.0
97.3
94.8
98.9
96.9
93.9
100.
0
97.297
.8 98.1
95.8
95.7
93.1
97.3
85
90
95
100
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
Table24showsthemeanageatwhichcurrentdailysmokersamongtherespondentsstartedtosmoke.Themeanageofonsetofdailytobaccosmokingwas18.1years(95%CI:17.8–18.5%)forbothsexes,andtherewasastatisticallysignificantdifferenceofthreeyearsbetweenmenandwomen(P<0.05).Theonsetoftobaccosmokingrosewithage,withyoungerrespondentsstartingtosmokeearlierinlifealsovariesbetweenagegroups:itwasloweramongyoungerparticipants,goingfrom16.3yearsamongparticipantsaged15–29yearsto23.0yearsamongtheparticipantsaged≥ 70(P<0.05fordifferenceacrossallagegroups),behaviourthatwasobservedinbothsexes,butmoremarkedinwomen.
Table 24. Mean age at which current daily smokers among respondents started smoking, by sex and age group
Age group (years)
Men Women Both sexes
NMean
(years)95% CI N
Mean (years)
95% CI NMean
(years)95% CI
15–29 204 15.8 15.5–16.2 99 18.0 17.1–18.8 303 16.3 16.0–16.7
30–44 319 17.6 17.0–18.1 263 20.1 18.8–21.4 582 18.5 17.9–19.0
45–59 262 18.2 17.4–18.9 176 21.2 20.0–22.4 438 19.2 18.5–19.9
60–69 99 18.1 16.8–19.5 32 23.5 19.7–27.2 131 19.6 18.2–21.0
≥ 70 23 18.5 16.6–20.3 9 31.6 24.6–38.5 32 23.0 19.4–26.7
Total 907 17.2 16.9–17.5 579 20.2 19.5–20.9 1486 18.1 17.8–18.5
The age of onset of daily tobacco consumption showed statistically significant differences betweenNUTS-1regions,althoughnotallregionsdifferedstatisticallyinapairwisecomparison.Nevertheless,theageofonsetwaslowestintheTRCandTR2(16.7and17.4years,respectively)andhighestinTR5andTR4(18.7and18.8,respectively).
44 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Fig. 10givesthepercentagesofdailysmokersusingmanufacturedcigarettes:97.3%ofalldailysmokers,97.2%forwomenand97.3%formen.Theuseofmanufacturedcigarettesdecreasedwithage,althoughthedifferenceswerenotstatisticallysignificantatthe5%level.
Fig. 10. Daily smokers using manufactured cigarettes by sex and age group
3
Fig. 4. Prevalence of daily smoking in respondents by NUTs-1 regions
Fig. 5. Daily smokers using manufactured cigarettes by sex and age group
29.7
35.3
28.8
35.9
33.5
26.225.8
25.1
30.2
26.9 26.7
24.1
29.2
20
22
24
26
28
30
32
34
36
38
TR1 TR2 TR3 TR4 TR5 TR6 TR7 TR8 TR9 TRA TRB TRC TOTAL
Perc
enta
ge
98.8
97.7
95.2
96.4
90.0
97.3
94.8
98.9
96.9
93.9
100.
0
97.297
.8 98.1
95.8
95.7
93.1
97.3
85
90
95
100
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
Table25showsthatdailysmokersamongtherespondentsusedanaveragenumberof15.5manufacturedtobacco cigarettes per day,withmen usingmore thanwomen (16.8 and 12.7, respectively,P < 0.05). Thenumberofmanufacturedcigarettesconsumeddailyincreasedwithage,from14.8forthoseaged15–29yearsto15.2forthoseaged≥ 70(Table25),abehaviourthat ismainlyobservedinwomen.Womenconsumedahigheraveragenumber(5.9cigarettes)betweentheagesof15–29and≥ 70.
Table 25. Mean amount of tobacco used by daily smokers by type and age group
Age group (years)
Manufactured cigarettes Hand-rolled cigarettes Pipes of tobacco
NMean
no.95% CI N
Mean no.
95% CI N Mean
no.95% CI
15–29 308 14.8 13.6–16.0 289 1.0 0.4–1.7 290 0.0 0.0–0.0
30–44 582 15.8 14.6–16.9 541 0.6 0.3–0.9 542 0.0 0.0–0.0
45–59 434 16.0 14.5–17.6 406 1.7 1.0–2.5 408 0.0 0.0–0.0
60–69 132 15.5 13.0–18.0 127 2.1 0.9–3.4 128 0.0 0.0–0.1
≥70 32 15.2 12.5–17.9 31 1.5 0.0–3.4 33 0.0 –
Total 1488 15.5 14.8–16.2 1394 1.1 0.8–1.4 1401 0.0 0.0–0.0
Table26presentsthelowratesofsmokeless-tobaccouseinTurkey:0.3%forbothsexes,0.6%formenand0.1%forwomen.Ratesformenwerehighestinthegroupsaged30–44and45–59;therateforwomenwashighestinthegroupaged60–69.
45
Table 26. Current users of smokeless tobacco by sex and age group
Age group (years)
Men Women Both sexes
NCurrent
users (%)95% CI N
Current users (%)
95% CI NCurrent
users (%)95% CI
15–29 497 0.2 0.0–0.5 673 0.2 0.0–0.5 1170 0.2 0.0–0.4
30–44 652 1.4 0.2–2.6 1050 – – 1702 0.7 0.1–1.3
45–59 642 0.4 0.0–0.9 974 – – 1616 0.2 0.0–0.5
60–69 381 – – 463 0.6 0.0–1.7 844 0.3 0.0–0.9
≥ 70 276 – – 445 – – 721 – –
Total 2448 0.6 0.1–1.0 3605 0.1 0.0–0.3 6053 0.3 0.1–0.6
Fig.11showsthepercentagesofcurrentsmokersinthestudypopulationwhohadtriedtostopsmokingduringprevious12monthsbysexandagegroup:27.4%forbothsexes,althoughtheratewashigherformen(29.4%)thanwomen(23.0%).Whilethepercentageofcurrentsmokerswhohadtriedtoquitvariedacrossagegroupsforbothmenandwomen,itwashighestformenaged60–69(40.0%)andforwomenaged15–29(26.9%).
Fig.12presentstheproportionsofcurrentsmokerswhosedoctorshadadvisedthemtostopsmokingintheprevious12months;theproportionwasmuchlowerformen(21.2%)thanwomen(24.7%)andvariedacrossagegroups.
Fig. 11. Current smokers who had tried to quit during the previous 12 months
4
Fig. 6. Current smokers who had tried to quit during the previous 12 months
Fig. 7. Current smokers advised by a doctor to stop smoking in the previous 12 months
26.3
30.8
28.8
40.0
34.2
29.4
26.8
22.9
21.2
18.3
9.1
23.0
26.4 28
.0
26.2
34.1
26.8 27.4
0
5
10
15
20
25
30
35
40
45
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Woman Both sexes
11.9
22.0 25
.3
45.1
44.3
21.2
14.2
27.0
27.1
39.5
39.6
24.7
12.5
23.8 26
.0
43.5
42.9
22.3
0
5
10
15
20
25
30
35
40
45
50
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Woman Both sexes
46 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Fig. 12. Current smokers advised by a doctor to stop smoking in the previous 12 months
4
Fig. 6. Current smokers who had tried to quit during the previous 12 months
Fig. 7. Current smokers advised by a doctor to stop smoking in the previous 12 months
26.3
30.8
28.8
40.0
34.2
29.4
26.8
22.9
21.2
18.3
9.1
23.0
26.4 28
.0
26.2
34.1
26.8 27.4
0
5
10
15
20
25
30
35
40
45
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Woman Both sexes
11.9
22.0 25
.3
45.1
44.3
21.2
14.2
27.0
27.1
39.5
39.6
24.7
12.5
23.8 26
.0
43.5
42.9
22.3
0
5
10
15
20
25
30
35
40
45
50
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Woman Both sexes
4.3.1. Conclusions
Someofthemostimportantresultsontobaccousebyrespondentsincludedthefollowing:
● 31.6%currentlyused(smokedorsmokeless)tobacco(males:43.6%,andfemales:19.7%); ● 31.5%currentlysmokedtobacco(males:43.4%,andfemales:19.7%); ● 29.2%currentlysmokedtobaccodaily(males:40.4%,andfemales:18.2%),andtheyhadstartedsmoking,onaverage,attheageof18.1years(males:17.2,andfemales:20.2);
● 97.3%dailysmokersusedmanufacturedcigarettes(males:97.3%,andfemales:97.2%); ● usersofmanufacturedcigarettessmokedameannumberof15.5perday(males:16.8,andfemales:12.7); ● 0.3%ofrespondentscurrentlyusedsmokelesstobacco(males:0.6%,andfemales:0.1%); ● amongthestudygroup,10.7%wereformersmokers(males:14.8%,andfemales:6.6%)and57.8%hadneversmoked(males:41.8%,andfemales:73.7%).2.3%werenondailysmokers(males:3.1%,andfemales:1.5%);
● thepercentageofcurrentsmokerswhotriedtostopsmokinginprevious12monthswas27.4%(males:29.4%,andfemales:23.0%);
● thepercentageofcurrentsmokersadvisedbyahealthcareprovidertostopsmokingintheprevious12monthswas22.3%(males:21.2%,andfemales:24.7%).
4.4. Alcohol consumption
Alcoholuseisrelatedtoseveraleffectsonhealth,suchasincreasedriskofcancer,strokeandcirrhosis;andmortalityanddisabilityresultingfromaccidents,injuries,assault,violence,homicideandsuicide(46).Alcoholconsumptionwasestimatedtoaccountfor5.9%(3.3million)ofalldeathsgloballyand5.1%ofDALYsin2012.In2010,alcoholconsumptionworldwidewasestimatedtobe6.2Lpurealcoholperpersonaged≥ 15years.TheharmfuluseofalcoholiscloselyassociatedwithNCDs.AccordingtoWHO,alcoholconsumptioninTurkeyin2010wasapproximatelyonethirdofthatintheworld.BothinTurkeyandintheworld,alcoholconsumptionishigheramongmenthanwomen (47).Someactionhasbeentakenagainsttheharmfuluseofalcohol inTurkey,includingadvertisingbansorcomprehensiverestrictions,andincreasedexcisetaxes(27).
47
Table 27 presents the findings for alcohol consumption by respondents, by sex and age group. Of allrespondents,4.1%reportedhavingconsumedalcohol in the12monthsbeforethesurvey.Theprevalenceofalcoholdrunkinthe30daysbeforethesurveywas8.0%forthesurveypopulationgroup,buthigher inmenthanwomen(13.1%and3.0%,respectively,P < 0.05).Italsovariedwithage,beingaround9.7%inthoseunder30yearsofageand1.7%inthoseaged≥ 70.Forbothmenandwomenrespondents,theprevalenceofalcoholconsumptionintheprevious30daysdeclinedwithage.Table27alsoindicatesthat83.6%ofthestudypopulationwerelifetimeabstainers,withahigherrateinwomen(92.7%)thanmen(74.4%),and4.3%ofthepopulationhadabstainedintheprevious12months,withahigherrateformen(6.5%)thanwomen(2.1%).
Fig.13presentsrespondents’alcoholconsumptionstatusbyNUTS-1regions.ThepercentagesofabstainerswerelowestinTR3,TR6andTR5regions,astatisticallysignificantdifferencewithTR6atthe5%significancelevel (P < 0.05), and highest in TR7, TRB and TRC, although no statistically significant differences wereobserved.
Table 27. Alcohol consumption among respondents by sex and age group
SexAge group (years)
N
Current drinker
(past 30 days)
Drank in previous 12 months, not
currently
Abstainer (previous 12
months)
Lifetime
abstainer
% 95% CI % 95% CI % 95% CI % 95% CI
Men 15–29 497 15.0 11.2–18.8 6.4 3.8–8.9 2.8 1.2–4.5 75.8 71.4–80.3
30–44 652 12.9 9.6–16.2 7.1 5.0–9.2 6.9 4.6–9.2 73.1 69.0–77.2
45–59 642 15.0 11.4–18.6 4.8 2.5–7.2 6.6 4.4–8.8 73.6 69.2–77.9
60–69 381 8.5 4.8–12.2 4.6 2.0–7.2 13.5 9.1–17.9 73.4 67.6–79.2
≥ 70 276 4.0 1.0–7.1 4.7 0.0–9.9 12.8 8.2–17.5 78.4 71.7–85.1
Total 2448 13.1 11.2–15.0 6.0 4.8–7.2 6.5 5.3–7.6 74.4 72.0–76.8
Women 15–29 673 4.2 2.2–6.1 2.9 1.2–4.5 1.3 0.5–2.2 91.6 89.0–94.3
30–44 1050 3.5 1.7–5.3 2.7 1.1–4.3 3.4 1.4–5.4 90.4 87.4–93.4
45–59 974 2.2 0.9–3.5 2.3 0.9–3.6 1.9 0.8–3.0 93.6 91.5–95.7
60–69 463 2.2 0.0–5.5 – – 0.9 0.1–1.7 96.9 93.5–100.0
≥ 70 445 – – – – 2.3 0.1–4.5 97.7 95.5–99.9
Total 3605 3.0 2.1–4.0 2.2 1.4–2.9 2.1 1.4–2.9 92.7 91.3–94.1
Both sexes
15–29 1170 9.7 7.5–11.9 4.6 3.1–6.2 2.1 1.1–3.0 83.6 80.8–86.3
30–44 1702 8.2 6.3–10.1 4.9 3.6–6.3 5.2 3.6–6.7 81.7 79.1–84.3
45–59 1616 8.6 6.6–10.7 3.6 2.0–5.1 4.3 3.0–5.5 83.5 80.9–86.2
60–69 844 5.2 2.8–7.7 2.2 1.0–3.5 7.0 4.7–9.2 85.6 82.2–89.0
≥ 70 721 1.7 0.4–3.0 2.0 0.0–4.2 6.7 4.0–9.4 89.6 86.1–93.1
Total 6053 8.0 7.0–9.1 4.1 3.3–4.8 4.3 3.6–5.0 83.6 82.1–85.1
48 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Fig. 13. Respondents’ alcohol consumption status by NUTS-1 regions
5
Fig. 8. Respondents’ alcohol consumption status by NUTS-1 regions
3.0
4.0
8.8
5.2
4.1
5.3
1.
0
4.0
1.3
2.8
1.2
1.0
4.1
1.8
1.2
11.8
5.1
4.7
4.3
0
.9
2.2
2.5
4.7
2.6
2.8
4.3
87.6
83.9
64.2
83.4
82.8
80.0
96.3
85.2
88.7
91.2
94.0
93.1
83.6
0 10 20 30 40 50 60 70 80 90 100
TR1
TR2
TR3
TR4
TR5
TR6
TR7
TR8
TR9
TRA
TRB
TRC
TOTAL
Percentage
Current drinker (past 30 days) Drank in past 12 months
Past 12 months abstainer Lifetime abstainer
7.5
10.9
15.2
6.3
8.4
10.4
1.8
8.6
7.5
1.4
2.2
3.1
8.0
Table28givesthemeannumberoftimesthatcurrentdrinkershaddrunk≥ 6standartdrinksinasingledrinkingoccasionintheprevious30days:3.6onaverage,withalowernumberformenthanwomen(3.4and4.4,respectively,P<0.05).Amongthosewhoconsumed≥ 6drinksonasingleoccasioninthepreviousmonth,themajorityhad3.0times(thegroupaged45–59).
Table 28. Mean number of episodes in which current drinkers drank ≥ 6 drinks on a single occasion in the previous 30 days, by sex and age group
Age group (years)
Men Women Both sexes
NMean
number95% CI
(number)N
Mean number
95% CI (number)
NMean
number95% CI
(number)
15–29 67 3.6 1.7–5.5 20 3.8 0.5–7.2 87 3.6 2.0–5.3
30–44 68 3.7 2.0–5.4 24 1.8 1.1–2.6 92 3.3 1.9–4.7
45–59 84 3.2 2.2–4.2 16 1.6 1.1–2.2 100 3.0 2.1–3.9
60–69 23 2.7 0.7–4.8 2 27.3 20.2–34.3 25 7.6 0.0–16.1
≥ 70 7 1.8 0.6–3.0 – – – 7 1.8 0.6–3.0
Total 249 3.4 2.6–4.3 62 4.4 0.7–8.1 311 3.6 2.6–4.6
49
Table29presentsthepercentageofrespondentswhohaddrunk≥ 6drinksonasingleoccasionintheprevious30days:anexcessiveconsumptionlevelforbothmenandwomen.Ingeneral,theprevalenceofexcessivealcoholconsumptionwas5.2%,withastatisticallysignificantdifferencebetweenmenandwomen:8.7%and1.8%,respectively(P<0.05).Theprevalenceofexcessivealcoholconsumptioningeneraldeclinedwithageinbothmenandwomen(exceptinthegroupaged45–59),butmorepronouncedlyinmen.
Table 29. Proportion of total respondents who drank ≥ 6 drinks on a single occasion in the previous 30 days, by sex and age group
Age group (years)
Men Women Both sexes
N % 95% CI N % 95% CI N % 95% CI
15–29 497 10.2 6.8–13.7 673 2.1 0.8–3.5 1170 6.3 4.3–8.2
30–44 652 8.6 5.7–11.4 1050 2.3 0.6–4.0 1702 5.5 3.8–7.1
45–59 642 9.9 6.9–12.9 974 1.6 0.4–2.8 1616 5.8 4.1–7.5
60–69 381 4.5 1.9–7.0 463 1.6 0.0–4.8 844 3.0 1.0–5.0
≥ 70 276 2.5 0.4–4.5 445 – – 721 1.0 0.2–1.9
Total 2448 8.7 7.0–10.3 3605 1.8 1.0–2.6 6053 5.2 4.3–6.2
4.4.1. Conclusions
Someofthemostimportantresultsonalcoholusebyrespondentsincludedthefollowing:
● 83.6%werelifetimeabstainers(males:74.4%,andfemales:92.7%); ● 4.3%hadabstainedintheprevious12months(males:6.5%,andfemales:2.1%); ● 8.0%werecurrentdrinkers(haddrunkalcoholintheprevious30days)(males:13.1%andfemales:3.0%);and
● 5.2%hadengagedinheavyepisodicdrinking(≥ 6drinksonanyoccasionintheprevious30days)(males:8.7%,andfemales:1.8%).
4.5. Use of addictive drugs (substances)
Psychoactivesubstancesareamajorcauseof threats to thehealthandeconomyofboth individualsandsocieties (48).Onein20adults(aged15–64years)aroundtheworldwasestimatedtohaveusedatleastoneillegaldrugin2010(49).Inadditiontooverdoses,asignificantproportionofdrug-relateddeathsisduetotheindirecteffectsofintoxication,whichresultinCVD,liverandmentaldisorders(50).InTurkey,itwasestimatedthattherewere0.2–0.5casesper1000ofhigh-riskopioiduse,andthat0.1%and0.7%ofadults(aged15–64)hadeverusedamphetaminesormarijuana,respectively,by2011(51).
Table30showsthat97.0%ofthestudypopulationreportedneverusingaddictivedrugsduringtheirlives:98.6%ofwomenand95.5%ofmen.Whilemenreportedlowerlevelsofneverusingdrugsinallagegroups,thedifferencewassmallerinthetwooldestgroups(thoseaged60–69and≥ 70).Menandwomenshowedsimilarpatterns:thepercentagesofthosewhohadneverusedaddictivedrugstendedtorisewithage.
50 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Table 30. Respondents who never used addictive drugs by sex and age group
Age group (years)
Men Women Both sexes
NNever used (%)
95% CI NNever used (%)
95% CI NNever used (%)
95% CI
15–29 497 92.9 88.5–97.3 673 97.8 96.3–99.3 1170 95.3 92.9–97.7
30–44 652 96.5 94.8–98.2 1050 98.7 97.8–99.6 1702 97.6 96.6–98.6
45–59 642 96.7 94.8–98.6 974 99.4 98.8–99.9 1616 98.0 97.0–99.0
60–69 381 96.9 94.6–99.2 463 98.6 97.3–99.8 844 97.8 96.5–99.0
≥ 70 276 98.1 96.7–99.6 445 98.8 97.7–99.9 721 98.5 97.6–99.4
Total 2448 95.5 93.9–97.1 3605 98.6 98.0–99.1 6053 97.0 96.2–97.9
Table31showsthat0.5%oftherespondentscurrentlyusedaddictivedrugs,althoughsuchusewashigherinmen(0.9%,)thanwomen(0.2%).Prevalencewashigherintheyoungeragegroupsandgraduallydecreasedwithage.
Astothosewhohadtriedaddictivedrugsatsometimeinthepast(Table32),theaverageformenwas2.6%;andtheyoungestagegroupreportedthehighestproportion(4.4%).Amongwomen,0.9%hadtriedaddictivedrugsinthepast,withthehighestproportionalsointheyoungestagegroups(1.9%).
Table 31. Respondents who currently use addictive drugs by sex and age group
Age group (years)
Men Women Both sexes
NCurrently using (%)
95% CI NCurrently using (%)
95% CI NCurrently using (%)
95% CI
15–29 497 1.5 0.3–2.6 673 – – 1170 0.7 0.1–1.3
30–44 652 1.0 0.0–2.0 1050 0.3 0.1–0.6 1702 0.7 0.1–1.2
45–59 642 0.2 0.0–0.6 974 0.4 0.0–0.9 1616 0.3 0.0–0.6
60–69 381 0.2 0.0–0.6 463 0.3 0.0–0.6 844 0.2 0.0–0.5
≥ 70 276 0.2 0.0–0.5 445 0.2 0.0–0.6 721 0.2 0.0–0.6
Total 2448 0.9 0.4–1.4 3605 0.2 0.1–0.4 6053 0.5 0.3–0.8
Table 32. Respondents who tried addictive drugs by sex and age group
Age group (years)
Men Women Both sexes
N Tried (%) 95% CI N Tried (%) 95% CI N Tried (%) 95% CI
15–29 497 4.4 0.2–8.7 673 1.9 0.5–3.3 1170 3.2 0.9–5.5
30–44 652 0.9 0.3–1.5 1050 0.5 0.1–0.8 1702 0.7 0.3–1.0
45–59 642 2.8 0.9–4.7 974 0.1 0.0–0.2 1616 1.4 0.5–2.4
60–69 381 2.0 0.3–3.8 463 1.2 0.0–2.4 844 1.6 0.5–2.7
≥ 70 276 1.0 0.0–2.2 445 1.0 0.0–1.9 721 1.0 0.2–1.7
Total 2448 2.6 1.1–4.0 3605 0.9 0.5–1.4 6053 1.7 1.0–2.5
51
4.5.1. Conclusions
Someofthemostimportantresultsondrugusebyrespondentsincludedthefollowing:
● 97.0%reportedneverhavingusedaddictivedrugs(males:95.5%,andfemales:98.6%); ● 0.5%currentlyusedaddictivedrugs(males:0.9%,andfemales:0.2%); ● 1.7%hadtriedaddictivedrugs(males:2.6%,andfemales:0.9%).
4.6. Diet: fruit and vegetable consumption
AhigherriskofCVDisstronglyassociatedwithincreaseddietaryintakeoftransfats,saturatedfatsandsalt,andalowintakeoffruits,vegetablesandfish(7,12,28).Nearly16millionDALYs(1.0%ofthetotal)and1.7milliondeaths(2.8%ofthetotal)aroundtheworldarelinkedwithlowfruitandvegetableconsumption.
Onaverage,respondentswerefoundtohaveeatenfruiton4.6daysinatypicalweek;thisvaluewasslightlyhigherinwomen(4.8days)thanmen(4.5days).Themeanwaslowerinthetwoyoungestagegroups,forbothmenandwomen(Table33).
Themeannumberofdaysinatypicalweekonwhichthegeneralpopulationofrespondentsatevegetableswas5.1(Table34);aswiththemeanforfruitconsumption,thisvaluewasslightlyhigherinwomen(5.2days)thanmen(4.9days).Vegetableconsumptionwaslowerinthetwoyoungestagegroupsandhigherinthetwooldest.
Table 33. Mean number of days in a typical week in which respondents consumed fruit by sex and age group
Age group (years)
Men Women Both sexes
NMean (days)
95% CI (days)
NMean (days)
95% CI (days)
NMean (days)
95% CI (days)
15–29 474 4.1 3.9–4.3 645 4.6 4.4–4.8 1119 4.3 4.2–4.5
30–44 629 4.2 4.0–4.4 1026 4.6 4.4–4.8 1655 4.4 4.2–4.5
45–59 618 4.8 4.6–5.1 939 5.0 4.9–5.2 1557 4.9 4.8–5.1
60–69 371 5.5 5.3–5.8 452 5.2 5.0–5.4 823 5.4 5.2–5.5
≥ 70 268 5.3 5.0–5.7 434 5.0 4.7–5.2 702 5.1 4.9–5.3
Total 2360 4.5 4.4–4.6 3496 4.8 4.7–4.9 5856 4.6 4.5–4.7
Table 34. Mean number of days in a typical week in which respondents consumed vegetables by sex and age
Age group (years)
Men Women Both sexes
NMean (days)
95% CI (days)
NMean (days)
95% CI (days)
NMean (days)
95% CI (days)
15–29 459 4.6 4.4–4.9 629 4.9 4.7–5.1 1088 4.8 4.6–4.9
30–44 622 5.0 4.8–5.2 1023 5.2 5.1–5.4 1645 5.1 5.0–5.2
45–59 614 5.0 4.8–5.2 942 5.4 5.3–5.6 1556 5.2 5.1–5.4
60–69 371 5.2 5.0–5.5 452 5.5 5.3–5.7 823 5.4 5.2–5.5
≥ 70 264 5.6 5.3–5.9 430 5.2 4.9–5.4 694 5.3 5.1–5.5
Total 2330 4.9 4.8–5.1 3476 5.2 5.1–5.3 5806 5.1 5.0–5.2
Table35showsthemeannumberofdaysoffruitandvegetableconsumptioninatypicalweekbyNUTS-1
52 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
regions.TRC(south-easternAnatolia)hadthelowestfruitconsumptionandTR7(centralAnatolia),thelowestvegetableconsumption. Incontrast,averagevegetableconsumptionwashighest inTR9andaveragefruitconsumptionwashighestinTR6.
Table 35. Mean number of days in a typical week in which respondents of both sexes consumed fruit and vegetables by NUTS-1 regions
NUTS-1 regions
Fruit consumption Vegetable consumption
Respondents (N)
Mean (days)
95% CI (days)
Respondents (N)
Mean (days)
95% CI (days)
TR1 852 4.6 4.4–4.8 853 4.8 4.6–5.0
TR2 324 4.1 3.7–4.5 326 4.8 4.3–5.3
TR3 895 5.0 4.7–5.2 897 5.2 5.0–5.4
TR4 724 4.8 4.6–5.0 725 4.4 4.1–4.8
TR5 680 4.4 4.2–4.6 680 5.3 5.1–5.5
TR6 728 5.1 4.8–5.3 723 5.6 5.4–5.9
TR7 313 4.4 4.0–4.7 311 3.8 3.4–4.3
TR8 400 4.7 4.3–5.0 403 5.5 5.2–5.8
TR9 252 4.4 4.0–4.8 253 6.1 5.8–6.3
TRA 157 4.9 4.4–5.5 158 5.6 5.2–6.0
TRB 242 4.8 4.6–5.1 241 5.6 5.1–6.0
TRC 289 3.8 3.4–4.3 236 4.8 4.5–5.2
Total 5856 4.6 4.5–4.7 5806 5.1 5.0–5.2
Table 36 andTable 37present the averagenumbersof servingsof fruits and vegetables, respectively, thatrespondentsconsumedonatypicaldayoftheweek.Averagefruitconsumptionwasslightlyhigherinmenthanwomen,andinbothmenandwomeninthetwooldestagegroups(Table36).Table36presentsthemeannumberofservingsoffruitsconsumedperdaybysexandagegroup:1.4forbothsexes,1.5forwomenand1.4formen.
Table 36. Mean number of servings of fruit consumed per day by sex and age group
Agegroup (years)
Men Women Both sexes
N Mean (servings)
95% CI (servings)
N Mean (servings)
95% CI (servings)
N Mean (servings)
95% CI (servings)
15–29 460 1.3 1.1–1.6 635 1.4 1.2–1.6 1095 1.3 1.2–1.5
30–44 622 1.3 1.1–1.4 1021 1.3 1.2–1.5 1643 1.3 1.2–1.4
45–59 614 1.5 1.3–1.7 935 1.6 1.4–1.9 1549 1.6 1.4–1.8
60–69 370 1.8 1.5–2.0 449 1.6 1.4–1.9 819 1.7 1.5–1.9
≥ 70 268 2.0 1.5–2.5 430 1.5 1.1–1.9 698 1.7 1.4–2.0
Total 2334 1.4 1.3–1.5 3470 1.5 1.3–1.6 5804 1.4 1.3–1.5
Table37presentsthemeannumberofservingsofvegetablesonaverageperdaybysexandagegroups:1.7forbothsexes,1.7forwomenand1.6formen,withnostatisticaldifferenceacrossthesexes.Thereisalsonostatisticaldifferenceacrosstheagegroupsintermsofmeannumberofservingsofvegetablesonaverageperday.
53
Table 37. Mean number of servings of vegetables on average per day by sex and age group
Age group (years)
Men Women Both sexes
NMean
(servings)95% CI
(servings)N
Mean (servings)
95% CI (servings)
NMean
(servings)95% CI
(servings)
15–29 458 1.6 1.3–1.9 627 1.6 1.3–1.9 1085 1.6 1.3–1.8
30–44 619 1.5 1.3–1.7 1019 1.7 1.5–2.0 1638 1.6 1.4–1.8
45–59 612 1.6 1.2–2.0 942 1.8 1.5–2.1 1554 1.7 1.4–2.0
60–69 369 1.5 1.1–1.8 449 2.0 1.6–2.4 818 1.7 1.5–2.0
≥ 70 263 2.1 1.5–2.8 428 1.8 1.2–2.3 691 1.9 1.5–2.3
Total 2321 1.6 1.4–1.8 3465 1.7 1.6–1.9 5786 1.7 1.5–1.8
Table38showsthat87.8%oftheproportionofthestudypopulationconsumedfewerthanfiveservingsoffruitand/orvegetablesonaverageperday.Thisproportionwashigherinthetwoyoungestagegroups,andhighestforbothmenandwomeninthegroupaged30–44years.Thus,87.8%oftherespondentsdidnotreachtherecommendeddailyconsumptionofatleastfiveservingsoffruitsorvegetables.Thisbehaviourdidnotshowstatisticallysignificantdifferencesbysex,agegroup,areaorregionofresidence(seeTable38).
Table 38. Proportion of respondents consuming fewer than five servings of fruit and/or vegetables on average per day by sex and age group
Age group (years)
Men Women Both sexes
N % 95% CI N % 95% CI N % 95% CI
15–29 464 89.3 85.4–93.2 639 89.3 86.2–92.4 1103 89.3 86.7–92.0
30–44 627 89.4 86.7–92.1 1028 89.4 87.0–91.9 1655 89.4 87.5–91.3
45–59 619 87.6 83.8–91.4 947 87.0 84.1–89.9 1566 87.3 84.7–89.9
60–69 372 83.3 78.3–88.2 452 82.8 78.5–87.1 824 83.0 79.7–86.3
≥ 70 268 79.1 72.8–85.4 432 85.5 80.3–90.6 700 82.7 78.7–86.8
Total 2350 87.8 85.8–89.8 3498 87.9 86.3–89.5 5848 87.8 86.4–89.3
4.6.1. Conclusions
Someofthemostimportantresultsonrespondents’fruitandvegetableconsumptionincludedthefollowing:
● themeannumberofdayswhenfruitswereconsumedinatypicalweekwas4.6(males:4.5,andfemales:4.8); ● themeannumberofservingsoffruitconsumedonaverageperdaywas1.4(males:1.4,andfemales:1.5); ● themeannumberofdayswhenvegetableswereconsumed ina typicalweekwas5.1 (males:4.9,andfemales:5.2);
● themeannumberofservingsofvegetablesconsumedonaverageperdaywas1.7(males:1.6,andfemales:1.7);
● 87.8%ofrespondentsatefewerthanfiveservingsoffruitand/orvegetablesonaverageperday(males:87.8%,andfemales:87.9%).
4.7. Dietary salt
Table 39presents the respondents’ salt-consumptionhabits by sex and agegroup.Whenboth sexes areconsidered,morethanonefourthofthestudypopulation (28.1%)alwaysoroftenaddedsalt totheirfood
54 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
beforeeating.Although therewasnostatistically significantdifferenceat5%significance levelbetweenmen(29.3%)andwomen(26.8%)inthisregard,thereweresignificantdifferencesbetweenagegroups.Theproportionofalwaysoroftenaddingsalttotheirfoodbeforeeatingwashighestinthegroupsaged15–29(33.1%),andprogressivelydeclinedinthegroupsaged30–44(26.8%),45–59(26.3%),60–69(23.1%)and≥ 70(22.8%).Similarly,aboutaquarteroftherespondents(26.0%)statedthattheyalwaysoroftenaddedsalttotheirfoodwhencookingorpreparingmealsathome,andthisproportionshoweddecliningtrendwithage:29.7%ofthoseaged15–29,26.8%ofthoseaged30–44,25.6%ofthoseaged45–59,20.2%ofthoseaged60–69and15.4%ofthoseaged≥ 70.Table39alsoshowstheproportionofrespondentswhoreportedalwaysorofteneatingprocessedfoodshighinsalt(25.5%);thiswashigherinmales(27.8%)thanfemales(23.3%).
Table 39. Respondents’ use of dietary salt by sex and age group
UseAge group (years)
Men Women Both sexes
N % 95% CI N % 95% CI N % 95% CI
Always or often add salt before eating or when eating
15–29 482 35.5 30.4–40.6 668 30.7 26.4–35.0 1150 33.1 29.7–36.5
30–44 640 25.8 21.5–30.0 1043 27.9 24.4–31.4 1683 26.8 24.0–29.7
45–59 634 28.4 23.6–33.2 970 24.2 19.5–28.8 1604 26.3 22.9–29.7
60–69 379 24.5 18.8–30.1 461 21.8 16.8–26.9 840 23.1 19.3–27.0
≥ 70 272 25.2 17.9–32.5 440 21.0 15.8–26.3 712 22.8 18.4–27.2
Total 2407 29.3 26.7–31.9 3582 26.8 24.6–29.0 5989 28.1 26.3–29.9
Always or often add salt when cooking or preparing food at home
15–29 461 29.7 24.7–34.7 662 29.8 25.4–34.2 1123 29.7 26.3–33.2
30–44 626 26.2 22.1–30.3 1041 27.4 23.5–31.3 1667 26.8 23.9–29.7
45–59 621 24.6 20.1–29.2 967 26.6 22.1–31.2 1588 25.6 22.3–28.9
60–69 365 21.8 16.4–27.2 458 18.8 14.2–23.5 823 20.2 16.6–23.9
≥ 70 262 16.5 11.0–22.1 432 14.6 10.2–19.1 694 15.4 11.7–19.2
Total 2335 25.9 23.3–28.5 3560 26.1 23.8–28.4 5895 26.0 24.2–27.9
Always or often consume processed food high in salt
15–29 484 35.1 30.1–40.0 665 32.2 27.6–36.7 1149 33.6 30.1–37.1
30–44 641 26.8 22.7–30.9 1044 23.5 19.7–27.2 1685 25.1 22.2–28.1
45–59 632 25.4 20.8–30.0 970 17.9 13.6–22.2 1602 21.6 18.4–24.9
60–69 381 18.3 13.7–22.8 459 16.1 11.8–20.5 840 17.2 13.9–20.4
≥ 70 267 17.5 11.9–23.1 427 11.5 6.4–16.6 694 14.1 10.3–17.9
Total 2405 27.8 25.3–30.3 3565 23.3 21.0–25.6 5970 25.5 23.7–27.4
Table39alsoshowsthatthepercentageofmenandwomenalwaysoroftenaddingsaltwhencookingorpreparingfoodathome(25.9%and26.1%,respectively).
Fig. 14 presents estimates of the proportions of the study populationwho thought lowering their dietarysaltintakeisveryimportant:75.6%overall.Theproportionwashigherinwomen(78.1%)thanmen(73.2%),althoughthedifferenceisnotsignificant.Thepercentagesofthestudypopulationgivinghighimportancetoloweringsaltintheirdietsdidnotvarymuchacrossagegroupsforeithermenandwomen,butwassomewhatlowerforthegroupaged15–29.
55
Fig. 14. Respondents who think lowering salt in diet is very important
6
Fig. 9. Respondents who think lowering salt in diet is very important
Fig. 10. Proportions of respondents not engaging in a vigorous physical activity by sex and age group
65.8
75.3
75.2
84.2
77.4
73.2
73.8 77
.3
83.2
81.4
80.0
78.1
69.8
76.3 79
.2 82.8
78.9
75.6
0
10
20
30
40
50
60
70
80
90
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Woman Both sexes
60.268.1
74.5
85.691.3
70.1
89.8 93.1 91.3 94.5 97.892.2
74.880.6 82.9
90.395.0
81.3
0
20
40
60
80
100
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
4.7.1. Conclusions
Someofthemostimportantresultsonrespondents’useofsaltincludedthefollowing:
● 28.1%alwaysoroftenaddedsaltorsaltysaucetotheirfoodbeforeeatingorastheywereeating(males:29.3%,andfemales:26.8%);
● 25.5%alwaysoroftenateprocessedfoodshighinsalt(males:27.8%,andfemales:23.3%); ● 75.6%thoughtthatreducingsaltintheirdietswasveryimportant(males:73.2%,andfemales:78.1%).
4.8. Physical activity
FortheanalysisofSTEPSdata,existingguidelineswerefollowedinthestudy:aperson’senergyconsumptionwhenbeingmoderatelyactiveisestimatedtobefourtimesashighasit iswhensittingquietly,andeighttimesashighwhenbeingvigorouslyactive.Throughoutaweek,includingactivityforwork,duringtransportandleisuretime,WHOrecommendsthat adultsshouldengageinatleast(44) :
● 150minutesofmoderate-intensityphysicalactivity;or ● 75minutesofvigorous-intensityphysicalactivity;or ● anequivalentcombinationofmoderate-andvigorous-intensityphysicalactivityachievingat least600MET-minutes.
Table 40 presents the physical activity of the study population using the definitions of levels of physicalactivitygiveninsection3.14.1.4:26.0%ofrespondentsperformedmoderateactivity;24.6%,highactivity;and49.4%,lowactivity.Asexpected,thegroupaged≥ 70reportedsignificantlylowerproportionswithmoderateorhighactivity(18.6%and10.8%,respectively)andagreaterproportionwithlowphysicalactivity(70.6%).Whilebothmenandwomenshowedthesametendencyforactivitytodeclinewithage,moremen(36.3%)thanwomen(13.1%)engagedinhighlevelsofphysicalactivity,astatisticallysignificantdifferenceatthe5%level(astheresultswith95%CIdonotoverlap–33.6–39.0%formenversus11.5–14.6%forwomen).Forthemoderatephysicalactivity levels, theproportion ishigher,butnotstatisticallysignificantat the5%level,26.3%formenand25.8%forwomen.Thepercentageswithlowlevelsofphysicalactivityshowedthesamepattern:37.4%formenandasignificantlyhigher(at5%level)61.1%forwomen.
56 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Table 40. Respondents’ levels of total physical activity as defined by WHO by sex and age group
SexAge group (years)
NLow activity Moderate activity High activity
% 95% CI % 95% CI % 95% CI
Men 15–29 467 31.7 26.3–37.2 25.6 20.9–30.3 42.6 37.0–48.3
30–44 623 37.3 32.6–42.1 23.4 19.0–27.9 39.2 34.5–44.0
45–59 626 37.5 33.0–42.0 28.5 24.2–32.9 34.0 29.0–38.9
60–69 371 47.2 41.0–53.4 30.8 25.4–36.2 22.0 16.8–27.3
≥ 70 272 51.5 44.0–59.0 29.1 22.4–35.8 19.5 13.2–25.7
Total 2359 37.4 34.7–40.1 26.3 23.9–28.7 36.3 33.6–39.0
Women 15–29 646 56.2 51.6–60.9 29.3 25.1–33.5 14.5 11.1–17.9
30–44 1009 58.0 53.9–62.1 28.2 24.5–31.8 13.9 11.1–16.6
45–59 946 58.4 53.9–62.9 26.3 22.2–30.3 15.3 12.4–18.3
60–69 449 72.1 66.9–77.3 19.1 14.7–23.5 8.8 5.6–12.0
≥ 70 439 84.9 81.0–88.7 10.9 7.5–14.2 4.3 2.0–6.6
Total 3489 61.1 58.9–63.3 25.8 23.8–27.8 13.1 11.5–14.6
Both sexes
15–29 1113 43.8 40.1–47.6 27.4 24.3–30.6 28.7 25.2–32.2
30–44 1632 47.7 44.5–50.9 25.8 22.9–28.7 26.5 23.6–29.4
45–59 1572 48.0 44.7–51.3 27.4 24.4–30.4 24.6 21.7–27.6
60–69 820 60.2 56.0–64.3 24.7 21.2–28.2 15.1 12.0–18.3
≥ 70 711 70.6 66.4–74.8 18.6 15.1–22.2 10.8 7.6–14.0
Total 5848 49.4 47.6–51.2 26.0 24.5–27.6 24.6 22.9–26.2
Thestudypopulationspentamedianof30.0minutes (interquartile range:4.3–90.0) inphysicalactivityonaverageperday.Thisvaluewashigherinmales(51.4minutes–interquartilerange:11.4–180.0)thanfemales(17.1minutes–interquartilerange:0.0–55.0).
Table41reportsrespondents’meanminutesofwork-relatedphysicalactivityonaverageperdaybysexandagegroup:56.4minutes.Themeanamountofwork-relatedphysicalactivitywassignificantlyhigherinmen(91.5minutes)thanwomen(22.1minutes).Thehighestamountswere132.6minutesformeninthegroupaged30–44yearsand26.9minutesforwomeninthegroupaged45–59.
Table 41. Respondents’ mean minutes of work-related physical activity on average per day by sex and age group
Agegroup (years)
Men Women Both sexes
NMean
(minutes)95% CI
(minutes)N
Mean (minutes)
95% CI (minutes)
NMean
(minutes)95% CI
(minutes)
15–29 467 80.4 58.6–102.2 646 23.4 14.4–32.3 1113 52.2 40.2–64.3
30–44 623 132.6 100.0–165.1 1009 25.8 18.9–32.6 1632 79.1 62.1–96.2
45–59 626 93.3 72.9–113.7 946 26.9 18.1–35.6 1572 60.1 48.8–71.4
60–69 371 40.4 23.4–57.3 449 9.6 4.7–14.6 820 24.4 15.6–33.1
≥ 70 272 15.9 7.6–24.2 439 6.2 3.2–9.3 711 10.4 6.3–14.4
Total 2359 91.5 77.8–105.2 3489 22.1 18.1–26.1 5848 56.4 49.2–63.6
57
Table42presentsthemeanminutesoftransport-relatedphysicalactivityonaverageperdaybysexandagegroup:33.1minutes(41.0minutesformenand25.3minutesforwomen).Themeanwashighestinthegroupaged45–59inbothmen(43.7minutes)andwomen(28.0minutes).Table43presentstherespondents’meanminutesofrecreation-relatedphysicalactivityonaverageperdaybysexandagegroup(10.2minutes),whichwassignificantlyhigherinmen(14.7minutes)thanwomen(5.8minutes).Thismeanishighestintheyoungestagegroup:22.2minutesformenand9.4minutesforwomen.
Table 42. Respondents’ mean minutes of transport-related physical activity on average per day by sex and age group
Age group (years)
Men Women Both sexes
NMean
(minutes)95% CI
(minutes)N
Mean (minutes)
95% CI (minutes)
NMean
(minutes)95% CI
(minutes)
15–29 467 43.5 36.7–50.4 646 26.6 23.2–29.9 1113 35.2 31.3–39.0
30–44 623 37.2 31.8–42.6 1009 27.6 23.6–31.6 1632 32.4 29.1–35.7
45–59 626 43.7 37.5–49.9 946 28.0 24.2–31.9 1572 35.9 32.1–39.6
60–69 371 37.8 30.6–45.1 449 20.7 15.0–26.4 820 28.9 23.9–33.9
≥ 70 272 42.0 29.1–54.8 439 10.3 7.7–12.8 711 23.8 17.8–29.8
Total 2359 41.0 37.7–44.4 3489 25.3 23.3–27.4 5848 33.1 31.0–35.1
Table 43. Respondents’ mean minutes of recreation-related physical activity on average per day by sex and age group
Age group (years)
Men Women Both sexes
NMean
(minutes)95% CI
(minutes)N
Mean (minutes)
95% CI (minutes)
NMean
(minutes)95% CI
(minutes)
15–29 467 22.2 17.4–27.0 646 9.4 4.4–14.3 1113 15.9 12.4–19.4
30–44 623 11.9 6.1–17.7 1009 4.7 3.1–6.2 1632 8.3 5.2–11.4
45–59 626 13.9 8.2–19.7 946 4.2 3.0–5.4 1572 9.1 6.1–12.0
60–69 371 7.1 2.8–11.5 449 5.4 1.3–9.5 820 6.2 3.2–9.2
≥ 70 272 4.6 1.7–7.5 439 1.2 0.0–2.5 711 2.7 1.2–4.1
Total 2359 14.7 12.0–17.5 3489 5.8 4.1–7.4 5848 10.2 8.6–11.8
Table44presentstheestimatesforthepercentageofrespondentswhodidnotmeettheWHOrecommendationsonphysicalactivityforhealth(< 150minutesofmoderate-intensityactivityperweek,orequivalent),brokendownbyagegroupandsex.Thepercentagewas43.6%overall,althoughmorewomen(53.6%)fellshortthanmen(33.1%):astatisticallysignificantdifferenceat5%level.ThepercentageofstudypopulationnotmeetingtheWHOrecommendationsshowedarisingtrendwithage:37.8%forthegroupaged15–29,risingto66.1%forthoseaged≥ 70whenbothsexesareconsideredjointly.
58 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Table 44. Proportions of respondents not meeting the WHO recommendations on physical activity for health by sex and age group
Age group (years)
Men Women Both sexes
N % 95% CI N % 95% CI N % 95% CI
15–29 467 26.7 21.5–31.9 646 49.2 44.4–54.0 1113 37.8 34.2–41.5
30–44 623 33.7 29.0–38.3 1009 49.8 45.6–54.0 1632 41.7 38.5–45.0
45–59 626 32.7 28.2–37.1 946 50.9 46.1–55.6 1572 41.8 38.4–45.2
60–69 371 43.8 37.7–50.0 449 66.2 60.6–71.8 820 55.5 51.3–59.7
≥ 70 272 47.8 40.3–55.3 439 79.8 75.4–84.2 711 66.1 61.8–70.5
Total 2359 33.1 30.5–35.6 3489 53.9 51.6–56.3 5848 43.6 41.8–45.4
Fig.15showstheproportionsofrespondentswhodidnotengageinvigorousphysicalactivity:81.3%overall,althoughmorewomen(92.2%)thanmen(70.1%)wereinactive.Theseproportionsrosewithage.
Fig. 15. Proportions of respondents not engaging in a vigorous physical activity by sex and age group
6
Fig. 9. Respondents who think lowering salt in diet is very important
Fig. 10. Proportions of respondents not engaging in a vigorous physical activity by sex and age group
65.8
75.3
75.2
84.2
77.4
73.2
73.8 77
.3
83.2
81.4
80.0
78.1
69.8
76.3 79
.2 82.8
78.9
75.6
0
10
20
30
40
50
60
70
80
90
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Woman Both sexes
60.268.1
74.5
85.691.3
70.1
89.8 93.1 91.3 94.5 97.8 92.2
74.880.6 82.9
90.395.0
81.3
0
20
40
60
80
100
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
4.8.1. Conclusions
Someofthemostimportantresultsonrespondents’physicalactivityincludedthefollowing:
● 43.6%hadinsufficientphysicalactivity,definedas<150minutesofmoderate-intensityactivityperweek,orequivalent(males:33.1%,andfemales:53.9%);
● themediantimespentinphysicalactivityonaverageperdaywas30.0minutes(males:51.4minutes,andfemales:17.1minutes);
● 81.3%ofrespondentsdidnotengageinvigorousactivity(males:70.1%,andfemales:92.2%).
4.9. History of raised blood pressure
Highsaltandfatconsumption,reducedintakeoffruitsandvegetables,overweightandobesity,harmfuluseofalcohol,physicalinactivity,psychologicalstress,socioeconomicdeterminantsandinadequateaccesstohealthcarearemodifiableriskfactorsforhypertension.Formostofthepeoplewithhypertension,however,
59
theprecise reason for thecondition isnotknown.Theaforementioned risk factorspredisposepeople toraisedbloodpressure.Themodifiablenatureofmostofthesefactorsshouldbeviewedasanopportunity.
Hypertensionhasahigherprevalenceamongmenthanwomen,andseemstobemorecommoninlow-incomecountries than high-income countries (7). Nearly a quarter of the population of Turkey has hypertension(52,53).
The survey assessedhypertension as a risk factor forNCDbymeasuring bloodpressure. Theproportionofrespondentswhohadneverhadtheirbloodpressuremeasuredwas13.6%;16.1%formenand11.1%forwomen.Thefrequencyofraisedbloodpressureorhypertensionhistoryinthestudypopulationwas16.2%;12.3%formenand20.0%forwomen(Fig.16).
Fig. 16. Blood pressure measurement and hypertension diagnosis among respondents by sex
7
Fig. 11. Blood pressure measurement and hypertension diagnosis among respondents by sex
Fig. 12. Blood sugar measurement and diabetes diagnosis among respondents by sex
16.1
71.5
8.04.3
11.1
68.9
10.2 9.813.6
70.2
9.1 7.1
0
10
20
30
40
50
60
70
80
Never measured Measured, not diagnosed Diagnosed, but not withinpast 12 months
Diagnosed withinpast 12 months
Perc
enta
ge
Men Women Both sexes
39.9
52.5
4.2 3.4
30.2
59.2
5.4 5.2
35.0
55.9
4.8 4.3
0
10
20
30
40
50
60
70
Never measured Measured, not diagnosed Diagnosed, but not withinpast 12 months
Diagnosed within past 12months
Perc
enta
ge
Men Women Both sexes
Althoughitwasknownthat72.7%ofthosepreviouslydiagnosedwithraisedbloodpressureorhypertensionwere currently takingmedication, ratesof useof thismedication variedbetweenagegroups. Theywerelowestinthegroupaged15–29(29.6%)andhighestinthoseaged≥ 70(85.4%).
Participantswhowerecurrentlytakingmedicationforraisedbloodpressurewereaskedabouttheiractivitiesformanaginghypertension;75.7%usedmedicationregularlywhile11.9%werenotdoinganything(Table45).
Table 45. Respondents’ activities to manage hypertension by sex
Sex
Activities (%)
Regular medication
Irregular medication
Herbal medicines
Physical activity
Diet Nothing Other
Men 72.9 5.2 2.1 3.4 12.1 12.0 3.2
Women 77.5 5.7 0.6 1.5 10.7 11.8 0.8
Both sexes 75.7 5.5 1.2 2.3 11.2 11.9 1.7
60 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
4.9.1. Conclusions
Someofthemostimportantresultsonrespondents’hypertensionincludedthefollowing:
● 13.6%ofrespondentshadneverhadtheirbloodpressurelevelsmeasured; ● 16.2%hadraisedbloodpressureorhypertension(men:12.3%,andwomen:20.0%),withfrequencyrisingwithage;
● 75.7%ofthosepreviouslydiagnosedwithraisedbloodpressureorhypertension,werecurrentlytakingmedication.
4.10. History of diabetesTheprevalenceofdiabetesisincreasinginTurkey:from7%ofthepopulationover20yearsofagein1997to13%in2009(53).Atpresent,13.2%ofthepopulationhasdiabetes.DiabetesistheeighthmostcommoncauseofdeathbydiseaseinTurkey(accountingfor2.2%ofdeaths).NearlyoneinthreepeopleinTurkeyhasmetabolicsyndrome.Females(41.1%)havehigherriskthanmales(28.8%)(42).
Thepercentageofrespondentswhohadneverhadtheirbloodglucoselevelsmeasuredwas35.0%;39.9%formenand30.2%forwomen.Accordingtotheparticipants’statements,thefrequencyofraisedbloodsugarordiabeteswas9.1%;7.6%formenand10.6%forwomen(Fig.17).Thefrequencyofraisedbloodsugarordiabetesinthestudypopulationincreasedfrom1.1%inthegroupaged15–29to28.8%inthegroupaged≥ 70.
Of all the respondents previously diagnosedwith raised blood glucose or diabetes, 23.7%were currently takingmedicationprescribedfordiabetes:26.4%formen21.7%forwomen.Further,72.1%ofallthosepreviouslydiagnosedwithraisedbloodglucoseordiabeteswerecurrentlytakinginsulin:69.8%formenand73.8%forwomen(Fig.18).
Theuseofmedicationfordiabetesvariedbetweentheagegroups.Itwasatthelowestlevelinthoseaged30–44(18.6%)andhighestinthoseaged60–69(29.5%).Participantswhowerecurrentlytakingmedicationforraisedbloodsugarwereaskedabouttheiractivitiesformanagingdiabetes:75.8%wereusingmedicationregularly,while12.5%werenottakinganything(Table46).
Fig. 17. Blood sugar measurement and diabetes diagnosis among respondents by sex
7
Fig. 11. Blood pressure measurement and hypertension diagnosis among respondents by sex
Fig. 12. Blood sugar measurement and diabetes diagnosis among respondents by sex
16.1
71.5
8.04.3
11.1
68.9
10.2 9.813.6
70.2
9.1 7.1
0
10
20
30
40
50
60
70
80
Never measured Measured, not diagnosed Diagnosed, but not withinpast 12 months
Diagnosed withinpast 12 months
Perc
enta
ge
Men Women Both sexes
39.9
52.5
4.2 3.4
30.2
59.2
5.4 5.2
35.0
55.9
4.8 4.3
0
10
20
30
40
50
60
70
Never measured Measured, not diagnosed Diagnosed, but not withinpast 12 months
Diagnosed within past 12months
Perc
enta
ge
Men Women Both sexes
61
Fig. 18. Percentages of respondents with raised blood glucose who are currently taking medication or insulin, by sex
8
Fig. 13. Percentages of respondents with raised blood glucose who are currently taking medication or insulin, by sex
Fig. 14. Cholesterol measurement and raised-cholesterol diagnosis among respondents by sex
26.421.7 23.7
69.873.8 72.1
0
10
20
30
40
50
60
70
80
Men Women Both sexes
Perc
enta
ge
Taking medication Taking insulin
50.4
41.1
4.9 3.6
40.9
47.3
5.7 6.1
45.6 44.2
5.3 4.8
0
10
20
30
40
50
60
Never measured Measured,not diagnosed
Diagnosed, but not withinpast 12 months
Diagnosed withinpast 12 months
Perc
enta
ge
Men Women Both sexes
Table 46. Respondents’ activities to manage diabetes by sex
Sex
Activities (%)
Regular medication
Irregular medication
Herbal medicines
Physical activity
Diet Nothing Other
Men 73.3 6.8 1.7 3.2 9.3 13.4 4.1
Women 77.6 2.9 0.1 3.3 15.5 11.8 1.7
Both sexes 75.8 4.5 0.7 3.3 13 12.5 2.7
4.10.1. Conclusions
Someofthemostimportantresultsonrespondents’bloodsugaranddiabetesincludedthefollowing:
● morethanoneoutofthreeneverhadtheirbloodglucoselevelsmeasured; ● 9.1%ofTurkey’sadultpopulationhadraisedbloodsugarordiabetes(7.6%formenand10.6%forwomen),withprevalenceincreasingwithage;and
● 23.7% of those previously diagnosed with raised blood glucose or diabetes were currently takingmedication,and72.1%werecurrentlytakinginsulinfordiabetes.
4.11. History of raised total cholesterol
CVDarethemostcommoncauseofdeathworldwideandoneofthemajormodifiableriskfactorsisabnormalbloodlipidprofile(54).AccordingtoOnatetal.(55),meantotalcholesterollevelsweresimilarinwomenandmen inTurkey, increasing from 149 mg/dl in thegroupaged20–29 to 187 mg/dl in thegroupaged40–49,whencomparedwithwesterncountries,Turkeycurrentlyhasrelativelylowlevelsoftotalcholesterolinblood.Nevertheless,12millionTurkishcitizenshavetotalcholesterollevelshigherthan200mg/dl(4).Cholesterol
62 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
levelsseemtohaveincreasedoverthelast20years.Meanbloodtriglyceridelevelsincreasedbyapproximately25mg/dlinmenand20mg/dlinwomensince1990(56).
Thepercentageofrespondentswhohadneverhadtheirbloodcholesterolmeasuredwas45.6%;50.4%formenand40.9%forwomen.Thefrequencyofahistoryofraisedcholesterol in thesurveypopulationwas10.1%(8.5%formenand11.8%forwomen–Fig.19)androsefrom1.2%inthegroupaged15–29to22.3%inthoseaged60–69.
Fig. 19. Cholesterol measurement and raised-cholesterol diagnosis among respondents by sex
8
Fig. 13. Percentages of respondents with raised blood glucose who are currently taking medication or insulin, by sex
Fig. 14. Cholesterol measurement and raised-cholesterol diagnosis among respondents by sex
26.421.7 23.7
69.873.8 72.1
0
10
20
30
40
50
60
70
80
Men Women Both sexes
Perc
enta
ge
Taking medication Taking insulin
50.4
41.1
4.9 3.6
40.9
47.3
5.7 6.1
45.6 44.2
5.3 4.8
0
10
20
30
40
50
60
Never measured Measured,not diagnosed
Diagnosed, but not withinpast 12 months
Diagnosed withinpast 12 months
Perc
enta
ge
Men Women Both sexes
Of all the respondents previously diagnosed with raised total cholesterol, 36.9% were currently takingmedicationprescribedforthecondition;39.8%formenand34.9%forwomen.Theuseofmedicationvariedsignificantlybetweenagegroups;itwaslowestinthegroupaged30–44(10.4%)andhighestinthoseaged≥ 70 (55.0%).Respondentswhowerecurrently takingdrugs (medication) for raisedtotalcholesterolwereaskedabouttheiractivitiesformanagingthecondition:38.5%wereusingmedicationregularly,while33.9%werenotdoinganything(Table47).
Table 47. Respondents’ activities to manage total cholesterol by sex
Sex
Activities (%)
Regular medication
Irregular medication
Herbal medicines
Physical activity
Diet Nothing Other
Men 39.2 3.0 3.3 4.5 22.2 34.6 1.0
Women 38.1 5.9 3.6 4.4 19.0 33.4 1.1
Both sexes 38.5 4.7 3.5 4.5 20.3 33.9 1.0
4.11.1. Conclusions
Someofthemostimportantresultsonrespondents’bloodcholesterolincludedthefollowing:
● almosthalfofrespondents(45.6%)hadneverhadtheirtotalcholesterollevelsmeasured; ● 10.1%ofTurkey’s adult populationhadhistory of raised total cholesterol (8.5% formenand 11.8% forwomen),andprevalenceincreasedwithageingeneral;
● 36.9%ofthosepreviouslydiagnosedwithraisedtotalcholesterolwerecurrentlytakingmedicationforit.
63
4.12. History of CVD
CVDareagroupofdiseasesaffectingtheheartandbloodvessels,suchasCHD,cerebrovasculardiseaseandperipheralarterialdisease.WhileNCDsaccountedforanestimated36milliondeaths(63%ofthe57milliondeathsthatoccurredgloballyin2008),CVDaccountedfor48%ofdeathsfromNCDs(7,9).CVDarethemostcommoncauseofdeathworldwide.
MortalityduetoCVDisprojectedtoincreasefrom17.5millionin2012to22.2millionin2030(13).WhilemortalityduetoCVDdeclinedinhigh-incomecountries,itwasrelativelyflatinmanylow-andmiddle-incomecountries(57).
NCDswere estimated to be responsible for 86% of total deaths in Turkey; CVD responsible for the 47%(37).Thetwomostcommoncausesofdeathbydisease inTurkeyare ischaemicheartdisease (22%)andcerebrovasculardiseases(15%)(53).TheprevalenceofCVDisincreasinginTurkey(53);CVDaccountedforthedeathsof102 386malesand103 071femalesin2000.Thesenumbersareprojectedtoriseto175 663and144 297in2020,and235 567and180 530in2030,respectively.By2030,mortalityduetoCVDisprojectedtoincreasebyabout2.3timesinmalesandabout1.8timesinfemales.
Thepercentageofrespondentswhohadhadaheartattackorchestpainfromheartdisease(angina)orastroke (cerebrovascularaccidentor incident)was5.0%;5.2%formenand4.8%forwomen.Womenhavealowerfrequencyinallagegroupsexceptthoseaged15–29and45–59.Inaddition,thefrequencyofheartattackorchestpainfromheartdisease,orstrokeincreasedwithage:from1.3%inthegroupaged15–29to18.8%inthoseaged≥ 70(Fig.20).
Fig. 20. Respondents who ever had a heart attack or chest pain from heart disease, or a stroke, by sex and age group
9
Fig. 15. Respondents who ever had a heart attack or chest pain from heart disease, or a stroke, by sex and age group
Fig. 16. Percentages of respondents who are currently taking aspirin or statins regularly to prevent or treat heart disease by sex
1.2 1.4
6.6
20.1
19.5
5.2
1.4 1.0
7.2
10.6
18.3
4.8
1.3 1.2
6.9
15.2
18.8
5.0
0
5
10
15
20
25
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
6.0
1.9
5.3
1.8
5.6
1.8
0
1
2
3
4
5
6
7
Taking asprin Taking statins
Perc
enta
ge
Men Women Both sexes
Ofalltherespondents,5.6%werecurrentlytakingaspirinregularlytopreventortreatheartdisease;6.0%formenand5.3%forwomen.Inaddition,1.8%ofthestudypopulationwerecurrentlytakingstatinsregularlyforthispurpose;1.9%formenand1.8%forwomen(Fig.21).Theagegroupsvariedintheiruseofaspirinorstatinstopreventortreatheartdisease.Thelevelofdrugusewaslowestinthegroupaged15–29(0.3%takingaspirinand0.5%,statins)andhighestinthoseaged≥ 70(24.4%takingaspirinand7.3%,statins).Theuseofaspirintopreventortreatheartdiseasealsovariedbetweenthesexes,asmorewomenusedituptotheageof44,andmoremenuseditfrom45yearsonward.Ontheotherhand,morewomenthanmenusedstatinsonlyinthegroupaged15–29.
64 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Fig. 21. Percentages of respondents who are currently taking aspirin or statins regularly to prevent or treat heart disease by sex
9
Fig. 15. Respondents who ever had a heart attack or chest pain from heart disease, or a stroke, by sex and age group
Fig. 16. Percentages of respondents who are currently taking aspirin or statins regularly to prevent or treat heart disease by sex
1.2 1.4
6.6
20.1
19.5
5.2
1.4 1.0
7.2
10.6
18.3
4.8
1.3 1.2
6.9
15.2
18.8
5.0
0
5
10
15
20
25
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
6.0
1.9
5.3
1.8
5.6
1.8
0
1
2
3
4
5
6
7
Taking asprin Taking statins
Perc
enta
ge
Men Women Both sexes
4.12.1. Conclusions
Someofthemostimportantresultsonrespondents’historyofCVDincludedthefollowing:
● 5.0%ofrespondentshadhadaheartattackorchestpainfromheartdisease,orstroke(5.2%formenand4.8%forwomen)andthefrequencyincreasedwithage;
● 5.6%of respondentswerecurrently takingaspirinand 1.8%werecurrently takingstatins regularly topreventortreatheartdisease,althoughtheuseofaspirinand/orstatinsvariedbetweenthesexes.
4.13. Family history of chronic diseases
WhilemajormodifiableriskfactorsforNCDsincludephysicalinactivity,unhealthydiet,abnormalbloodlipids,obesityanddiabetes,aswellashighbloodpressure,tobaccouseandharmfulalcoholuse,thenonmodifiableriskfactorsincludeage,geneticfeaturesorfamilyhistory,genderandethnicbackground(54).
Almost half of participants’ parents or siblings (45.8%) had a known, diagnosed chronic disease requiringmedication.
Themostcommonlydiagnosedconditionswere:hypertension(51.0%),type-2diabetes(46.4%)andheartattack(22.4%)(Fig.22).Amongrespondents’parentsorsiblings,19.8%hadhadaheartattackorchestpainfromheartdisease(angina)orastroke(cerebrovascularaccidentorincident).
65
Fig. 22. Types of diagnosed chronic disease requiring medication for respondents’ parents or siblings
2.3
6.2
21.5
29.7 30.5
11.9
0.6
4.6
21
34.7
34.5
12.2
1.5
5.4
21.3
32.3 32.9
12
0
5
10
15
20
25
30
35
40
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
51
46.4
22.4
11.3 11.17.2
1.8
11.1
0
10
20
30
40
50
60
Hypertension Type 2 diabetes Heart attack Cancer Hypercholes-terolemia
Chest painfrom heart
disease (angina)
Stroke(cerebrovascular
accidentor incident)
Other
Perc
enta
ge
4.13.1. Conclusions
Someofthemostimportantresultsonrespondents’familyhistoryofNCDsincludedthefollowing:
● Almosthalfofparticipants’(45.8%)parentsorsiblingshadaknown,diagnosedchronicdiseaserequiringmedication;
● hypertensionwasthemostcommonconditiondiagnosed.
4.14. History of asthma, chronic obstructive pulmonary disease or cancer
Chronicrespiratorydiseasesarealeadingcauseofdeathworldwide,andtendtohavehighunderdiagnosisrates.Mostofthedeathsduetochronicrespiratorydiseasesoccur in low-incomecountries.Generalriskfactorsincludecigarettesmoke,occupationaldustandchemicals,second-handsmoke,indoor/outdoorairpollution,genetics,infections,socioeconomicfactorsandageing(58).
Asthmaischaracterizedbyrecurrentattacksofbreathlessnessandwheezing.Thesymptomscandifferinseverityandasthmamaycausefatigueandsleepiness.Eventhoughthefatalityrateis low,thediseaseisusuallyunderdiagnosed.Asthmaaffectsapproximately235millionpeople(59).
Chronicobstructivepulmonarydisease(COPD)isagroupoflungdiseasesthatpreventproperlungairflow.Gathering accurate epidemiological data on COPD prevalence, morbidity and mortality is difficult andexpensive.WHOestimatedthat65millionpeopleworldwidehadmoderate-to-severeCOPDandapproximately3millionpeoplediedofitin2015(5%ofalldeaths)(60).
Cancer killed 7.6million people in 2008 and about 70%of such deaths occur in low- andmiddle-incomecountries.Cancermortalityisprojectedtoreach13.1millionby2030.Approximately30%ofcancercasesareassociatedwithbehaviouralriskfactors(61,62).
Lung,breast,colorectal,stomachandlivercancercausemorethan50%ofcancerdeaths.Inhigh-incomecountries, themost frequentcauseofcancerdeaths in thepopulation is lungcancer, followedbybreastcanceramongwomenandcolorectalcanceramongmen.Thetypesandfrequenciesofcancerdifferamong
66 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
countries.Insub-SaharanAfrica,cervicalcancerisstilltheleadingcauseofcancerdeathamongwomen(7).
Cancerisanimportantpublichealthconcern.InTurkey,itisthesecondmostimportantcauseofdeathbutisprojectedtobetheleadingcauseofdeathby2030.Approximately175 000newcancercaseswerediagnosedinTurkeyin2012(63).
Thepercentageof respondentswhohadeverbeendiagnosedwith asthma (includingallergic asthma)by adoctorwas6.9%;5.0%formenand8.7%forwomen.Thefrequencyofdiagnosisrosefrom4.7%inthegroupaged15–29to12.5%inthegroupaged≥ 70,demonstratingthatthevalueingeneralincreasedwithage(Fig.23).
Fig. 23. Proportions of respondents with an asthma diagnosis, by sex and age group
10
Fig. 17. Types of diagnosed chronic disease requiring medication for respondents’ parents or siblings
Fig. 18. Proportions of respondents with an asthma diagnosis, by sex and age group
4,1 4.25.7
6.8
8.5
5.05.47.0
12.0 11.7
15.5
8.7
4.75.6
8.8 9.3
12.5
6.9
0
2
4
6
8
10
12
14
16
18
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
COPDisthethirdmostcommoncauseofdeathbydiseaseinTurkey(accountingfor6%),followingischaemicheartdiseaseandcerebrovasculardiseases(36):3.6%oftherespondentshadbeendiagnosedwithCOPDbyadoctor;3.1%formenand4.1%forwomen.Likeasthmadiagnoses,thefrequencyofCOPDdiagnosisrosewithage,from1.8%inthegroupaged15–29to8.6%inthegroupaged≥ 70(Fig.24).
Fig. 24. Proportions of respondents with COPD diagnoses, by sex and age group
11
Fig. 19. Proportions of respondents with COPD diagnoses, by sex and age group
Fig. 20. Respondents’ perception of their weight by sex
1,3
2.7 3.
4
7.4
8.0
3.1
2.4
3.2
4.2
7.4
9.1
4.1
1.8
3.0
3.8
7.4
8.6
3.6
0
1
2
3
4
5
6
7
8
9
10
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
10.8
56.3
28.8
3.6
0.5
7.6
44.9
38.1
8.7
0.8
9.2
50.5
33.5
6.1
0.6
0
10
20
30
40
50
60
Low weight Normal weight Overweight Obese Morbidly obese
Perc
enta
ge
Men Women Both sexes
67
Amongrespondents,0.7%hadreceivedacancerdiagnosisbyadoctorintheprevious12months;0.4%formenand0.9%forwomen.Thefrequencyofcancerdiagnosis,too,increasedwithage,from0.3%inthegroupaged15–29to2.2%inthegroupaged≥ 70.
4.14.1. Conclusions
Someofthemostimportantresultsonrespondents’historyofasthma,COPDorcancerincludedthefollowing:
● 6.9%hadbeendiagnosedwithasthma,includingmorewomen(8.7%)thanmen(5.0%); ● 3.6%hadbeendiagnosedwithCOPD,includingmorewomen(4.1%)thanmen(3.1%); ● 0.7%hadbeendiagnosedwithcancerintheprevious12months,includingmorewomen(0.9%)thanmen(0.4%);
● Thefrequencyofasthma,COPDandcancerdiagnosesincreasedwithage.
4.15. Lifestyle advice
Severalapproacheshavebeenproposedtoreduceand/orpreventNCDs.WHOdescribesasetofevidence-based best-buy interventions that are cost-effective and feasible (64). These interventions’ aims includeto reduce or prevent tobacco use and to promote physical activity and adequate and balanced nutrition,includingreducingsaltandfatintake,andconsumingatleastfiveservingsoffruitorvegetablesaday(65,66).
Respondentswereaskedabouttheirperceptionsoftheirweight:9.2%thoughttheywerethin;50.5%,normal;33.5%,overweight;and6.1%,obese(Fig.25).Perceptionsofnormalorlowweightweremorecommonamongmen,andperceptionsofoverweightandobesityweremorecommonamongwomen.
Fig. 25. Respondents’ perception of their weight by sex
11
Fig. 19. Proportions of respondents with COPD diagnoses, by sex and age group
Fig. 20. Respondents’ perception of their weight by sex
1,3
2.7 3.
4
7.4
8.0
3.1
2.4
3.2
4.2
7.4
9.1
4.1
1.8
3.0
3.8
7.4
8.6
3.6
0
1
2
3
4
5
6
7
8
9
10
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
10.8
56.3
28.8
3.6
0.5
7.6
44.9
38.1
8.7
0.8
9.2
50.5
33.5
6.1
0.6
0
10
20
30
40
50
60
Low weight Normal weight Overweight Obese Morbidly obese
Perc
enta
ge
Men Women Both sexes
Perceptions of weight varied among the age groups. The proportion of those perceiving their weightas low and normal decreased from 15.8% and 60.5%, respectively, in the group aged 15–29 to 4.7% and41.4%,respectively,inthegroupaged60–69.Conversely,perceptionsofexcessweightrosewithage,withproportionsofrespondentsconsideringthemselvesoverweightrisingfrom21.0%inthegroupaged15–29to42.9%inthegroupaged45–59,andtheshareofthoseconsideringthemselvesobeseincreasingfrom2.3%inthegroupaged15–29to10.7%inthegroupaged≥ 70.
68 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Fig.26showstheproportionsofrespondentswhohadreceivedarangeofadviceonchangingtheirlifestylesfromadoctororotherhealthworker:
● 14.8%(18.6%formenand11.1%forwomen)wereadvisedtoquitornottostartusingtobacco,withthefrequencydecreasingfrom17.2%inthegroupaged30–44to8.1%inthegroupaged≥ 70;
● 22.3% (20.8% formenand23.9% forwomen)were advised to reduce salt intake,with the frequencyincreasingingeneralwithage,from13.3%inthegroupaged15–29to39.1%inthegroupaged≥ 70;
● 19.9%(19.3%formenand20.4%forwomen)wereadvisedtoeatfiveormoreservingsoffruitand/orvegetableseachday,with thefrequency increasing ingeneralwithage, from15.7% in thegroupaged15–29to31.0%inthegroupaged≥ 70;
● 22.4%(19.6%formenand25.2%forwomen)wereadvisedtoreducefatintheirdiets,withthefrequencyincreasingingeneralwithage,from13.9%inthegroupaged15–29to35.7%inthegroupaged≥ 70;
● 23.2%(20.3%formenand26.2%forwomen)wereadvisedtoincreasetheirphysicalactivity,withthefrequencyincreasingfrom15.0%inthegroupaged15–29to34.2%inthegroupaged60–69;
● 22.1%(18.9%formenand25.4%forwomen)wereadvisedtomaintainahealthybodyweightortoloseweight,withthefrequency increasingfrom14.5%inthegroupaged15–29,to31.3%inthegroupaged60–69.
Fig. 26. Percentage of respondents who received lifestyle advice from a doctor or health worker during the previous 12 months by age group
12
Fig. 21. Percentage of respondents who received lifestyle advice from a doctor or health worker during the previous 12 months by age group
Fig. 22. Percentage of respondents who could name two or more negative health effects of any of the selected NCD risk factors
12.2
0
13.3
0 15.7
0
13.9
0
15.0
0
14.5
017.2 19
.7
19.1 20
.5 21.5
20.6
16.2
27.5
21.0
28.1 30
.8
29.8
17.6
37.0
25.5
34.7
34.2
31.3
8.1
39.1
31.0
35.7
29.8
27.3
14.8
22.3
19.9 22
.4
23.2
22.1
0
5
10
15
20
25
30
35
40
45
Tobacco Salt Fruit and/orvegetables
Fat Physical activity Body weight
Perc
enta
ge
15–29 30–44 45–59 60–69 ≥70 TOTAL
87.8 92
.3
90.1
86.6
79.2
89.1
89.1
90.0
84.9
76.7
66.9
85.588
.4 91.2
87.5
81.5
72.1
87.3
0
20
40
60
80
100
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
Thepercentageofrespondentswhohadreceivedcounsellingoreducationfromhealthworkersononeormoresubjects related tohealthy living (healthynutrition,weight reduction,smokingcessationorphysicalactivity) during theprevious 12monthswas40.5%; 38.1% formenand42.9% forwomen.The frequencyincreasedfrom29.7%inthegroupaged15–29to55.3%inthegroupaged60–69.
69
4.15.1. Conclusions
Someofthemostimportantresultsonlifestyleadvicegiventorespondentsincludedthefollowing:
● morementhanwomenperceivedtheirweightasnormal,andmorewomenthanmenperceivedthemselvesasoverweight;
● adoctororhealthworkerhadadvised:
� fewerthanoneoutofsevenindividualstoquitusingtobaccoornottostart;
� fewerthanoneoutoffourindividualstoreducesaltintheirdiets;
� fewerthanoneoutoffiveindividualstoeatfiveormoreservingsoffruitand/orvegetableseachday;
� fewerthanoneoutoffourindividualstoreducefatintheirdiets;
� fewerthanoneoutoffourindividualstostartbeingorbemorephysicallyactive;
� fewerthanoneoutoffourindividualstomaintainahealthybodyweightortoloseweight;
● ingeneral,moremenwereadvisedtoquitusingtobaccoornottostart,andmorewomenwereadvisedtoreducesaltinthediet,toeatfiveormoreservingsoffruitand/orvegetablesperday,toreducefatintheirdiets,tostartbeingorbemorephysicallyactive,andtomaintainahealthybodyweightortoloseweight;
● two infiveofrespondents (40.5%–38.1%formenand42.9%forwomen)hadreceivedcounsellingoreducationfromhealthworkersononeormoresubjectsrelatedtohealthylivingduringtheprevious12months.
4.16. Awareness of harm to health from selected risk factors for NCDs
Tobaccoisoneofthemostimportantcausesofpreventabledeath;tobaccouseaccountsforthedeathof7%ofmenand12%ofwomenannually(24,64).WHOestimatedthat8millionpeoplewilldiefromtobaccouseby2030(24).Inaddition,tobaccouseisaprominentcauseofmorbidityincludingCVD,chronicrespiratorydisease,canceranddiabetes.
Physically inactivepeoplehavehigher riskofdeath than thoseengaging inaminimumof 150minutesofmoderate-intensity physical activity per week (19). Physical activity has been shown to reduce body fat,decrease risksofCVDandmetabolicdisease, improvebonehealth,anddecreaseanxietyanddepressionsymptoms(19).
WHOreportedthat23%ofadults(> 18years)and81%ofadolescents(11–17years)wereinsufficientlyphysicallyactive in 2010 (11).Womenareusuallylessactivethanmen,andolderpeoplelessactivethanyoungerpeople.TheidealmedianBMIforadultsisacceptedas21–23kg/m2andthetargetedBMIrangeis18.5−24.9kg/m2. OverweightisdefinedashavingaBMI≥ 25kg/m2,whileobesityisconsideredashavingaBMI≥ 30kg/m2.Bothmayresultinanincreasedriskforseveralconditions(31).Combined,theycauseabout3.4milliondeathsand93.6millionDALYseachyear(18).
The respondents’ awarenessofhealth risks fromNCD risk factorswasassessedbyasking them to statetwoormorenegativehealtheffectsofanyoftheselectedriskfactors:87.3%(89.1%formenand85.5%forwomen)coulddoso.Thefrequencydecreasedfrom91.2%inthegroupaged30–44to72.1%inthegroupaged≥ 70(Fig.27).
70 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Fig. 27. Percentage of respondents who could name two or more negative health effects of any of the selected NCD risk factors
12
Fig. 21. Percentage of respondents who received lifestyle advice from a doctor or health worker during the previous 12 months by age group
Fig. 22. Percentage of respondents who could name two or more negative health effects of any of the selected NCD risk factors
12.2
0
13.3
0 15.7
0
13.9
0
15.0
0
14.5
017.2 19
.7
19.1 20
.5 21.5
20.6
16.2
27.5
21.0
28.1 30
.8
29.8
17.6
37.0
25.5
34.7
34.2
31.3
8.1
39.1
31.0
35.7
29.8
27.3
14.8
22.3
19.9 22
.4
23.2
22.1
0
5
10
15
20
25
30
35
40
45
Tobacco Salt Fruit and/orvegetables
Fat Physical activity Body weight
Perc
enta
ge
15–29 30–44 45–59 60–69 ≥70 TOTAL
87.8 92
.3
90.1
86.6
79.2
89.1
89.1
90.0
84.9
76.7
66.9
85.588
.4 91.2
87.5
81.5
72.1
87.3
0
20
40
60
80
100
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
Varyingproportionsofrespondentscouldstatetwoormorenegativehealtheffectsofeachriskfactor(Table48):
● smoking tobacco: 76.2% (77.0% formen and 75.5% forwomen),with the frequency decreasing from80.4%inthegroupaged30–44to61.2%inthegroupaged≥ 70;
● high-saltdiet:71.6%(72.3%formenand71.0%forwomen),withthefrequencydecreasingfrom76.7%inthegroupaged45–59to56.8%inthegroupaged≥ 70;
● lowconsumptionoffruitsand/orvegetables(32.8%formenand33.6%forwomen),withthefrequencydecreasingfrom35.2%inthegroupaged30–44to20.7%inthegroupaged≥ 70;
● physicalinactivity:58.3%(59.6%formenand57.1%forwomen); ● high-fatdiet:64.3%(65.7%formenand62.8%forwomen),withthefrequencydecreasingfrom69.9%inthegroupaged30–44to45.0%inthegroupaged≥ 70;
● alcoholuse:74.2%(75.9%formenand72.5%forwomen),withthefrequencydecreasingfrom79.9%inthegroupaged30–44to54.1%inthegroupaged≥ 70;
● substanceabuse:73.4%(75.5%formenand71.4forwomen),withthefrequencydecreasingfrom79.3%inthegroupaged30–44to53.7%inthegroupaged≥ 70;
Nogender differenceswere found in termsof indicating twoormorenegative health effects of different riskfactors.
Table 48. Proportions of respondents that could state two or more negative health effects of different risk factors, by age group
Age group (years)
Risky behaviour (%)
Smoking tobacco
High-salt diet
Low fruits and/or vegetable intake
Physical inactivity
High-fat diet
Harmful alcohol use
Substance abuse
15–29 76.1 68.8 34.0 57.2 62.2 73.7 74.2
30–44 80.4 75.9 35.2 63.5 69.9 79.9 79.3
45–59 77.7 76.7 34.7 60.1 67.5 76.6 74.2
60–69 70.8 66.8 30.0 55.5 59.6 67.0 64.6
≥ 70 61.2 56.8 20.7 39.8 45.0 54.1 53.7
Total 76.2 71.6 33.2 58.3 64.3 74.2 73.4
71
4.16.1. Conclusions
MostrespondentscouldstatetwoormorenegativehealtheffectsofNCDriskfactors:
● anyoftheselectedNCDriskfactors:nearlynineoutof10; ● smokingtobacco:threeoutoffour; ● high-saltdiet:approximatelythreeoutoffour; ● alcoholuseandsubstanceabuse:nearlythreeoutoffour; ● high-fatdiet:morethansixoutof10; ● physicalinactivity:nearlythreeoutoffive; ● lowconsumptionoffruitsand/orvegetables:approximatelyoneoutofthree.
4.17. Cancer screening tests
Breastcancermainlyoccursinwomen,althoughtherearerarecasesinmen(61).Awoman’slifetimeriskofbeingdiagnosedwithbreastcancer isaboutone ineight.Riskfactorsforbreastcancer includehormonetherapy,overweightandphysicalinactivity,ethnicbackground,genetics/familyhistory,genemutations,andolderage.Colorectalcancer is thethirdmostcommontypeofcancer.Therisk factors for thiscancerofthedistalpartofthedigestivesystemincludeageing,Africanethnicbackground,unhealthydiet,physicalinactivity,diabetesandfamilyhistory (66).Cervicalcancer isacancerofthefemalereproductivesystem.Nearly all cases are linked to genital infectionwith human papillomavirus (HPV); HPV infection, smoking,immunedeficiencies,poverty,lackofaccesstothePaptestandfamilyhistoryareamongtheriskfactors.
The respondentswereaskedwhat theyknewabout theavailabilityofvariousscreening tests forcancer:42.1%(37.8%formenand46.4%forwomen)hadheardthatcancerscreeningwasavailablefreeofchargeinfamilyhealthcentres(FHC)andcancerearlydiagnosisscreeningandtrainingcentres(CEDSTC).
TheproportionsthathadheardthatcancerscreeningwasavailableinFHCandCEDSTCincreasedfrom34.8%inthegroupaged15–29to50.0%inthegroupaged45–59,andthendeclinedinthetwooldestgroups(Fig.28).
Fig. 28. Percentages of respondents who have heard that the cancer screenings are available free in FHC and CEDSTC, by sex and age group
13
Fig. 23. Percentages of respondents who have heard that the cancer screenings are available free in FHC and CEDSTC, by sex and age group
Fig. 24. Types of accidents causing injuries suffered by the respondents in the previous 12 months, by sex
32.1
19.1
37.0
13.916.7
55.7
8.3
19.3
27.330.5
28.1
15.6
0
10
20
30
40
50
60
Traffic Household Occupational work Other
Perc
enta
ge
Men Women Both sexes
27.5
41.6
45.5
46.4
32.0
42.4
51.854.6
40.3
27.3
34.8
46.7 50.0
43.2
29.3
20
30
40
50
60
15–29 30–44 45–59 60–69 ≥70
Perc
enta
ge
Men Women Both sexes
72 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Varyingpercentagesofrespondentshadhadvariouscancertests:
● 74.5%(76.5%formenand72.4%forwomen)ofthoseaged50–70hadneverhadaguaiacfaecaloccultbloodtest;
● 12.1%(11.1%formenand13.2%forwomen)aged50–70hadhadacolonoscopyintheprevious10years; ● 57.4%ofwomenaged40–69hadeverhadmammography; ● 54.2%ofwomenaged30–65hadeverhadcervicalcancerscreening.
4.17.1. Conclusions
Someofthemostimportantresultsonrespondents’historyofcancerscreeningincludedthefollowing:
● two out of five respondents had heard that cancer screening was available free of charge, althoughawarenesswaslowerinmen(37.8%)thanwomen(46.4%);
● threeoutoffourparticipantsaged50–70hadneverhadaguaiacfaecaloccultbloodtest; ● approximatelyoneoutofnineindividualsaged50–70hadhadacolonoscopyintheprevious10years; ● twooutoffivewomenaged40–69hadneverhadmammography; ● approximatelyhalfofwomenaged30–65hadneverhadcervicalcancerscreening.
4.18. Accidents and injuriesInjurieswereestimatedtoberesponsiblefor7%oftotaldeathsinTurkey(37).Amongthesurveypopulation,3.9% (5.4% formenand2.4% forwomen)hadbeen injuredasa result of anaccident in theprevious 12months.Thisproportionwashighest(7.5%)inmalesintheyoungestagegroup.Fig.29showstheleadingtypesofaccidentscausing injuriessuffered intheprevious12months:trafficaccidents (27.3%of injuredrespondents),householdaccidents(30.5%ofinjuredrespondents),occupationalaccidents(28.1%)andothertypesofaccidents(15.6%).
Fig. 29. Types of accidents causing injuries suffered by the respondents in the previous 12 months, by sex
13
Fig. 23. Percentages of respondents who have heard that the cancer screenings are available free in FHC and CEDSTC, by sex and age group
Fig. 24. Types of accidents causing injuries suffered by the respondents in the previous 12 months, by sex
32.1
19.1
37.0
13.916.7
55.7
8.3
19.3
27.330.5
28.1
15.6
0
10
20
30
40
50
60
Traffic Household Occupational work Other
Perc
enta
ge
Men Women Both sexes
27.5
41.6
45.5
46.4
32.0
42.4
51.854.6
40.3
27.3
34.8
46.7 50.0
43.2
29.3
20
30
40
50
60
15–29 30–44 45–59 60–69 ≥70
Perc
enta
ge
Men Women Both sexes
Among respondents injured as a result of an accident in the previous 12 months 58.5% had receivedambulatorycare(53.9%formenand68.6%forwomen)and27.0%hadreceivedinpatientcare(31.5%formenand17.0%forwomen).
These proportions varied among the age groups. The share of thosewho had received ambulatory careranged from66.6% in thegroupaged 15–29 to40.4% in thoseaged60–69.Theproportionwho receivedinpatientcarerosefrom20.6%inthegroupaged15–29andto38.3%inthoseaged60–69(Fig.30).
73
Fig. 30. Percentages of respondents injured as a result of an accident in the previous 12 months who received ambulatory or inpatient care, by age group
14
Fig. 25. Percentages of respondents injured as a result of an accident in the previous 12 months who received ambulatory or inpatient care, by age group
Fig. 26. Type and length of care received by respondents who had visited a hospital for the treatment of hypertension, CVD, diabetes, cancer, COPD or asthma in the previous 12 months
66.6
59.5
50.3
40.4
59.9 58.5
20.623.7
35.438.3
31.427.0
0
10
20
30
40
50
60
70
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Ambulatory care Inpatient treatment
79.8
11.1 13.0
81.8
14.08.0
81.0
12.8 10.1
0
10
20
3040
50
60
70
80
90
Ambulatory care Inpatient care lasting lessthan 24 hours
Inpatient care lasting longerthan 24 hours
Perc
enta
ge
Men Women Both sexes
4.18.1. Conclusions
Someof themost important resultson injuries to respondents fromaccidents in theprevious 12monthsincludedthefollowing:
● 3.9%hadbeeninjuredasaresultofanaccident; ● accidentsintraffic(27.3%),thehousehold(30.5%)andtheworkplace(28.1%),andothertypesofaccidents(15.6%)weremainlyresponsiblefortheseinjuries;
● morethaneightoutof10injuredrespondentshadreceivedmedicalcare; ● thefrequencyandcausesofinjuries,andthetypesofmedicalcarereceivedvariedbetweenthesexes:moremenwereinjuredasaresultoftrafficandoccupational/workaccidents,whilemorewomenwereinjuredasaresultofhouseholdandothertypesofaccidents;andmoremenreceivedinpatienttreatment,whilemorewomenreceivedambulatorycare.
4.19. Ambulatory or inpatient care
Thepercentageofthoseinthesurveypopulationwhohadvisitedahospitalforthetreatmentofhypertension,CVD,diabetes,cancer,COPDorasthmaintheprevious12monthswas30.3%;28.8%formenand31.4%forwomen.Theseproportionsrosefrom15.9%inthegroupaged15–29to39.7%inthegroupaged≥ 70(Table49).
Table 49. Percentages of respondents who had visited a hospital for the treatment of hypertension, CVD, diabetes, cancer, COPD or asthma in the previous 12 months, by sex and age group
Age group (years)
Men Women Both sexes
% 95% CI % 95% CI % 95% CI
15–29 12.6 2.6–22.7 18.5 8.3–28.8 15.9 8.3–23.4
30–44 18.1 9.5–26.8 22.9 16.8–28.9 20.8 15.7–25.8
45–59 28.5 22.1–34.9 32.3 25.5–39.0 30.6 25.8–35.5
60–69 39.1 31.9–46.2 39.5 32.4–46.6 39.3 34.2–44.4
≥ 70 42.0 32.7–51.3 38.2 31.5–45.0 39.7 34.1–45.3
Total 28.8 25.1–32.5 31.4 27.9–34.9 30.3 27.6–32.9
74 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Ofthosewhohadvisitedahospitalforthetreatmentofhypertension,CVD,diabetes,cancer,COPDorasthmaintheprevious12months,81%hadreceivedambulatorycare(79.8%formenand81.8%forwomen),12.8%hadreceivedinpatientcarelastingfewerthan24hours(11.1%formenand14.0%forwomen)and10.1%hadreceivedcarelastinglongerthan24hours(13.0%formenand8.0%forwomen)(Fig.31).
Fig. 31. Type and length of care received by respondents who had visited a hospital for the treatment of hypertension, CVD, diabetes, cancer, COPD or asthma in the previous 12 months
14
Fig. 25. Percentages of respondents injured as a result of an accident in the previous 12 months who received ambulatory or inpatient care, by age group
Fig. 26. Type and length of care received by respondents who had visited a hospital for the treatment of hypertension, CVD, diabetes, cancer, COPD or asthma in the previous 12 months
66.6
59.5
50.3
40.4
59.9 58.5
20.623.7
35.438.3
31.427.0
0
10
20
30
40
50
60
70
15–29 30–44 45–59 60–69 ≥70 TOTALPe
rcen
tage
Ambulatory care Inpatient treatment
79.8
11.1 13.0
81.8
14.08.0
81.0
12.8 10.1
0
10
20
3040
50
60
70
80
90
Ambulatory care Inpatient care lasting lessthan 24 hours
Inpatient care lasting longerthan 24 hours
Perc
enta
ge
Men Women Both sexes
4.19.1. Conclusions
Someofthemostimportantresultsonhospitaltreatmentofrespondentsincludedthefollowing:
● nearlyoneoutofthreehadvisitedahospitalforthetreatmentofhypertension,CVD,diabetes,cancer,COPDorasthmaintheprevious12months;
● morethanfouroutoffiveofthosewhovisitedahospitalforthesereasonsreceivedambulatorycare.
4.20. Ambulatory diagnosis, treatment and home care
Investigatorsdeterminedtheproportionsofrespondentsthathadreceivedvarioustypesofhealthcare.Forexample,12.9%ofrespondentshadnevervisitedadentist,but6.7%hadvisitedadentistwithinthepreviousmonth.Inaddition,15.5%ofrespondentshadnevervisitedageneralpractitioner(GP)orfamilydoctor,while17.6%haddonesowithinthepreviousmonth.Similarly,10.7%hadnevervisitedaspecialistphysicianwhile16.8%haddonesowithinthepreviousmonth.
ThepercentageofrespondentswhohadvisitedsomehealthpersonnelisgiveninFig.32bysex.
75
Fig. 32. Percentages of respondents who had visited health personnel, by sex
15
Fig. 27. Percentages of respondents who had visited health personnel, by sex
Fig. 28. Percentages of respondents who had visited health personnel within the previous month, by age group
5.6 7.8
15.6
16.3
13.0
13.5
50.9
51.6
14.9
10.813
.8
21.4 26
.0 28.3
14.1
13.4
29.0
22.9
17.1
13.9
12.9
20.6 27
.1 32.2
15.9
13.5
31.1
25.2
12.9
8.5
0
10
20
30
40
50
60
Men Women Men Women Men Women Men Women Men Women
Within the last month More than 1, less than6 months ago
More than 6, less than12 months ago
12 months or moreago
Never
Perc
enta
ge
Dentist GP Specialist
6.27.4 6.7 7.2
5.36.7
13.9 12.8
20.2
30.6 29.9
17.614.7
13.5
18.3
25.0 24.4
16.8
0
5
10
15
20
25
30
35
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Visited dentist Visited a GP or family doctor Visited a specialist physician
Visitstohealthcareprovidersalsovariedbetweenagegroups:17.9%ofrespondentsinthegroupaged15–29hadnevervisitedadentist,butthisfrequencywasapproximatelyoneoutof10inotheragegroups.Amongrespondents in thegroupaged 15–29, 16.3%hadnevervisitedaGPor familydoctorand 13.9%hadnevervisitedaspecialistphysician;thecorrespondingfiguresfortheotheragegroupsdecreased,to13.4%and6.9%,respectively,inthegroupaged≥ 70.
Visitstohealthprofessionalsincreasedwithage.Inthegroupaged15–29,6.2%ofrespondentshadvisitedadentistwithinthepreviousmonth,13.9%hadvisitedaGPorfamilydoctorand14.7%hadvisitedaspecialist.Thecorrespondingfiguresforthegroupaged60–69were7.2%,30.6%and25.0%,respectively(Fig.33).
Fig. 33. Percentages of respondents who had visited health personnel within the previous month, by age group
15
Fig. 27. Percentages of respondents who had visited health personnel, by sex
Fig. 28. Percentages of respondents who had visited health personnel within the previous month, by age group
5.6 7.8
15.6
16.3
13.0
13.5
50.9
51.6
14.9
10.813
.8
21.4 26
.0 28.3
14.1
13.4
29.0
22.9
17.1
13.9
12.9
20.6 27
.1 32.2
15.9
13.5
31.1
25.2
12.9
8.5
0
10
20
30
40
50
60
Men Women Men Women Men Women Men Women Men Women
Within the last month More than 1, less than6 months ago
More than 6, less than12 months ago
12 months or moreago
Never
Perc
enta
ge
Dentist GP Specialist
6.27.4 6.7 7.2
5.36.7
13.9 12.8
20.2
30.6 29.9
17.614.7
13.5
18.3
25.0 24.4
16.8
0
5
10
15
20
25
30
35
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Visited dentist Visited a GP or family doctor Visited a specialist physician
Theaverage(mean)numberoftimesinwhichrespondentshadvisitedaGPorfamilydoctorinthepreviousfourweekswas1.2;1.3timesformenand1.2timesforwomen.Menandwomenhadmadethesameaverage(mean)numberofvisitstospecialistphysiciansinthepreviousfourweeks:1.4.
76 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Further,1.2%ofrespondentshadreceivedmedicalcareathomeintheprevious12months(1.1%formenand1.3%forwomen).Thisproportionrosewithage:from0.6%inthegroupaged30–44to5.0inthegroupaged≥ 70(Fig.34).
Fig. 34. Percentages of respondents who had received medical care at home in the previous 12 months
16
Fig. 29. Percentages of respondents who had received medical care at home in the previous 12 months
Fig. 30. Respondents’ mean SBP and DBP (mmHg) by sex and age group
1.1
0.60.8
1.9
5.0
1.2
0
1
2
3
4
5
6
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
121.7
121.1 12
8.3 135.
3
138.
7
125.
3
74.1 78
.5 81.8
82.2
79.7
78.2
112.7
114.6 12
7.0 134.
2
140.
7
120.
8
75.0 78.0 82
.1
82.6
81.2
78.7
117.3
117.8 12
7.6 134.
7
139.
9
123.
0
74.5 78.2 81.9
82.4
80.6
78.4
0
20
40
60
80
100
120
140
160
15–29 30–44 45–59 60–69 ≥70 Total 15–29 30–44 45–59 60–69 ≥70 TOTAL
Mean SBP Mean DBP
mm
Hg
Men Women Both sexes
4.20.1. Conclusions
Someofthemostimportantresultsonrespondents’useofcareincludedthefollowing:
● nearlyoneoutofeighthadnevervisitedadentist, althoughmore thanhalfhadvisitedadentist≥ 12monthspreviously;
● about16%oftherespondentshadnevervisitedaGPorafamilydoctor,butnearly45%haddonesowithintheprevioussixmonths;
● themeannumbersofvisits toaGPor familydoctorand tospecialistphysicians (in theprevious fourweeks)were1.2and1.4,respectively;
● morethanoneoutof10hadnevervisitedaspecialistphysician; ● about1%hadreceivedmedicalcareathomewithintheprevious12months.
4.21. Physical measurements
HypertensionasariskfactorforNCDswasassessedbymeasuringbloodpressure.ThemeanSBPofthestudypopulation,includingthosecurrentlyonmedicationforraisedbloodpressure,was123.0mmHg;125.3mmHgformenand120.8mmHgforwomen.SBProsefrom117.3mmHginthegroupaged15–29to139.9mmHginthegroupaged≥ 70,underliningthatthevalueingeneralincreaseswithage(Fig.35).ThemeanDBPofthestudypopulation,includingthosecurrentlyonmedicationforraisedbloodpressure,was78.4mmHg;78.2mmHgformenand78.7mmHgforwomen.DBPalsoincreasedwithage:from74.5mmHginthegroupaged15–29to82.4mmHginthoseaged60–69(Fig.35).
77
Fig. 35. Respondents’ mean SBP and DBP (mmHg) by sex and age group
16
Fig. 29. Percentages of respondents who had received medical care at home in the previous 12 months
Fig. 30. Respondents’ mean SBP and DBP (mmHg) by sex and age group
1.1
0.60.8
1.9
5.0
1.2
0
1
2
3
4
5
6
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
121.7
121.1 12
8.3 135.
3
138.
7
125.
3
74.1 78
.5 81.8
82.2
79.7
78.2
112.7
114.6 12
7.0 134.
2
140.
7
120.
8
75.0 78.0 82
.1
82.6
81.2
78.7
117.3
117.8 12
7.6 134.
7
139.
9
123.
0
74.5 78.2 81.9
82.4
80.6
78.4
0
20
40
60
80
100
120
140
160
15–29 30–44 45–59 60–69 ≥70 Total 15–29 30–44 45–59 60–69 ≥70 TOTAL
Mean SBP Mean DBP
mm
Hg
Men Women Both sexes
Fig.36showstheproportionsofrespondentswhohadraisedbloodpressureorwerecurrentlyonmedicationfortheconditionattwodifferentlevels:27.7%hadanSBP≥ 140and/orDBP≥ 90mmHgand17.1%,anSBP≥ 160and/orDBP≥ 100mmHg.
Fig. 36. Percentages of respondents with raised blood pressure or currently on medication for raised blood pressure, by sex
17
Fig. 31. Percentages of respondents with raised blood pressure or currently on medication for raised blood pressure, by sex
Fig. 32. Percentages of respondents with raised blood pressure, excluding those on medication for raised blood pressure, by age group
26.1
29.327.7
14.7
19.417.1
0
5
10
15
20
25
30
35
Men Women Both sexes
Perc
enta
ge
SBP ≥140 and/or DBP ≥ 90 mmHg SBP ≥160 and/or DBP ≥ 100 mmHg
10.0 13
.3
26.0
36.7
50.0
18.0
4.2
3.1 7.
6 11.9
22.3
5.8
0
10
20
30
40
50
60
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
SBP ≥140 and/or DBP ≥ 90 mmHg SBP ≥160 and/or DBP ≥ 100 mmHg
The proportions of respondents who had raised blood pressure or were currently on medication for itincreasedwithage,from11.2%inthegroupaged15–29to73.0%inthegroupaged≥ 70forthosewithanSBP≥ 140and/orDBP≥ 90mmHg,andfrom5.5%inthegroupaged15–29to58.0%inthegroupaged≥ 70forthosewithanSBP≥ 160and/orDBP≥ 100mmHg.
Ofalltherespondentsexcludingthoseonmedicationforthecondition,18.0%hadanSBP≥ 140and/orDBP≥ 90mmHg;18.6%formenand17.3%forwomen.
78 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Theproportionsof theserespondentsrosewithage, from10.0%inthegroupaged15–29to50.0%inthegroupaged≥ 70.Similarly,5.8%oftherespondentshadanSBP≥ 160and/orDBP≥ 100mmHg;6.0%formenand5.7%forwomen.Theseproportionsalsorose,from4.2%inthegroupaged30–44to22.3%inthoseaged≥ 70(Fig.37).
Fig. 37. Percentages of respondents with raised blood pressure, excluding those on medication for raised blood pressure, by age group
17
Fig. 31. Percentages of respondents with raised blood pressure or currently on medication for raised blood pressure, by sex
Fig. 32. Percentages of respondents with raised blood pressure, excluding those on medication for raised blood pressure, by age group
26.1
29.327.7
14.7
19.417.1
0
5
10
15
20
25
30
35
Men Women Both sexes
Perc
enta
ge
SBP ≥140 and/or DBP ≥ 90 mmHg SBP ≥160 and/or DBP ≥ 100 mmHg
10.0 13
.3
26.0
36.7
50.0
18.0
4.2
3.1 7.
6 11.9
22.3
5.8
0
10
20
30
40
50
60
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
SBP ≥140 and/or DBP ≥ 90 mmHg SBP ≥160 and/or DBP ≥ 100 mmHg
57.1%oftherespondentswithraisedbloodpressure(SBP≥140and/orDBP≥90mmHg)werenotonmedication(64.7%formenand50.5%forwomen).
Theproportionofallhypertensivepeoplewithcontrolledbloodpressurewerecalculatedtoshowhypertensioncontrolinthepopulation.Bloodpressurewasundercontrolfor23.8%ofthepopulation;18.5%formenand28.4%forwomen(Table50).
Table 50. Proportion of all hypertensive people with controlled blood pressure in the population
Age group (years)
Men Women Both sexes
N % 95% CI N % 95% CI N % 95% CI
15–29 55 6,9 (0,5-14,3) 60 8,5 (1,4-15,7) 115 7,6 (1,3-13,9)
30–44 100 7,2 (0,5-13,8) 181 23,0 (14,3-31,7) 281 15,2 (9,4-21,0)
45–59 230 20,0 (13,6-26,4) 412 32,4 (24,1-40,8) 642 26,7 (21,1-32,2)
60–69 201 26,5 (19,8-33,1) 293 35,4 (28,5-42,2) 494 31,4 (26,6-36,3)
≥ 70 185 31,0 (22,5-35,2) 336 29,3 (23,1-35,5) 521 30,0 (24,8-35,1)
TOTAL 771 18,5 (15,2-21,7) 1282 28,4 (24,5-32,3) 2053 23,8 (21,0-26,5)
Anthropometric measurements such as height, weight, and waist and hip circumference were used tocalculateBMIandmeanwaist–hipratio(WHR),inordertoestimatetheprevalenceofoverweightandobesityinthestudypopulation(excludingpregnantwomen)byageandsex.Themeninthestudypopulationhadameanheightof171.4cmandmeanweightof78.0kg;thecorrespondingfiguresforwomenwere157.7cmand70.1kg.Therespondents’meanBMIwas27.4kg/m2;26.6kg/m2formenand28.3kg/m2forwomen.Thevaluesincreasedfrom23.8 kg/m2inthegroupaged15–29to31.1kg/m2inthoseaged60–69(Fig.38).
79
Fig. 38. Respondents’ mean BMI, by sex and age group
18
Fig. 33. Respondents’ mean BMI, by sex and age group
Fig. 34. Distribution by BMI category, by sex
23.9
27.128.4 28.9 28.4
23.7
28.0
31.3
33.132.1
23.8
27.5
29.931.1
30.5
20
22
24
26
28
30
32
34
15–29 30–44 45–59 60–69 ≥70
kg/m
2
Men Women Both sexes
1.5
2.2
1.8
35.7
31.8
33.8
41.2
30.1
35.6
21.6
35.9
28.8
0 10 20 30 40 50 60 70 80 90 100
Men
Women
Both sexes
Underweight Normal weight Overweight Obese
Ofall the respondents, 1.8%wereunderweight (BMI< 18.5);33.8%werenormalweight (BMIof 18.5–24.9);35.6%overweight(BMIof25.0–29.9);and28.8%wereobese(BMI≥30.0)(Fig.39).Overweightpredominatedamongmales,andobesityamongfemales.
Fig. 39. Distribution by BMI category, by sex
18
Fig. 33. Respondents’ mean BMI, by sex and age group
Fig. 34. Distribution by BMI category, by sex
23.9
27.128.4 28.9 28.4
23.7
28.0
31.3
33.132.1
23.8
27.5
29.931.1
30.5
20
22
24
26
28
30
32
34
15–29 30–44 45–59 60–69 ≥70
kg/m
2
Men Women Both sexes
1.5
2.2
1.8
35.7
31.8
33.8
41.2
30.1
35.6
21.6
35.9
28.8
0 10 20 30 40 50 60 70 80 90 100
Men
Women
Both sexes
Underweight Normal weight Overweight Obese
Menhadagreatermeanwaistcircumference(91.3cm)thanwomen(87.9cm),whilewomenhadagreatermeanhipcircumference(102.5cm)thanmen(98.7cm).WHRwascomputedforallrespondents,excludingpregnant women, usingmeasurements of waist and hip circumferences, showing thatmen (0.93) had agreaterWHRthanwomen(0.86).
80 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
4.21.1. Conclusions
Someofthemostimportantresultsonphysicalmeasurementsofrespondentsincludedthefollowing:
● themeanbloodpressurewasanSBPof123.0mmHgandaDBPof78.4mmHg; ● 26.1%ofmenand29.3%ofwomenhadraisedbloodpressureorcurrentlyonmedicationforraisedbloodpressure,andthepercentageofrespondentswithraisedbloodpressureincreasedwithage;
● 57.1%of therespondentswith raisedbloodpressure (SBP≥ 140and/orDBP≥90mmHg) werenotonmedication(64.7%formenand50.5%forwomen);
● proportionofallhypertensivepeoplewithcontrolledbloodpressureinthepopulationwas23.8%(18.5%ofmenand28.4%ofwomen);
● whilemenweretallerandweighedmorethanwomen,womenhadahighermeanBMI; ● themeanBMIwas27.4kg/m2forbothsexes(26.6kg/m2formenand28.3kg/m2forwomen); ● 64.4%wereoverweight(BMI≥ 25kg/m2)and28.8%obese(BMI≥ 30kg/m2):62.8%and21.6%ofmenand66.0%and35.9%ofwomen,respectively;
● whilemenhadagreatermeanwaistcircumference(91.3cmversus87.9cm),womenhadagreatermeanhipcircumference(102.5cmversus98.7cm).
4.22. Biochemical measurements
DiabetesasariskfactorforNCDswasassessedbymeansoffastingbloodglucoseandHbA1cmeasurements.Fig.40showsthemeanfastingbloodglucoseofthestudypopulation,includingthosecurrentlyonmedicationfordiabetes(butexcludingnon-fastingrecipients),was97.8 mg/dl.The increases in levelsforbothsexes,from86.3mg/dl in thegroupaged 15–29 to 116.2mg/dl in thegroupaged≥ 70,underlines that this valueincreasesingeneralwithage.
Fig. 40. Mean fasting blood glucose, by sex and age group
19
Fig. 35. Mean fasting blood glucose, by sex and age group
Fig. 36. Prevalence of impaired fasting glycaemia by sex and age group
86.3 93
.8 102.
3
118.8
106.
5
96.2
86.4 95
.8
106.
5 115.1 12
3.0
99.3
86.3 94
.8
104.
4 116.9
116.2
97.8
0
20
40
60
80
100
120
140
15–29 30–44 45–59 60–69 ≥70 TOTAL
mg/
Dl
Men Women Both sexes
4.5
9.1 9.
9 10.4
13.2
8.1
5.0
4.0
11.9
14.9
12.2
7.7
4.7
6.6
10.9
12.8
12.6
7.9
0
2
4
6
8
10
12
14
16
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
Ofalltherespondents,7.9%hadimpairedfastingglycaemia(plasmavenousvalueof110–126mg/dl);8.1%formenand7.7%forwomen.Thefrequencyincreasedfrom4.7%inthegroupaged15–29to12.6%inthegroupaged≥ 70(Fig.41).
81
Fig. 41. Prevalence of impaired fasting glycaemia by sex and age group
19
Fig. 35. Mean fasting blood glucose, by sex and age group
Fig. 36. Prevalence of impaired fasting glycaemia by sex and age group
86.3 93
.8 102.
3
118.8
106.
5
96.2
86.4 95
.8
106.
5 115.1 12
3.0
99.3
86.3 94
.8
104.
4 116.9
116.2
97.8
0
20
40
60
80
100
120
140
15–29 30–44 45–59 60–69 ≥70 TOTAL
mg/
Dl
Men Women Both sexes
4.5
9.1 9.
9 10.4
13.2
8.1
5.0
4.0
11.9
14.9
12.2
7.7
4.7
6.6
10.9
12.8
12.6
7.9
0
2
4
6
8
10
12
14
16
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
Further,11.1%ofthestudypopulationhadraisedbloodglucose(plasmavenousvalue≥ 126mg/dl)orwerecurrentlyonmedicationfordiabetes;10.6%formenand11.5%forwomen.Thefrequencyincreasedfrom1.5%inthegroupaged15–29to29.3%inthegroupaged≥ 70(Fig.42).
Fig. 42. Proportions of respondents who had raised blood glucose or were currently on medication for diabetes, by sex and age group
20
Fig. 37. Proportions of respondents who had raised blood glucose or were currently on medication for diabetes, by sex and age groups
Fig. 38. Percentage of respondents with raised HbA1c.� 6.5%. by sex and age group
2.1
7.8
14.5
30,6
27.0
10.6
0.9
8.9
18.4
21.8
30.9
11.5
1.5
8.4
16.5
26.0
29.3
11.1
0
5
10
15
20
25
30
35
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
TheproportionofrespondentswithmeanHbA1cresults,includingthosecurrentlyonmedicationfordiabetes(butexcludingnon-fastingrespondents),was5.9%;5.9%forbothmenandwomen(Table51).ThemeanHbA1clevelincreasedfrom5.5%inthegroupaged15–29to6.5%inthoseaged≥70.
82 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Table 51. Proportions of respondents with mean HbA1c, by sex and age group
Age group (years)
Men Women Both sexes
N Mean (%) 95% CI N Mean (%) 95% CI N Mean (%) 95% CI
15–29 251 5.5 5.4–5.6 319 5.4 5.4–5.5 570 5.5 5.4–5.5
30–44 332 5.7 5.6–5.9 524 5.7 5.6–5.7 856 5.7 5.6–5.8
45–59 348 6.2 6.0–6.4 557 6.3 6.1–6.5 905 6.3 6.1–6.4
60–69 226 6.8 6.4–7.2 283 6.5 6.3–6.8 509 6.7 6.4–6.9
≥ 70 182 6.4 6.2–6.6 316 6.6 6.3–6.9 499 6.5 6.3–6.7
Total 1339 5.9 5.8–6.0 1999 5.9 5.8–6.0 3338 5.9 5.8–6.0
Ofalltherespondents,12.0%hadraisedHbA1c;11.9%formenand12.2%forwomen.Thefrequencyincreasedfrom1.5%inthegroupaged15–29to32.9%inthoseaged≥ 70(Fig.43).
Fig. 43. Percentage of respondents with raised HbA1c ≥ 6.5%, by sex and age group
2.3
6.2
21.5
29.7 30.5
11.9
0.6
4.6
21
34.7
34.5
12.2
1.5
5.4
21.3
32.3 32.9
120
5
10
15
20
25
30
35
40
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
51
46.4
22.4
11.3 11.17.2
1.8
11.1
0
10
20
30
40
50
60
Hypertension Type 2 diabetes Heart attack Cancer Hypercholes-terolemia
Chest painfrom heart
disease (angina)
Stroke(cerebrovascular
accidentor incident)
Other
Perc
enta
ge
13.3%ofthestudypopulationhadraisedHbA1C(≥6,5%)orwerecurrentlyonmedicationfordiabetes(12.7%formenand13.8%forwomen)(Table52).
Table 52. Proportion of respondents with raised HbA1C (≥6.5%) or who were currently on medication for diabetes
Age group (years)
Men Women Both sexes
N % 95% CI N % 95% CI N % 95% CI
15–29 240 2.3 0.2–4.5 310 1.4 0.0–2.9 550 1.9 0.6–3.2
30–44 324 7.0 3.8–10.2 511 6.1 2.9-9.4 835 6.6 4.3–8.9
45–59 336 22.4 15.9–28.9 546 22.2 16.0–28.3 882 22.3 17.8–26.8
60–69 224 32.5 23.3–41.8 283 39.0 30.5–47.5 507 35.9 29.6–42.1
≥ 70 179 32.7 21.1–44.4 304 36.2 27.0–45.4 483 34.8 27.6–42.0
Total 1303 12.7 10.4–15.1 1954 13.8 11.5–16.1 3257 13.3 11.6–14.9
83
In addition, 17.3%of the studypopulationhad raisedHbA1cor raisedbloodglucoseorwere currently onmedication;16.3%formenand18.3%forwomen.Thefrequencyincreasedfrom2.8%inthegroupaged15–29to43.0%inthegroupaged≥ 70(Fig.44).
Fig. 44. Proportions of respondents with raised HbA1c or raised blood glucose or were currently on medication, by sex and age group
21
Fig. 39. Proportions of respondents with raised HbA1c or raised blood glucose or were currently on medication, by sex and age group
Fig. 40. Percentages of respondents with total cholesterol levels � 190 mg/dl or � 240 mg/dl or currently on medication for raised cholesterol, by sex
4.0
10.9
26.8
38.2
38.9
16.3
1.6
10.9
30.4
44.3 45
.9
18.3
2.8
10.9
28.6
41.3 43
.0
17.3
0
5
10
15
20
25
30
35
40
45
50
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
20.9
6.5
28.5
9.5
24.7
8.0
0
5
10
15
20
25
30
Total cholesterol ≥ 190 mg/dl Total cholesterol ≥ 240 mg/dl
Perc
enta
ge
Men Women Both sexes
Themeantotalcholesterollevelofthestudypopulation,includingthosecurrentlyonmedicationforraisedcholesterol,was161.2mg/dl;154.9mg/dlformenand167.3mg/dlforwomen.Themeanlevelrosefrom139.7mg/dlinthegroupaged15–29to178.6mg/dlinthoseaged45–59(Table53).
Table 53. Mean total cholesterol, by sex and age group
Age group (years)
Men Women Both sexes
NMean
(mg/dl)95% CI (mg/dl)
NMean
(mg/dl)95% CI (mg/dl)
NMean
(mg/dl)95% CI (mg/dl)
15–29 246 137.8 132.4–143.2 311 141.8 136.6–147.0 557 139.7 135.9–143.6
30–44 326 160.4 153.6–167.2 520 163.4 158.3–168.5 846 161.9 157.7–166.1
45–59 342 168.1 161.1–175.2 551 189.5 180.9–198.2 893 178.6 173.0–184.2
60–69 226 164.4 156.4–172.4 287 191.2 184.9–197.5 513 178.4 172.9–183.8
≥ 70 180 156.9 148.9–165.0 314 192.0 177.8–206.2 494 177.5 167.7–187.4
Total 1320 154.9 151.4–158.5 1983 167.3 163.7–171.0 3303 161.2 158.5–163.8
Therespondentscurrentlyonmedicationforraisedcholesterolincluded24.7%withatotalcholesterol≥ 190mg/dl(20.9%formenand28.5%forwomen)and8.0%withatotalcholesterol≥ 240mg/dl(6.5%formenand9.5%forwomen)(Fig.45).Table54showsthemeanHDLlevelinthestudypopulation:45.9mg/dl(40.5mg/dlformenand51.2mg/dlforwomen).ThemeanHDLcholesterolofwomenwas50.1mg/dlinthegroupaged15–29andingeneralincreasedwithage,reaching52.5mg/dlinthoseaged≥70.ThemeanHDLcholesterolfor
84 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
menwasthelowestwith38.8mg/dlinthoseaged30–44andincreasedwithage,risingto43.2mg/dlinthegroupaged≥70.
Fig. 45. Percentages of respondents with total cholesterol levels ≥ 190 mg/dl including ≥ 240 mg/dl or currently on medication for raised cholesterol, by sex
21
Fig. 39. Proportions of respondents with raised HbA1c or raised blood glucose or were currently on medication, by sex and age group
Fig. 40. Percentages of respondents with total cholesterol levels � 190 mg/dl or � 240 mg/dl or currently on medication for raised cholesterol, by sex
4.0
10.9
26.8
38.2
38.9
16.3
1.6
10.9
30.4
44.3 45
.9
18.3
2.8
10.9
28.6
41.3 43
.0
17.3
0
5
10
15
20
25
30
35
40
45
50
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women Both sexes
20.9
6.5
28.5
9.5
24.7
8.0
0
5
10
15
20
25
30
Total cholesterol ≥ 190 mg/dl Total cholesterol ≥ 240 mg/dl
Perc
enta
ge
Men Women Both sexes
Table 54. Respondents’ mean HDL cholesterol levels, by sex and age group
Age group (years)
Men Women Both sexes
NMean
(mg/dl)95% CI (mg/dl)
NMean
(mg/dl)95% CI (mg/dl)
NMean
(mg/dl)95% CI(mg/dl)
15–29 246 42.0 39.8–44.2 317 50.1 48.1–52.1 563 46.0 44.4–47.6
30–44 328 38.8 37.2–40.4 522 51.2 49.2–53.2 850 44.9 43.5–46.4
45–59 343 39.3 37.5–41.1 556 51.8 49.8–53.9 899 45.5 44.0–47.1
60–69 224 41.6 39.2–44.1 284 52.0 50.0–54.0 508 47.0 45.3–48.8
≥ 70 182 43.2 39.9–46.5 315 52.5 49.9–55.1 497 48.7 46.6–50.7
Total 1323 40.5 39.4–41.5 1994 51.2 50.2–52.2 3317 45.9 45.0–46.7
Low HDL is defined as a plasma venous value < 50mg/dl for women and < 40mg/dl for men; 52.3% ofrespondentshadlowHDL(55.6%formenand49.1%forwomen)(Fig.46).Inaddition,61.7%ofthemenaged30–44wasbelowtheoptimallevelofHDLcholesterol;thisproportionfellto40.4%inthoseaged≥70;thispercentagedecreasedwithage ingeneral.ThepercentageofHDLcholesterolbelowtheoptimal level forwomenwassimilarinallagegroups.
85
Fig. 46. Percentages of respondents with low HDL cholesterol, by sex and age group (< 50 mg/dl for women and < 40 mg/dl for men)
22
Fig. 41. Percentages of respondents with low HDL cholesterol, by sex and age group (< 50 mg/dl for women and < 40 mg/dl for men)
Fig. 42. Percentages of respondents with fasting triglycerides levels � 150 mg/dl and � 180 mg/dl, by sex
50.1
61.7 60.8
52.1
40.4
55.6
48.050.9 48.7 48.9 48.4 49.1
0
10
20
30
40
50
60
70
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women
30.2
19.921.0
13.6
25.6
16.7
0
5
10
15
20
25
30
35
Fasting triglycerides ≥ 150 mg/dl Fasting triglycerides ≥ 180 mg/dl
Perc
enta
ge
Men Women Both sexes
Table55showsthatthemeanfastingtriglycerideslevelforallrespondents(excludingnon-fastingrespondents)was122.8mg/dl;129.0mg/dlformenand116.7mg/dlforwomen.Themeanlevelincreasedfrom99.1mg/dlinthegroupaged15–29to144.5mg/dlinthegroupaged45–59,andtendedtodecreaseinolderage.
Table 55. Respondents’ mean fasting triglycerides by sex and age group
Age group (years)
Men Women Both sexes
NMean
(mg/dl)95% CI (mg/dl)
NMean
(mg/dl)95% CI(mg/dl)
NMean
(mg/dl)95% CI (mg/dl)
15–29 239 109.9 99.9–119.8 306 87.7 82.2–93.2 545 99.1 93.0–105.1
30–44 321 137.1 126.7–147.5 509 112.2 102.4–122.0 830 124.8 117.5–132.1
45–59 331 143.1 132.6–153.6 540 145.8 128.7–162.9 871 144.5 134.3–154.6
60–69 220 144.0 126.1–162.0 281 141.4 128.9–154.0 501 142.7 131.7–153.6
≥ 70 173 116.4 105.2–127.6 297 135.6 123.0–148.3 470 127.7 118.6–136.8
Total 1284 129.0 123.2–134.9 1933 116.7 110.8–122.5 3217 122.8 118.5–127.1
Ofalltherespondents,25.6%hadfastingtriglycerides≥ 150mg/dl(30.2%formenand21.0%forwomen)and16.7%hadfastingtriglycerides≥ 180mg/dl(19.9%formenand13.6%forwomen)(Fig.47).
86 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Fig. 47. Percentages of respondents with fasting triglycerides levels ≥ 150 mg/dl and ≥ 180 mg/dl, by sex
22
Fig. 41. Percentages of respondents with low HDL cholesterol, by sex and age group (< 50 mg/dl for women and < 40 mg/dl for men)
Fig. 42. Percentages of respondents with fasting triglycerides levels � 150 mg/dl and � 180 mg/dl, by sex
50.1
61.7 60.8
52.1
40.4
55.6
48.050.9 48.7 48.9 48.4 49.1
0
10
20
30
40
50
60
70
15–29 30–44 45–59 60–69 ≥70 TOTAL
Perc
enta
ge
Men Women
30.2
19.921.0
13.6
25.6
16.7
0
5
10
15
20
25
30
35
Fasting triglycerides ≥ 150 mg/dl Fasting triglycerides ≥ 180 mg/dl
Perc
enta
ge
Men Women Both sexes
Respondents’meansaltintakewas9.9gperday;11.0gformenand8.7gforwomen.
4.22.1. Conclusions
Someofthemostimportantresultsfrombiochemicalmeasurementsofrespondentsincludedthefollowing:
● themeanfastingglucoselevelwas97.8mg/dl(96.2mg/dlformenand99.3mg/dlforwomen)andlevelsincreasedinolderage,includingthosecurrentlyonmedicationfordiabetes;
● 7.9%hadimpairedfastingbloodglycaemia levels (≥ 110mg/dland< 126mg/dlandthisproportionwashigheramongmen(8.1%)thanwomen(7.7%);
● 11.1% had raised fasting blood glucose or currently on medication for diabetes, without significantdifferencesbetweenmenandwomen;
● meanHbA1clevelswerealsosimilarinmenandwomen,althoughthefrequencyofraisedHbA1c(≥ 6.5%)was12.0%andincreasedwithage;
● 13.3%hadraisedHbA1C(≥6,5%)orwerecurrentlyonmedicationfordiabetes(12.7%formenand13.8%forwomen)
● 17.3%hadfastingplasmavenousglucose≥ 126mg/dlorHbA1c≥ 6.5%orwerecurrentlyonmedicationforraisedbloodglucose;thefrequencyofallthreeincreasedwithage;
● themeantotalbloodcholesterollevelwas161.2mg/dl,althoughwomen(167.3mg/dl)tendedtohavehigherlevelsthanmen(154.9mg/dl);
● 24.7%hadaraisedtotalcholesterollevel,withahigherproportioninwomen(28.5%)thanmen(20.9%); ● suboptimallevelsofHDLcholesterolwerefoundin55.6%ofmen(< 40mg/dl)and49.1%ofwomen(< 50mg/dl);
● menhadhighermeanlevelsoffastingtriglycerides,and19.9%ofmenand13.6%ofwomenhadraisedtriglycerides(≥ 180mg/dl);
● themeandailyintakeofsaltwas9.9gandmenconsumedmorethanwomenonaverage(11.0gperdayversus8.7gperday).
4.23. CVD risk
ThemodernconceptofprimarypreventionofCVDentailsassessingaperson’sglobalriskandchoosingtherightmanagementinaccordancewiththeseresults.Aten-yearCVDriskof≥ 30%isdefinedaccordingtoage,sex,bloodpressure,smokingstatus(currentsmokersorthosewhoquitsmokinglessthanayearbeforethe
87
assessment),totalcholesterolanddiabetes(previouslydiagnosedorafastingplasmaglucoseconcentration> 126mg/dl).Amongrespondentsbetween40–69yearsold,10.5%hadaten-yearCVDrisk≥ 30%oralreadyhadCVD;13.3%formenand7.8%forwomen.
Thefrequencymorethandoubled,from6.3%inthegroupaged40–54to17.0%inthoseaged55–69(Table56).Ofalltheeligiblerespondents(definedasthoseaged40–69yearswithaten-yearCVDrisk≥ 30%,includingthosewhoalreadyhadCVD),49.2%werereceivingdrugtherapyandcounsellingtopreventheartattacksandstrokes.Counsellingisdefinedasreceivingadvicefromadoctororotherhealthworkertoquitornottostartusingtobacco,reducesaltindiet,eatatleastfiveservingsoffruitand/orvegetablesperday,reducefatinthediet,startordomorephysicalactivity,andmaintainahealthybodyweightorloseweight.
Table 56. Percentage of respondents who had a ten-year CVD risk ≥ 30% or already had CVD, by sex and age group
Age group (years)
Men Women Both sexes
N % 95% CI N % 95% CI N % 95% CI
40–54 310 7.2 3.0–11.3 530 5.4 3.2–7.7 840 6.3 3.9–8.6
55–69 338 22.5 14.8–30.2 471 11.6 6.4–16.8 809 17.0 12.3–21.7
Total 648 13.3 9.2–17.4 1001 7.8 5.3–10.3 1649 10.5 8.1–12.9
Halfofmen(50.7%)and46.8%ofwomenreceivedcounsellingtopreventheartattacksandstrokes:33.7%in thegroupaged45–54and58.0% in thegroupaged55–69.Theproportions receivingdrug therapyandcounsellingforthispurposevariedwithageandsex.Inthegroupaged45–54,moremen(41.2%)thanwomen(24.1%)were receivingdrug therapyandcounselling; thegroupaged55–69showedtheoppositepattern:morewomen(63.3%)thanmen(55.3%)werereceivingdrugtherapyandcounselling(Fig.48).
Fig. 48. Percentage of respondents with a ten-year CVD risk ≥ 30% or already with CVD and receiving drug therapy and counselling to prevent heart attacks and strokes, by sex and age group
23
Fig. 43. Percentage of respondents with a ten-year CVD risk � 30% or already with CVD and receiving drug therapy and counselling to prevent heart attacks and strokes, by sex and age group
Fig. 44. Summary of combined risk factors in respondents aged 18–69 by sex and age group
41.2
55.350.7
24.1
63.3
46.8
33.7
58.0
49.2
0
10
20
30
40
50
60
70
45–54 55–69 TOTAL
Perc
enta
ge
Men Women Both sexes
2.1
1.0
1.7
1.3
.0 1
0.8
1.7
0.5
1.3
52.3
37.5
46.8
59.8
29.9
48.7
56.1
33.6
47.8
45.6
61.5
51.5
38.9
70.0
50.5
42.2
65.9
51.0
0 10 20 30 40 50 60 70 80 90 100
18–44
45–69
TOTAL
18–44
45–69
TOTAL
18–44
45–69
TOTAL
Men
Wom
enBo
th s
exes
Percentage
0 risk factors 1–2 risk factors 3–5 risk factors
The proportion of eligible persons who were receiving drug therapy and counseling (including glycemiccontrol)topreventheartattacksandstrokeswere55.9%forbothsexes,55.1%formenand57.0%forwomen(Table57).
88 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
Table 57. Proportion of eligible persons1 receiving drug therapy and counseling to prevent heart attacks and strokes
Age group (years)
Men Women Both sexes
N % 95% CI N % 95% CI N % 95% CI
40–54 28 41.2 10.2–72.2 33 24.1 9.0–39.1 61 33.7 14.5–52.9
55–69 65 55.3 33.8–76.8 48 63.3 40.2–86.5 113 58.0 41.4–74.6
≥ 70 35 78.4 62.9–93.8 50 78.7 65.1–92.3 85 78.6 68.6–88.5
Total 128 55.1 39.6–70.7 131 57.0 44.3–69.8 259 55.9 45.3–66.6
1 eligible persons:aged≥40yearswitha10-yearCVDrisk≥30%includingthosewithexistingCVD)
4.23.1. Conclusions
Someofthemostimportantresultsonrespondents’CVDriskincludedthefollowing:
● 10.5%of respondentsaged40–69 yearshada ten-yearCVD risk≥ 30%or alreadyhadCVD, andmen(13.8%)hadhigherrisksthanwomen(7.8%);
● lessthan50%ofthepeopleeligiblefordrugtherapyandcounsellingtopreventheartattacksandstrokeswerereceivingthem;
● theproportionsreceivingdrugtherapyandcounsellingvariedbysexandagegroup; ● the proportion of eligible personswhowere receiving drug therapy and counselling to prevent heartattacksandstrokeswere55.9%(55.1%formenand57.0%forwomen).
4.24. Summary of combined risk factors
InvestigatorsassessedthesummaryofcombinedriskfactorsforNCDsbydeterminingthepercentagesofrespondentswithzero,1–2or3–5ofthefollowingriskfactors:currentdailysmoking,consumingfewerthanfiveservingsoffruitand/orvegetablesperday,notmeetingWHOrecommendationsonphysicalactivityforhealth(<150minutesofmoderateactivityperweek,orequivalent),beingoverweightorobese(BMI≥ 25kg/m2),raisedbloodpressure(SBP≥ 140and/orDBP≥ 90mmHgorcurrentlyonmedication).
Fig.49showsthedistributionofriskfactorsamongrespondentsaged18–69years:1.3%hadnoriskfactors;47.8%had1–2riskfactorsand51.0%had3–5.Thepercentageswithnoand1–2riskfactorsdecreasedwithage (from1.7%and56.1% in thegroupaged 18–44to0.5%and33.6%in thoseaged45–69, respectively),whilethepercentageswith3–5riskfactorsincreasedwithage(from42.2%inthegroupaged18–44to65.9%inthoseaged45–69).Resultsalsovariedbetweenthesexes:1.7%ofmenand0.8%ofwomen(aged18–69)hadnoriskfactors;46.8%ofmenand48.7%ofwomenhad1–2riskfactors;and51.5%ofmenand50.5%ofwomenhad3–5riskfactors.
89
Fig. 49. Summary of combined risk factors in respondents aged 18–69 by sex and age group
23
Fig. 43. Percentage of respondents with a ten-year CVD risk � 30% or already with CVD and receiving drug therapy and counselling to prevent heart attacks and strokes, by sex and age group
Fig. 44. Summary of combined risk factors in respondents aged 18–69 by sex and age group
41.2
55.350.7
24.1
63.3
46.8
33.7
58.0
49.2
0
10
20
30
40
50
60
70
45–54 55–69 TOTAL
Perc
enta
ge
Men Women Both sexes
2.1
1.0
1.7
1.3
.0 1
0.8
1.7
0.5
1.3
52.3
37.5
46.8
59.8
29.9
48.7
56.1
33.6
47.8
45.6
61.5
51.5
38.9
70.0
50.5
42.2
65.9
51.0
0 10 20 30 40 50 60 70 80 90 100
18–44
45–69
TOTAL
18–44
45–69
TOTAL
18–44
45–69
TOTAL
Men
Wom
enBo
th s
exes
Percentage
0 risk factors 1–2 risk factors 3–5 risk factors
Fig.50showstheresultsforallrespondents,distributedintothreegroups:thoseaged15–44,45–69and≥ 70years.Thepatternshownissimilar:1.3%hadnoriskfactors(1.9%formenand0.8%forwomen);47.5%had1–2riskfactors(47.8%formenand47.3%forwomen);and51.2%had3–5riskfactors(50.3%formenand51.9%forwomen).Theproportionswithlowernumbersofriskfactorsdeclinedwithage,andtheproportionswiththehighestnumberincreasedwithage.
Fig. 50. Summary of all respondents’ combined risk factors by sex and age group
24
Fig. 45. Summary of all respondents’ combined risk factors by sex and age groups
Fig. 46. Respondents’ perceptions of their health status by sex
Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan
2.5
1.0
1.0
1.9
1.3
0.1
0.2
0…
1.9
0.5
0.6
1.3
54.7
37.5
33.1
47.8
61.4
29.9
11.7
47.3
58.1
33.6
21.1
47.5
42.8
61.5
65.9
50.3
37.3
70.0
88.1
51.9
40.0
65.9
78.3
51.2
0 10 20 30 40 50 60 70 80 90 100
15–44
45–69
≥70
TOTAL
15-44
45-69
≥70
TOTAL
15-44
45-69
≥70
TOTAL
Men
Wom
enBo
th s
exes
Percentage
0 risk factors 1–2 risk factors 3–5 risk factors
19.6
54.8
20.7
4.2
0.7
12.7
51.8
26.6
8.1
0.8
16.1
53.3
23.6
6.2
0.8
0
10
20
30
40
50
60
Very good Good Average Bad Very bad
Perc
enta
ge
Men Women Both sexes
90 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
4. SURVEY RESULTS
4.24.1. Conclusions
Someofthemostimportantresultsonrespondents’combinedriskfactorsincludedthefollowing:
● lessthan2%ofthestudypopulationhadnoneofthestatedriskfactors,while51.2%had3–5; ● thefrequencyofhaving3–5riskfactorsincreasedwithagewhilethefrequencyofhaving0–2riskfactorsdecreasedwithage.
4.25. Health perception
Health perception (or perceived health status) are people’s subjective ratings of their health status.Investigators assessed respondents’ healthperceptionswith thequestion typically used in the literature:Whatdoyouthinkofyourhealthstatusingeneral?Inanswering,respondentschoseanumberrangingfrom1(verygood)to5(verybad).
Morethanhalfoftherespondents(53.3%)perceivedtheirhealthstatusasgood;54.8%formenand51.8%forwomen(Fig.51).Table58presentstheperceptionofhealthstatusbyage.Theperceptionsofhealthstatusasverygoodandgooddecreasedwithage,whileincreasingproportionschosetheotheroptions.
Fig. 51. Respondents’ perceptions of their health status by sex
24
Fig. 45. Summary of all respondents’ combined risk factors by sex and age groups
Fig. 46. Respondents’ perceptions of their health status by sex
Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan
2.5
1.0
1.0
1.9
1.3
0.1
0.2
0…
1.9
0.5
0.6
1.3
54.7
37.5
33.1
47.8
61.4
29.9
11.7
47.3
58.1
33.6
21.1
47.5
42.8
61.5
65.9
50.3
37.3
70.0
88.1
51.9
40.0
65.9
78.3
51.2
0 10 20 30 40 50 60 70 80 90 100
15–44
45–69
≥70
TOTAL
15-44
45-69
≥70
TOTAL
15-44
45-69
≥70
TOTAL
Men
Wom
enBo
th s
exes
Percentage
0 risk factors 1–2 risk factors 3–5 risk factors
19.6
54.8
20.7
4.2
0.7
12.7
51.8
26.6
8.1
0.8
16.1
53.3
23.6
6.2
0.8
0
10
20
30
40
50
60
Very good Good Average Bad Very bad
Perc
enta
ge
Men Women Both sexes
4.25.1. Conclusions
Themostimportantresultsonrespondents’perceptionsoftheirhealthincludedthefollowing:
● 53.3%perceivedtheirhealthstatusasgood(54.8%formenand51.8%forwomen); ● Whilethemostpositiveperceptionsofhealthdecreasedwithage,theothersincreased.
91
Table 58. Health status perception of individuals, by age group
Age group (years)
N
Very good Good Average Bad Very bad
%%95 CI
(%)%
%95 CI (%)
%%95 CI
(%)%
%95 CI (%)
%%95 CI
(%)
15–29 1166 27.0 23.6–30.3 58.5 55.0–62.1 11.9 9.9–14.0 2.2 1.2–3.2 0.4 0.0–0.8
30–44 1700 15.4 13.1–17.7 57.9 54.7–61.1 23.0 20.3–25.7 3.4 2.0–4.8 0.3 0.0–0.6
45–59 1612 9.3 7.3–11.4 51.6 48.2–55.0 30.5 27.6–33.4 8.2 5.9–10.5 0.4 0.1–0.6
60–69 843 6.5 4.1–8.8 43.4 39.0–47.9 37.8 33.4–42.1 10.9 8.7–13.1 1.4 0.4–2.5
≥ 70 720 4.2 2.1–6.3 28.6 24.3–32.9 39.2 34.8–43.6 23.3 19.4–27.2 4.7 2.2–7.1
Total 6041 16.1 14.6–17.6 53.3 51.5–55.1 23.6 22.3–25.0 6.2 5.3–7.0 0.8 0.5–1.0
92 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
CONCLUSION
Concernabout theprevalenceofNCDs is growingaround theworld, andmanycountrieshaveprioritizedthepreventionofNCDsintheirnationalpublicpolicies.PoliciestopreventNCDsrequiretheparticipationofvarioussectors(includinghealth,educationandtransport),so that strategies for population intervention to prevent and control the evaluated riskfactorsandtopromoteahealthylifefromanearlyageareimplementedandsustainedinacoordinatedmanner.ThisrequirescontinuousmonitoringoftheNCDriskfactorsbasedonsamplesrepresentativeofthepopulation.
ThisresearchstudiesasampleoftheadultpopulationofTurkey,ofbothsexesandwithinthegroupaged≥ 15years, toobtain informationon therisk factors forNCDs.This is thefirststudyconductedinTurkeythatusedtheSTEPSmethodologydevelopedbyWHOforthesurveillanceofriskfactorsforchronicdiseases.
ThemethodologyusedfollowstheestablishedstandardsoftheWHOSTEPwiseapproach,whichensures the technical and scientificquality of the survey. The studyhasobtainedvaluable informationonawiderangeofNCDriskfactors inTurkey:tobaccouse;harmfulalcoholuse;lowconsumptionoffruitsandvegetablesandhighconsumptionofsaltinthediet;physicalinactivity;andoverweightandobesity.
For example, the survey showed that 31.6% of respondents currently used tobacco(smokedorsmokeless);43.6%formenand19.7%forwomen.Ofdailysmokers,97.3%usedmanufactured cigarettes; 97.3% for men and 97.2% for women. Users of manufacturedcigarettessmokedameanof15.5cigarettes;16.8formenand12.7forwomen.
As to alcohol consumption, the survey showed that 8.0%of respondents had consumedalcohol in theprevious30days; 13.1%formenand3.0%forwomen. Inaddition,5.2%ofrespondentshadengagedinheavyepisodicdrinking(≥ 6ormoredrinksonanyoccasionintheprevious30days);8.7%formenand1.8%forwomen.
Thesurveyresultsshowthatrespondentsatefruitandvegetablesonmeannumbersof4.6and5.1days,respectively,inatypicalweek;4.5formenand4.8forwomen,and4.9formenand5.2forwomen,respectively.Further,87.8%atefewerthanfiveservingsoffruitand/orvegetablesonaverageperday;87.8%formenand87.9%forwomen.
Respondents’salt intakecamefromvarioussources:28.1%alwaysoroftenaddedsaltorsaltysaucetotheirfoodbeforeorwhileeating(29.3%formenand26.8%forwomen),and25.5%alwaysoroftenateprocessedfoodshighinsalt(27.8%formenand23.3%forwomen).
Thesurveyshowedlowlevelsofphysicalactivity;43.6%hadinsufficientphysicalactivity(< 150minutesofmoderate-intensityactivityperweekorequivalent);33.1%formenand53.9%forwomen.Italsoshowedthatthemediantimespentinphysicalactivityonaverageperdaywas30.0minutes;51.4formenand17.1forwomen.Inaddition,81.3%(70.1%ofmenand92.2%ofwomen)werenotengaginginvigorousphysicalactivity.
Further, 40.5% of respondents (38.1% for men and 42.9% for women) had receivedcounsellingoreducationfromhealthworkersononeormoresubjects related tohealthylivingduringtheprevious12months.
CONCLUSION
93
AwarenessofhealthrisksfromtheselectedNCDriskfactorsvariedbetweenthesexes.Morementhanwomencouldstatetwoormorenegativehealtheffectsof:anyoftheselectedNCDriskfactors(89.1%versus85.5%),smokingtobacco(77.0%versus75.5%),ahigh-saltdiet (72.3%versus71.0%),physical inactivity (59.6%versus57.1%),ahigh-fatdiet (65.7%versus 62.8%), twoormorenegativehealth effectsof alcohol use (75.9%versus 72.5%)andsubstanceabuse(75.5%versus71.4%).Incontrast,morewomenthanmencouldstatetwoormorenegativehealtheffectsoflowconsumptionoffruitsand/orvegetables(33.6%versus32.8%).
Oneinfourrespondentsaged50–70yearsoldhadhadafaecaloccultbloodtest.Whilemorethanhalfofwomenaged30–65(54.2%)reportedhavingbeenscreenedforcervicalcancer,threeinfivewomenaged40–69hadhadmammography.
Moreover,inthepreviousmonth,6.7%oftherespondentshadvisitedadentist;17.6%,aGPorfamilydoctor;and16.8%,aspecialistphysician.
Raisedbloodpressurewasfoundin26.1%ofmenand29.3%ofwomen,andpercentagesofrespondentswithraisedbloodpressureincreasedwithage.
ThemeanBMIwas27.4kg/m2forbothsexes;64.4%ofrespondentswereoverweight(BMI≥ 25kg/m2)and28.8%wereobese(BMI≥ 30kg/m2).
Almostoneinsixofparticipants(17.3%)hadfastingplasmavenousglucose≥ 126mg/dlorHbA1c ≥ 6.5%orwere currently onmedication for raised blood glucose. This proportionincreasedwithage.
Oneinfourrespondents(24.7%)hadaraisedtotalcholesterollevel,withtheproportionofbeinghigher inwomen (28.5%) thanmen (20.9%).ThepercentageswithsuboptimalHDLcholesterolwere55.6%formen(< 40mg/dl)and49.1%forwomen(< 50mg/dl).
Meandailysaltintakewas9.9g,andmenconsumedmoresaltthanwomenonaverage(11.0gperdayversus8.7gperday).
Tosummarizeall therisk factors, thesurveyconsideredthecombinedrisk factorsasanintegratedriskmetric.Forexample,10.5%ofrespondentshadaten-yearCVDrisk≥ 30%oralreadyhadCVD.Lessthan2%didnothaveanyofthestatedriskfactors,while51.2%had3–5ofthem,and47.8%had1–2.Thefrequencyofhaving3–5riskfactorsincreasedwithageandthefrequencyofhavingfewerthanthreedecreasedwithage.
In addition to obtaining valuable information on NCD risk factors for people of differentagegroups,sexandregions,theresultsofthesurveyprovideasignificantinputforpolicy-makers.TheresultsobtainedinthestudyshowthecurrentprevalenceofNCDriskfactorsamongtheTurkishpopulation.RepeatedSTEPS-basedassessmentsofNCDriskfactorscanhelppolicy-makerstomonitortheprogressofNCDpolicyinTurkey.
94 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
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98 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 1
Supervisors Health professionals Data collectors
Istanbul region (İstanbul, Edirne, Kırklareli, Tekirdağ)
MrMehmetKaragöz
MsHaticeKaragöz
MsCemileKis
MsSemaÜngör
MrMehmetÇakar
MsÖzlemÇengel
MsMenekşeÇinel
MrEyüpSabriGenç
MrFurkanMaden
MrSerdarMurat
MsFatmaSelbi
MsNesrinTüysüz
MsEbrarAkyüz
MrEsatBekdemir
MrMehmetBilecen
MrBatuhanBerkKarasu
MrMuratKurt
MsEbruMaden
MrSerdarMurat
MsTuğbaYavuz
MrBurakYazgan
MrGürkanYüksel
Konya region (Konya, Karaman, Aksaray, Afyon)
MsPınarTuran
MrRızaTuran
MsDilekAydın
MrZiyaEmreBosnalı
MrAkifGezeroğlu
–
İzmir region (İzmir, Aydın, Denizli, Manisa, Muğla, Uşak)
MrHüseyinMertElik
MrMehmetKarasu
MrYasinAksoy
MsNurayÇelik
MsAşkınÇevirgen
MrTuranGörkemDoğan
MsNurNisaÖğük
MrFurkanÖzkan
MsHabibeSeyman
MsMuallaTuran
MrHüseyinMertElik
MsRojdaErat
MrOkanÖztürk
MsTuğçeŞivga
MrMertSolak
MsGizemYelizYücel
Trabzon region (Trabzon, Giresun, Rize, Bayburt, Gümüşhane, Artvin)
MsHülyaÖzdin
MsDilekTomar
MsElvanArmutçu
MsSemihaKöse
MrYetkinSamancı
MrVuralEmbiya
MrMehmetKeremSerin
MsBernaUsta
Samsun region (Samsun, Ordu, Sinop, Amasya, Bartın, Zonguldak, Kastamonu, Tokat)
MsMihriArzuKıyıcı MrZeydGüdül
MsEsraKalyoncu
MrAliKemalKul
MsNazliSarıoğlu
MrArdaCermen
MsDeryaCermen
MrTemelHakkıYazıcı
ANNEX 1. FIELD TEAMS BY REGION
99
Supervisors Health professionals Data collectors
Diyarbakır region (Diyarbakır, Batman, Bingöl, Bitlis, Elazığ, Mardin, Muş, Siirt, Tunceli, Van, Adıyaman, Gaziantep, Kahramanmaraş, Kilis, Malatya, Şanlıurfa)
–
MrMetinBişkin
MsDidemEr
MsDilanUğurlu
MrMesutAyberk
MsHavvaYüce
Erzurum region (Erzurum, Ağrı, Ardahan, Artvin, Bayburt, Erzincan, Kars, Iğdır)
–MrOnurKorkmaz
MrOğuzhanTurgut
MsNilayKalaycı
MrOnurTurgut
Adana region (Adana – excluding Anamur, Mersin)
MsNihalBilgin MsYeşimÇoşkun MrNiyaziBerk
MrAbdullahDemir
Antalya region (Antalya–including Anamur, Burdur, Isparta)
MrİbrahimAkkol MsCansuBulut
MsFidanTosun
MrİbrahimSarıkaş
Ankara region (Ankara, Afyon, Çankırı, Eskişehir, Kırıkkale)
MrTolgaÇomak
MsİlaydaUrvaylıoğlu
MrHüseyinAltun
MsEsraKüçükoğlu
MsNecmiyeSarıyıldız
MsMerveTemizyürek
MrSerkanAytaş
MsBüşraGüdek
MrMuratSarıyıldız
Hatay region (Hatay, Osmaniye)
MsSerapMiroğluKoçak MrOktayİnanç
MrFurkanMaden–
Bursa region (Bursa, Balıkesir, Bilecik, Bolu, Çanakkale, Karabük, Düzce, Kocaeli, Kütahya, Sakarya,Yalova)
MrGürcanŞenol
MrSerkanŞenol
MsDamlaBilir
MsHaticeDikmen
MrMuhammedÖzkan
MsAleynaSoytürk
MrMücahitYıldırım
MsSaadetAçık
MsNurcanDeleş
MsAyşegülDuran
MrTalhaSerkanKaragöz
MsElifŞenbiçer
Kayseri region (Kayseri, Çorum, Sivas, Tokat, Yozgat)
MrEmreYıldız MrAdemAltunbaş
MsGülerCeylan
MrMuzafferAliAteş
MsGamzeBoynueğri
MsSemaŞahin
100 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 2
TheWHOSTEPwiseapproachtosurveillance(STEPS)isasimple,standardizedmethodforcollecting,analysinganddisseminatingdataonnoncommunicablediseases(NCDs)andriskfactors.Dataarecollectedon theestablished risk factorsandconditions thatdeterminethemajorshareoftheNCDburden,including:tobaccouse,useofalcohol,unhealthydiet,insufficient physical activity, overweight and obesity, raised bloodpressure, raised bloodglucose and abnormal blood lipids. Countries can use data from STEPS surveys to helpmonitortheirprogressinmeetingtheglobalvoluntarytargetsrelatedtospecificriskfactorssuchastobacco,alcohol,dietandphysicalinactivity.
ASTEPSsurveyinTurkeywascarriedoutfromApriltoSeptember2017inthreesteps:
1. collectionofsociodemographicandbehaviouralinformation;
2. collectionofphysicalmeasurements,suchasheight,weightandbloodpressure;
3. collection of biochemicalmeasurements to assess bloodglucose, haemoglobinA1c orglycatedhaemoglobin(HbA1c),totalcholesterollevels,andmeandailysaltconsumption.
Thepopulation-based surveyof adults aged≥ 15 yearsusedamultistagecluster sampledesigntoproducerepresentativedataforthepopulationinthatagerangeinTurkey.Atotalof6053adultsparticipatedinthesurvey.Theoverallresponseratewas(70.0%).Arepeatsurveyisplannedfor2019toassesschanges.
Highlights
Tobacco use
● 43.6%ofmen,19.7%ofwomenand31.6%overallwerecurrenttobaccousers. ● 43.4%ofmen,19.7%ofwomenand31.5%overallwerecurrenttobaccosmokers. ● 3in10currentsmokershadtriedtoquitintheprevious12months.
Alcohol use
● 13.1%ofmen,3.0%ofwomenand8.0%overallwerecurrentalcoholusers. ● 1in20currentalcoholusersengagedinheavyepisodicdrinking.
Diet
● 87.8%ofmen,87.9%ofwomenand87.8%overallatefewerthanfiveservingsoffruitand/orvegetablesperday.
● meandailysaltconsumptionwas9.9goverall,11.0gformenand8.7gforwomen.
ANNEX 2. NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY – PREVALENCE OF NONCOMMUNICABLE DISEASE RISK FACTORS, 2017 FACT SHEET
101
Physical activity
● 4in10adultshadinsufficientphysicalactivity(< 150minutesofmoderateactivityperweek).
Cancer screening
● 5in10womenaged30–65yearshadeverhadacervicalsmeartest. ● 6in10womenaged40–69yearshadeverhadmammography. ● 1in10adultsaged50–70yearshadhadacolonoscopyintheprevious10years.
Obesity
● 62.8%ofmen,66.0%ofwomenand64.4%overallwereoverweight (bodymass index(BMI)≥ 25kg/m2).
● 21.6%ofmen,35.9%ofwomenand28.8%overallwereobese(BMI≥ 30kg/m2).
High blood pressure
● 26.1%ofmen,29.3%ofwomenand27.7%overallhadraisedbloodpressure.
High blood glucose
● 10.6%ofmen,11.5%ofwomenand11.1%overallhadraisedbloodglucose.
The following table gives the survey results for adults aged ≥ 15 years, including 95%confidenceinterval(Cl).Adultsrefertopersonsaged≥ 15years.ThedatawereweightedtoberepresentativeofallmenandwomeninthatagegroupinTurkey.
Topics Both sexes (95%CI)
Men (95%CI)
Women (95%CI)
Tobacco use
Respondentswhocurrentlyusedtobacco(smokedorsmokeless)(%)
31.6
(29.8–33.4)
43.6
(40.9–46.2)
19.7
(17.6–21.8)
Respondentswhocurrentlysmokedtobacco(%) 31.5
(29.7–33.3)
43.4
(40.8–46.0)
19.7
(17.6–21.8)
Respondentswhocurrentlysmokedtobaccodaily(%)
29.2
(27.5–31.0)
40.4
(37.8–43.0)
18.2
(16.1–20.3)
Dailysmokers
● Averageageofstartingsmoking(years)
18.1
(17.8–18.5)
17.2
(16.9–17.5)
20.2
(19.5–20.9)
● Useofmanufacturedcigarettes(%) 97.3
(96.3–98.3)
97.3
(96.1–98.5)
97.2
(95.4–99.0)
● Meannumberofmanufacturedcigarettessmokedperday(bysmokersofmanufacturedcigarettes)
15.5
(14.8–16.2)
16.8
(16.0–17.7)
12.7
(11.6–13.7)
102 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 2
Topics Both sexes (95%CI)
Men (95%CI)
Women (95%CI)
Respondentswhocurrentlyusedsmokelesstobacco(%)
0.3
(0.1–0.6)
0.6
(0.1–1.0)
0.1
(0.0–0.3)
Currentnon-usersofsmokedand/orsmokelesstobacco
● Formertobaccosmokers(%)10.7
(9.7–11.8)
14.8
(13.1–16.5)
6.6
(5.5–7.8)
● Neversmokers(%) 57.8
(55.9–59.7)
41.8
(39.0–44.5)
73.7
(71.4–75.9)
Currentsmokerswhohadtriedtoquitintheprevious12months(%)
27.4
(24.5–30.4)
29.4
(25.8–33.1)
23.0
(18.5–27.6)
Currentsmokersadvisedbyahealthcareprovidertostopsmokingintheprevious12months1(%)
22.3
(19.5–25.1)
21.2
(17.8–24.6)
24.7
(20.0–29.3)
Alcohol consumption
Lifetimeabstainers(%) 83.6
(82.1–85.1)
74.4
(72.0–76.8)
92.7
(91.3–94.1)
Abstainersfortheprevious12months(%) 4.3
(3.6–5.0)
6.5
(5.3–7.6)
2.1
(1.4–2.9)
Currentdrinkers(haddrunkalcoholintheprevious30days)(%)
8.0
(7.0–9.1)
13.1
(11.2–15.0)
3.0
(2.1–4.0)
Respondentsengaginginheavyepisodicdrinking(≥ 6drinksonanyoccasionintheprevious30days)(%)
5.2
(4.2–6.2)
8.7
(7.0–10.3)
1.8*
(1.0–2.6)
Diet
Fruitconsumption
● Meannumberofdaysinatypicalweek 4.6
(4.5–4.7)
4.5
(4.4–4.6)
4.8
(4.7–4.9)
● Meannumberofservingsonaverageperday 1.4
(1.3–1.5)
1.4
(1.3–1.5)
1.5
(1.3–1.6)
Vegetableconsumption
● Meannumberofdaysinatypicalweek 5.1
(5.0–5.2)
4.9
(4.8–5.1)
5.2
(5.1–5.3)
103
Topics Both sexes (95%CI)
Men (95%CI)
Women (95%CI)
● Meannumberofservingsonaverageperday 1.7
(1.5–1.8)
1.6
(1.4–1.8)
1.7
(1.6–1.9)
Respondentswhoate≤ 5servingsoffruitand/orvegetablesonaverageperday(%)
87.8
(86.4–89.3)
87.8
(85.8–89.8)
87.9
(86.3–89.5)
Respondentswhoalwaysoroftenaddedsaltorsaltysaucetotheirfoodbeforeorduringeating(%)
28.1
(26.3–29.9)
29.3
(26.7–31.9)
26.8
(24.6–29.0)
Respondentswhoalwaysoroftenateprocessedfoodshighinsalt(%)
25.5
(23.7–27.4)
27.8
(25.3–30.3)
23.3
(21.0–25.6)
Respondentsthinkingloweringsaltindietisveryimportant(%)
75.6
(73.7–77.6)
73.2
(70.0–76.0)
78.1
(75.9–80.3)
Physical activity
Respondentswithinsufficientphysicalactivity(< 150minutesofmoderate-intensityactivityperweek,orequivalent)2 (%)
43.6
(41.8–45.4)
33.1
(30.5–35.6)
53.9
(51.6–56.3)
Mediantimespentinphysicalactivityonaverageperday(presentedwithinterquartilerange)(minutes)
30.0
(4.3–90.0)
51.4
(11.4–180.0)
17.1
(0,0–55.0)
Respondentsnotengaginginvigorousactivity(%)
81.3
(79.7–82.8)
70.1
(67.5–72.6)
92.2
(90.8–93.6)
Cancer screening
Womenaged30–65yearswhohadeverhadacervicalsmeartest(%)
54.2
(51.2–57.1)
Womenaged40–69yearswhohadeverhadmammography(%)
57.4
(54.1–60.7)
Respondentsaged50–70yearswhohadeverhadafaecaloccultbloodtest
25.5 23.5 27.6
(22.8–28.2) (19.7–27.2) (24.0–31.3)
Respondentsaged50–70yearswhohadhadacolonoscopyintheprevious10years(%)
12.1 11.1 13.2
(10.1–14.2) (8.1–14.0) (10.4–16.0)
Physical measurements
MeanBMI(kg/m2) 27.4 26.6 28.3
(27.2–27.6) (26.3–26.8) (28.0–28.6)
Overweightrespondents(BMI≥ 25kg/m2)(%) 64.4 62.8 66.0
(62.6–66.2) (60.2–65.4) (63.7–68.4)
104 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 2
Topics Both sexes (95%CI)
Men (95%CI)
Women (95%CI)
Obeserespondents(BMI≥ 30kg/m2)(%) 28.8 21.6 35.9
(27.3–30.4) (19.5–23.8) (33.8–38.0)
Averagewaistcircumference(cm)_
91.3 87.9
(90.5–92.2) (87.1–88.8)
Averagehipcircumference(cm)_
98.7 102.5
(97.9–99.4) (101.8–103.2)
Meansystolicbloodpressure(SBP),includingthoseonmedicationforraisedbloodpressure(mmHg)
123.0 125.3 120.8
(122.1–123.8) (124.2–126.3) (119.7–121.8)
Meandiastolicbloodpressure(DBP),includingthoseonmedicationforraisedbloodpressure(mmHg)
78.4 78.2 78.7
(78.0–78.9) (77.6–78.8) (78.2–79.2)
Respondentswithraisedbloodpressure(SBP≥ 140and/orDBP≥ 90mmHg)orcurrentlyonmedicationforraisedbloodpressure
27.7 26.1 29.3
(26.0–29.4) (23.7–28.5) (27.2–31.5)
Respondentswithraisedbloodpressure(SBP≥ 140and/orDBP≥ 90mmHg)whowerenotonmedication(%)
57.1 64.7 50.5
(53.8–60.3) (60.3–69.1) (46.4–54.6)
Proportionofallhypertensivepeoplewithcontrolledbloodpressureinthepopulation(%)
23.8 18.5 28.4
(21.0-26.5) (15.2-21.7) (24.5-32.3)
Biochemical measurement
Meanfastingbloodglucose,includingthosecurrentlyonmedicationforraisedbloodglucose(mg/dl)
97.8 96.2 99.3
(95.6–99.9) (93.7–98.8) (96.0–102.5)
Respondentswithimpairedfastingglycaemia(plasmavenousvalue≥ 110mg/dland< 126mg/dl)
7.9 8.1 7.7
(6.3–9.5) (5.9–10.4) (5.5-10.0)
Respondentswithraisedfastingbloodglucose(plasmavenousvalue≥ 126mg/dl)orcurrentlyonmedicationfordiabetes
11.1
(9.4–12.8)
10.6
(8.3–13.0)
11.5
(9.1–13.9)
RespondentswithHbA1c≥ 6.5% 12.0 11.9 12.2
(10.5–13.6) (9.6–14.1) (10.1–14.4)
RespondentswithHbA1c≥ 6.5%orcurrentlyonmedicationfordiabetes(%)
13.3 12.7 13.8
(11.6–14.9) (10.4–15.1) (11.5–16.1)
Meantotalbloodcholesterol,includingthosecurrentlyonmedicationforraisedcholesterol(mg/dl)
161.2 154.9 167.3
(158.5–163.8) (151.4–158.5) (163.7–171.0)
Respondentswithraisedtotalcholesterol(≥ 190mg/dl)orcurrentlyonmedicationforraisedcholesterol(%)
24.7 20.9 28.5
(22.3–27.1) (17.6–24.1) (25.0–31.9)
105
Topics Both sexes (95%CI)
Men (95%CI)
Women (95%CI)
Respondentswithraisedtriglycerides(≥ 180mg/dl)(%)
16.7 19.9 13.6
(14.6–18.9) (16.4–23.4) (11.2–16.0)
RespondentswithsuboptimalHDLcholesterol(< 40mg/dlformenand< 50mg/dlforwomen)(%)
52.3 55.6 49.1
(49.4–55.3) (51.3–59.9) (45.1–53.1)
Meanintakeofsaltperday(g) 9.9 11.0 8.7
(9.7–10.1) (10.8–11.3) (8.5–8.8)
Risk of CVD
Respondentsaged40–69yearswithaten-yearCVDrisk≥ 30%orwithexistingCVD3(%)
10.5 13.3 7.8
(8.1–12.9) (9.2–17.4) (5.3–10.3)
Theproportionofeligiblepersonswhowerereceivingdrugtherapyandcounsellingtopreventheartattacksandstrokes(%)
55.9 55.1 57.0
(45.3–66.6) (39.6–70.7) (44.3–69.8)
Summary of combined risk factors: current daily smokers, fewer than 5 servings of fruits and vegetables per day, insufficient physical activity, overweight, raised blood pressure
Respondents(aged≥ 15)with0riskfactors(%) 1.3* 1.9* 0.8*
(0.7–2.0) (0.7–3.1) (0.4–1.2)
Respondents(%)with≥ 3riskfactors:
● aged18–44years 42.2 45.6 38.9
(39.4–44.9) (41.4–49.8) (35.6–42.3)
● aged45–69years 65.9 61.5 70.0
(63.2–68.6) (57.5–65.5) (66.5–73.5)
● aged18–69years 51.0 51.5 50.5
(48.9–53.0) (48.5–54.5) (47.8–53.1)
● aged≥ 15years 51.2 50.3 51.9
(49.3–53.0) (47.5–53.2) (49.5–54.4)
Lifestyle advice on selected NCD risk factors
Respondentswhohadreceivedcounsellingoreducationfromhealthworkerson≥ 1subjectsrelatedtohealthyliving(healthynutrition,weightreduction,smokingcessationorphysicalactivity)duringprevious12months(%)
40.5
(38.4–42.5)
38.1
(35.3–40.9)
42.9
(40.4–45.3)
Awareness of health harm from selected NCD risk factors
Adults(%)thatcanstate≥ 2negativehealtheffectsof:
● anyoftheselectedNCDriskfactors587.3 89.1 85.5
(85.9–88.6) (87.4–90.8) (83.8–87.1)
● smokingtobacco 76.2 77.0 75.5
(74.4–78.1) (74.3–79.6) (73.4–77.6)
106 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 2
Topics Both sexes (95%CI)
Men (95%CI)
Women (95%CI)
● high-saltdiet 71.6 72.3 71.0
(69.8–73.5) (69.8–74.9) (68.8–73.2)
● high-fatdiet 64.3 65.7 62.8
(62.2–66.3) (63.0–68.4) (60.3–65.4)
● lowconsumptionoffruitsand/orvegetables 33.2 32.8 33.6
(31.2–35.2) (30.1–35.6) (31.2–36.1)
● physicalinactivity 58.3
(56.2–60.5)
59.6
(56.7–62.4)
57.1
(54.5–59.8)
● alcoholuse 74.2 75.9 72.5
(72.3–76.1) (73.4–78.4) (70.3–74.7)
● substance abuse 73.4 75.5 71.4
(71.6–75.3) (73.1–77.9) (69.1–73.6)
1 Among those who visited a health care provider in the previous 12 months.
2 For complete definitions of insufficient physical activity, refer to the Global Physical Activity Questionnaire (GPAQ) analysis guide (Geneva: World Health Organization; 2018 (http://www.who.int/ncds/surveillance/steps/resources/GPAQ_Analysis_Guide.pdf?ua=1)) or theWHOglobal recommendationsonphysical activity forhealth (In:WorldHealthOrganization [website]. Geneva: World Health Organization; 2018 (http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/index.html).
3 A 10-years CVD risk ≥ 30% is defined according to age, sex, blood pressure, smoking status (current smokers OR those who quit smoking less than 1 year before the assessment), total cholesterol and diabetes (previously diagnosed or a fasting plasma glucose concentration >126 mg/dl).
4 NCD risk factors include tobacco smoking, high salt diet, high fat diet, less consumption of fruits and/or vegetables, physical inactivity, alcohol use and substance abuse.
* N < 50.
Foradditional information,pleasecontact:DrTokerErgüder([email protected]),NationalProfessional Officer, Noncommunicable Diseases and Life-course, WHO Country Office,Turkey.
FinancialsupportforthesurveywasprovidedbytheMinistryofHealthoftheRepublicofTurkey under the “Health Systems Strengthening and Support Project” loan agreementthatwassignedby theGovernmentof theRepublicofTurkeyand the InternationalBankforReconstructionandDevelopment(WorldBank).TechnicalassistanceforthesurveywasprovidedbyWHOtotheMinistryofHealthoftheRepublicofTurkeywithinthescopeoftheAgreementsignedon10November2016betweenWHOandtheGovernmentoftheRepublicofTurkey.
107
ANNEX 3. WHO STEPS INSTRUMENT FOR NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY: PREVALENCE OF NONCOMMUNICABLE DISEASE RISK FACTORS, 2017 (SURVEY INFORMATION QUESTIONNAIRE)Survey Information
Participant Identification Number └─┴─┴─┘└─┴─┴─┘└─┴─┴─┘
Location and Date Response Code
InterviewNumber(first4digitsclusterID,next2digitshouseholdranknumber,lastdigitisforsubstitutionnumber)
Enter information from list provided.
└─┴─┴─┴─┴─┴─┘
IX1
Provincename IX2
Townname IX3
Cluster/Centre/VillageID
EnterCluster,CentreorVillageIDfromlistprovided. └─┴─┴─┴─┴─┴─┘I1
Cluster/Centre/Villagename
EnterCluster,CentreorVillagenameasappropriate. └─┴─┴─┴─┴─┴─┘I2
InterviewerID(NameandSurname)
Enter interviewer’s identification.I3
Dateofcompletionoftheinstrument
Enter date when instrument actually completed. └─┴─┘ └─┴─┘ └─┴─┴─┴─┘
ddmmyear
I4
108 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
Consent, Interview Language and Name Response Code
Consenthasbeenreadandobtained
Select relevant response.
Yes 1I5
No 2 If NO, END
Timeofinterview
(24hourclock)
Enter time interview started.
└─┴─┘: └─┴─┘hrsmins
I7
FamilySurname
Enter family surname (reassure the participant on the confidential nature of this information and that this is only needed for follow up).
I8
FirstName
Enter first name of respondent (reassure the participant on the confidential nature of this information and that this is only needed for follow up).
I9
Contactcellphonenumberoftheparticipantwherepossible
Enter phone number (reassure the participant on the confidential nature of this information and that this is only needed for follow up).
I10
Contacthomephonenumberoftheparticipantwherepossible
Enter phone number (reassure the participant on the confidential nature of this information and that this is only needed for follow up).
IX4
Contactphonenumberoftheparticipant’srelativewherepossible
Enter phone number (reassure the participant on the confidential nature of this information and that this is only needed for follow up).
X5
109
Step 1 Demographic Information
CORE: Demographic Information
Question Response Code
Sex(Record Male / Female as observed)
Select Male / Female as observed.
Male1
Female2
└─┴─┘ └─┴─┘ └─┴─┴─┴─┘ If known, Go to C4
ddmmyear
C2
C1
Whatisyourdateofbirth?
Don’t Know 77 77 7777
Enter date of birth of participant. If unknown, select “don’t know”.
Interviewer Note: If age is told directly then birth date will be calculated and entered
Howoldareyou?
If the age is unknown, help participant estimate their age by interviewing them about their recollection of widely known major events.
Years└─┴─┘ C3
Intotal,howmanyyearshaveyouspentatschoolandinfull-timestudy(excludingpre-school)?
Enter total number of years of education (excluding pre-school and kindergarten).
Years└─┴─┘ C4
Whatisthehighest level of educationyouhavecompleted?
If a person attended a few months of the first year of secondary school but did not complete the year, select “primary school completed”. If a person only attended a few years of primary school, select “less than primary school”.
Select appropriate response.
The last completed school will be asked. if f a person has not completed a school then if he/she is illiterate or not will be asked
İlliterate 1
C5
Literate,butnotcompletedformalschool
2
Primaryschoolcompleted 3
Primary,secondaryorvocationalsecondaryschool
completed4
Highschoolorvocationalhighschoolcompleted
5
2or3yearcollegecompleted 6
4yearcollegeorfacultycompleted
7
Masterdegree(Including5or6yearfaculties)completed
8
PhDdegreecompleted 9
Whatisyourmarital status?
Select the appropriate response.
Single 1
C7
Married 2
Divorced 3
Widowed 4
110 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
Areyourparentsrelatives?
Select the appropriate response.
Yes 1CC1
No 2
Whichofthefollowingbestdescribesyourmainworkstatusoverthepast12months?
(USESHOWCARD)
The purpose of this question is to help answer other questions such as whether people in different kinds of occupations may be confronted with different risk factors.
Select appropriate response.
Governmentemployee
Non-governmentemployee
Self-employed
Non-paid
Student
Homemaker
Retired
Unemployed(abletowork)
Unemployed(unabletowork)
Refused
1
2
3
4
5
6
7
8
9
88
C8
Howmanypeopleliveinyourhouseholdincludingyou? Numberofpeople└─┴─┘ CC2
Howmanypeopleolderthan15years,includingyourself,liveinyourhousehold?
Enter the total number of people living in the household who are 15 years or older. Definition of 15 years and older will be indicated as years
Numberofpeople└─┴─┘ CC3
Howmanypeopleolderthan18years,includingyourself,liveinyourhousehold?
Enter the total number of people living in the household who are 18 years or older. Definition of 18 years and older will be indicated as years
Numberofpeople└─┴─┘ C9
Whatisthetotalaveragemonthlyincomeofyourhousehold,consideringthelastone-yearperiod?TurkishLira/month
Enter the average earnings of the household by month If refused to answer, skip to X7.
permonth└─┴─┴─┴─┴─┴─┴─┘Go to X7
C10
Refused88 C10d
Doyouhaveaccesstoanymeansofsocialsecurity?
Yes,SocialSecurityInstitution(GovernmentRetirement
Fund,Pensionfund)1
CC4Yes,GreenCard 2
Yes,PrivateInsurance 3
Other 4
No 5
Don’tknow 6
111
Health Status
Question Response Code
Whatdoyouthinkaboutofyourhealthstatusingeneral?
Read options
VeryGood 1
HS 1
Good 2
Average 3
Bad 4
VeryBad 5
Step 1 Behavioural Factors Affecting Health
Tobacco Use
NowIamgoingtoaskyousomequestionsabouttobaccouse.
Question Response Code
Doyoucurrentlysmokeanytobaccoproductssuchascigarettes,hand–rolledcigarettes,pipes,cigarsandwaterpipes/shisha?
(USESHOWCARD)
Ask the participant to think of any tobacco products he/she is smoking currently.
Yes 1
No2IfNo,gotoT8
T1
Doyoucurrentlysmoketobaccoproductsdaily?
This question is only for current smokers of tobacco products.
Yes 1
No 2T2
Howoldwereyouwhenyoufirst started smoking?
For current smokers only. Ask the participant to think of the time when he/she started to smoke any tobacco products.
Age(years)
Don’tknow77└─┴─┘ If Known, go to T5a/T5aw
T3
Doyourememberhowlongagoitwas?
(RECORD ONLY 1, NOT ALL 3)
Don’t know 77
If the participant doesn’t remember his/her age when smoking started, then record the time in years, months or weeks as appropriate.
InYears└─┴─┘ IfKnown,gotoT5a/T5aw T4a
ORinMonths└─┴─┘ If Known, go to T5a/T5aw T4b
ORinWeeks└─┴─┘ T4c
112 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
Onaverage,how manyofthefollowingproductsdoyousmokeeach day/week?
(IF LESS THAN DAILY, RECORD WEEKLY)
(RECORD FOR EACH TYPE, USE SHOWCARD)
Don’t Know 7777
For current smokers only. Specify zero if no products were used in each category instead of leaving categories blank.
Record daily consumption for daily smokers. If products are smoked less than daily by daily smokers, enter weekly consumption. Also enter weekly consumption for current, non-daily smokers.
VERIFY THIS IS # OF CIGARETTES, NOT PACKS
DAILY↓ WEEKLY↓Manufactured
cigarettes└─┴─┴─┴─┘└─┴─┴─┴─┘ T5a/T5aw
Hand-rolledcigarettes
└─┴─┴─┴─┘└─┴─┴─┴─┘ T5b/T5bw
Pipesfulloftobacco └─┴─┴─┴─┘└─┴─┴─┴─┘ T5c/T5cw
Cigars,cheroots,cigarillos
└─┴─┴─┴─┘└─┴─┴─┴─┘ T5d/T5dw
NumberofWaterpipe/Shisha
sessions└─┴─┴─┴─┘└─┴─┴─┴─┘ T5e/T5ew
Other└─┴─┴─┴─┘└─┴─┴─┴─┘
If Other, go to T5other, else go to T6 T5f/T5fw
Other(pleasespecify):
└─┴─┴─┴─┴─┴─┘T5other/
T5otherw
Ifyouareusingdailyorweeklywaterpipe(Shisha)howoldwereyouwhenyoufirststartedusing?
Age └─┴─┘ TX1
Duringthepast12months,haveyoutriedto stop smoking?
For current smokers only. Ask the participant to think of any quit attempt during the past 12 months.
Yes 1
No 2 T6
Duringanyvisittoadoctororotherhealthworkerinthepast12months,wereyouadvisedtoquitsmokingtobacco?
For current smokers only. Ask the participant to think of visits to a doctor or other health worker during the past 12 months. If no visit, select “no visit during the past 12 months”.
Yes1IfT2=Yes,gotoT12;ifT2=No,gotoT9
No2IfT2=Yes,gotoT12;ifT2=No,gotoT9
Novisitduringthepast12months
3IfT2=Yes,gotoT12;ifT2=No,gotoT9
T7
Inthepast,didyouever smokeanytobaccoproducts? (USE SHOWCARD)
Ask the participant to think of the time when he/she may have been smoking tobacco products.
Yes 1
No2IfNo,gotoT12T8
Inthepast,didyoueversmokedaily?
Ask the participant to think of the time when he/she may have been smoking tobacco products on a daily basis.
Yes1IfT1=Yes,gotoT12,elsegotoT10
No2IfT1=Yes,gotoT12,elsegotoT10T9
113
Howoldwereyouwhenyoustopped smoking?
Ask the participant to think of the time when he/she stopped smoking tobacco products.
Age(years)└─┴─┘ If Known, go to T12
Don’tKnow77T10
Howlong agodidyoustopsmoking?
(RECORD ONLY 1, NOT ALL 3)
Don’t Know 77
If the participant doesn’t remember his/her age when they stopped smoking, then record the time in weeks, months or years as appropriate.
Yearsago └─┴─┘ If Known, go to T12 T11a
ORMonthsago └─┴─┘ If Known, go to T12 T11b
ORWeeksago └─┴─┘ T11c
Whatwasthemostimportantreasonforquittingsmokingtobacco?
Inordertoprotectmyfamily1
TX2
Iwassick 2
Myfamily,friendswantedmetoquit
3
IwasaffectedbyPublicService
Announcements4
Iwasadvisedbyhealthpersonnel(doctors,
nurses,pharmacists,etc.)
5
Other 6
Doyoucurrently use anysmokeless tobaccoproductssuchas[snuff, chewing tobacco, betel]?
(USE SHOWCARD)
Ask the participant to think of any smokeless tobacco products that he/she is using currently.
Yes 1
T12No 2
Doyoucurrently use smokeless tobaccoproductsdaily?
For current users of smokeless tobacco products only.
Yes 1
T13No 2
Do you currently use electronic cigarette?Yes 1
TX3No 2
Duringthepast30days,didsomeonesmoke in your home?
The participant should only think about other people, not about him-/herself. Smokers should exclude themselves.
The question is asking about inside the participant’s home. This only includes fully enclosed areas of the home.
Yes
No
1
2T17
114 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
Duringthepast30days,didsomeonesmokeinclosedareas in your workplace(inthebuilding,inaworkareaoraspecificoffice)?
For those not working in a closed area, record “don’t work in a closed area”. Ask the participant to think of seeing somebody smoke or smelling the smoke in indoor areas at work during the past 30 days.
Yes 1
T18
No 2
Don’tworkinaclosedarea
3
Doyousupporttobaccocontrollawsimposingabanonsmokinginclosedplacesandpublicareassuchasrestaurants,cafes,coffeehousesandbars?
Yes 1
TX4No 2
Notsure/Don’tknow 3
Alcohol Consumption
Thenextquestionsaskabouttheconsumptionofalcohol.
Question Response Code
Haveyoueverconsumedanyalcoholsuchasbeer,wine,raki,vodka,ginorspirits?
(USE SHOWCARD OR SHOW EXAMPLES)
Ask the participant to think of any drinks that contain alcohol, with the exception of alcohol-based medication that is taken due to health reasons.
Yes
No
1
2 A1
Haveyouconsumedanyalcoholwithinthepast 12 months?
Ask the participant to think of any drinks that contain alcohol, with the exception of alcohol-based medication that is taken due to health reasons.
Even if the participant has only consumed a few sips of alcohol in the past 12 months, the response should be “Yes”.
Yes
No
1
2A2
Haveyouconsumedanyalcoholwithinthepast 30 days?
Select the appropriate response. Even if the participant has only consumed a few sips of alcohol in the past 30 days, the response should be “Yes”.
Yes
No
1
2 A5
Duringthepast30days,howmanytimesdidyouhave
six or morestandarddrinksinasingledrinkingoccasion?
Ask the participant to think of the past 30 days only, and to report the number of occasions when he/she had six or more standard drinks.
Numberoftimes
Don’tKnow77 └─┴─┘ A9
115
Addictive Drug (Substance) Consumption for example: cannabis and derivatives, volatiles (glue, bally, thinner), stimulants (ecstasy, energy drinks) heroin, cocaine
Thenextquestionsareabouttheconsumptionofaddictive(substance)andwillbeaskedonlytoobtaininformationforyourhealthstatus
Question Response Code
Haveyoueverusedaddictivedrugs(substances)otherthantobaccooralcohol?
Neverused 1
ADD1
Tried 2
Used,butquitonmyown 3
Used,butquitwithtreatment 4
Currentlyusing 5
Haveyoubeenaskedwhetheryouusedrugs(substances)byhealthworkersordoctorsatahealthcenterduringthelast12months
YesataFamilyHealthCenter 1
ADD2Yesatadifferenthealth
institution2
No 3
Duringthepast12monthsHaveyounoticedanyinformationaboutharmsofdrugs(substances)usethroughbrochures/posters,trainingbyprofessionals,informativemeetings,publicserviceannouncements
(detailedexplanationoninterviewerguidethatdrugs(substances)shouldbeotherthanalcoholortobacco)
Yes 1 ADD3
No 2
Haveyouheardabout“Alo191”Anti-SubstanceAbuseCounsellingandSupportLine?
Yes 1 ADD4
No 2
CORE: Diet
Thenextquestionsaskaboutthefruitsandvegetablesthatyouusuallyeat.Ihaveanutritioncardherethatshowsyousomeexamplesoflocalfruitsandvegetables.Eachpicturerepresentsthesizeofaserving.Asyouanswerthesequestionspleasethinkofatypicalweekinthelastyear.
Question Response Code
Inatypicalweek,onhowmanydaysdoyoueat fruit?
(USE SHOWCARD)
Ask the participant to think of any fruit on the showcard. A typical week means a “normal” week when the diet is not affected by cultural, religious, or other events. Ask the participant to not report an average over a period.
Numberofdays Don’tKnow77
└─┴─┘ IfZerodays,goto D3 D1
Howmanyservingsoffruitdoyoueatononeofthosedays?(USE SHOWCARD)
Ask the participant to think of one day he/she can recall easily. Refer to the showcard for serving sizes.
Numberofservings
Don’tKnow77└─┴─┘ D2
116 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
In a typical week, on how many days do you eat vegetables? (USE SHOWCARD)
Ask the participant to think of any vegetable on the showcard. A typical week means a “normal” week when the diet is not affected by cultural, religious, or other events. Ask the participant to not report an average over a period.
Numberofdays Don’tKnow77
└─┴─┘ IfZerodays,goto D5
D3
Howmany servingsofvegetablesdoyoueatononeofthosedays?(USE SHOWCARD)
Ask the participant to think of one day he/she can recall easily. Refer to the showcard for serving sizes.
Numberofservings
Don’tknow77└─┴─┘ D4
Howoftendo you consumesugar addedbeverages(fizzy or unfizzy) such as juice, fruit nectars,concentrated juice, fruitsyrupandsugaradded teaorcoffeeetc.?
Always 1
DX1
Often 2
Sometimes 3
Rarely 4
Never 5
Don’tknow 77
How often do you consume processed food high insugar?Byprocessedfoodhighinsugar,Imeanfoodsthathavebeenalteredfromtheirnaturalstate,suchascandies,sweets,jellybeans,hard/softcandies,allchocolatetypes(soldseparately,oradded;chocolatechips, creamy chocolate, chocolate drops etc.),desserts with sherbet or syrups; cake, pastry andcookieswithcreamorchocolatefillingorjelly.
Always 1
DX2
Often 2
Sometimes 3
Rarely 4
Never 5
Don’tknow 77
Dietary salt
Withthenextquestions,wewouldliketolearnmoreaboutsaltinyourdiet.Dietarysaltincludesordinarytablesalt,unrefinedsaltsuchasseasalt, iodizedsalt,saltystockcubesandpowders,andsaltysaucessuchassoyasauceorfishsauce(seeshowcard).Thefollowingquestionsareonaddingsalttothefoodrightbeforeyoueatit,onhowfoodispreparedinyourhome,oneatingprocessedfoodsthatarehighinsalt,andquestionsoncontrollingyoursaltintake.Pleaseanswerthequestionsevenifyouconsideryourselftoeatadietlowinsalt.Readthisopeningstatementoutloud.Don’tforgettousetheshowcardwhichwillhelptherespondentwhenansweringtothequestions.
Howoftendoyouadd salt or a salty sauce such as soya sauce toyourfoodrightbeforeyoueatitorasyouareeatingit?
(SELECT ONLY ONE)
(USE SHOWCARD)
Read out all the answer options. Use the showcard that shows
salt and salty sauces.
Always 1
D5
Often 2
Sometimes 3
Rarely 4
Never 5
Don’tknow 77
Howoftenissalt, salty seasoning, meaty bullions, premade mixes with high spice and salt content etc. or a salty sauce addedincookingorpreparingfoodsinyourhousehold?
Read out all the answer options. Select the appropriate response.
Always 1
D6
Often 2
Sometimes 3
Rarely 4
Never 5
Don’tknow 77
117
How often do you eat processed food high in salt? Byprocessed food high in salt, I mean foods that have beenaltered from their natural state, such as packaged saltysnacks, canned salty food including pickles and preserves,salty food prepared at a fast food restaurant, cheese,pastrami, fermented sausage, sausage, fermented carrotjuice andprocessedmeat (USE SHOWCARD) Read out all the answer options. Use the showcard that shows processed food high in salt.
Always 1
D7
Often 2
Sometimes 3
Rarely 4
Never 5
Don’tknow 77
How much salt or salty sauce doyouthinkyouconsume?
Read out all the answer options and select the appropriate response.
Fartoomuch 1
D8
Toomuch 2
Justtherightamount 3
Toolittle 4
Fartoolittle 5
Don’tknow 77
How important to you is lowering the salt in your dietconsideringyourhealthstatus?
Select the appropriate response.
Veryimportant 1
DX3
Somewhatimportant 2
Notatallimportant 3
Don’tknow 77
Doyoudoanyof the followingona regularbasis tocontrolyoursaltintake?
(RECORDFOREACH)
Limitconsumptionofprocessedfood
Lookatthesaltorsodiumcontentponthefoodlabels
Buylowsalt/sodiumalternatives
Usespeciesotherthansaltwhencooking
Avoideatingfoodpreparedoutsiteofahome
Dootherthingsspeciallytocontrolyoursaltintake
Other(pleasespecify)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
└─┴─┘└─┴─┘└─┴─┘
1
2
1
2
1
2
1
2
1
2
1(ifyesgotoD11other)
2
D11a
D11b
D11c
D11d
D113e
D11f
D11Other
118 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
Whattypeofoil or fat is most oftenusedformealpreparationinyourhousehold?
(USE SHOWCARD)
(SELECT ONLY ONE)
Select the appropriate response.
Oliveoil,nutoil 1
D12
Sunflowerseedoil,soyaoil,cornoil
2
Lard 3
Butter 4
Margarine 5
OtherIfOther,gotoD12other 6
Noneinparticular 7
Noneused 8
Don’tknow 77
Other └─┴─┘ D12other
Onaverage,howmanymealsperweekdoyoueatthatwerenot prepared at a home? By meal, I mean breakfast, lunchanddinner.Record the number of meals. Ask the participant to think of
meals those were not prepared at a home, including his/her own home, the home of other family members or friends.
Number └─┴─┘
D13Don’tknow 77
Howmanyglassesofwateryoudrinkperday?Number └─┴─┘
DX4Don’tknow 77
119
Physical Activity
NextIamgoingtoaskyouaboutthetimeyouspenddoingdifferenttypesofphysicalactivityinatypicalweek.Pleaseanswerthesequestionsevenifyoudonotconsideryourselftobeaphysicallyactiveperson.
Thinkfirstaboutthetimeyouspenddoingwork.Thinkofworkasthethingsthatyouhavetodosuchaspaidorunpaidwork,study/training,householdchores,harvesting food/crops,fishingorhunting for food,seekingemployment.[Insert other examples if needed]. Inansweringthefollowingquestions‘vigorous-intensityactivities’areactivitiesthatrequirehardphysicaleffortandcauselargeincreasesinbreathingorheartrate,‘moderate-intensityactivities’areactivitiesthatrequiremoderatephysicaleffortandcausesmallincreasesinbreathingorheartrate.
Read this opening statement out loud. It should not be omitted. The respondent will have to think first about the time he/she spends doing work (paid or unpaid work, household chores, harvesting food, fishing or hunting for food, seeking employment [Insert other examples if needed]), then about the time he/she travels from place to place, and finally about the time spent in vigorous as well as moderate physical activity during leisure time.
Remind the respondent when he/she answers the following questions that ‘vigorous-intensity activities’ are activities that require hard physical effort and cause large increases in breathing or heart rate, ‘moderate-intensity activities’ are activities that require moderate physical effort and cause small increases in breathing or heart rate. Don’t forget to use the showcard which will help the respondent when answering to the questions.
Question Response Code
Work
Doesyourworkinvolvevigorous-intensityactivitythatcauseslarge increases in breathing or heart rate like [carrying or lifting heavy loads, digging or construction work] foratleast10minutescontinuously?
[INSERT EXAMPLES] (USE SHOWCARD)
Ask the participant to think about vigorous-intensity activities at work only. Activities are regarded as vigorous intensity if they cause large increases in breathing and/or heart rate.
Yes 1
P1
No 2 If No, go to P 4
In a typical week, on how many days do you do vigorous-intensityactivitiesaspartofyourwork?
“Typical week” means a week when the participant is engaged in his/her usual activities. Valid responses range from 1-7.
Numberofdays └─┘ P2
How much time do you spend doing vigorous-intensityactivitiesatworkonatypicalday?
Ask the participant to think of a typical day he/she can recall easily in which he/she engaged in vigorous-intensity activities at work. The participant should only consider those activities undertaken continuously for 10 minutes or more. Probe very high responses (over 4 hrs) to verify.
Hours:minutes └─┴─┘: └─┴─┘hrsmins
P3 (a-b)
Does your work involve moderate-intensity activity thatcauses small increases in breathing or heart rate such asbriskwalking [or carrying light loads] forat least 10minutescontinuously?
[INSERT EXAMPLES] (USE SHOWCARD)
Ask the participant to think about moderate-intensity activities at work only. Activities are regarded as moderate intensity if they cause small increases in breathing and/or heart rate.
Yes 1
P4No 2 If No, go to P 7
120 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
In a typical week, on howmany days do you do moderate-intensityactivitiesaspartofyourwork?
“Typical week” means a week when the participant is engaged in his/her usual activities. Valid responses range from 1-7.
Numberofdays └─┘ P5
How much time do you spend doing moderate-intensityactivitiesatworkonatypicalday?
Ask the participant to think of a typical day he/she can recall easily in which he/she engaged in moderate-intensity activities at work. The participant should only consider those activities undertaken continuously for 10 minutes or more. Probe very high responses (over 4 hrs) to verify.
Hours:minutes └─┴─┘: └─┴─┘hrsmins
P6 (a-b)
Travel to and from places
Thenextquestionsexcludethephysicalactivitiesatworkthatyouhavealreadymentioned.
NowIwouldliketoaskyouabouttheusualwayyoutraveltoandfromplaces.Forexampletowork,forshopping,tomarket,toplaceofworship. [Insert other examples if needed]
The introductory statement to the following questions on transport-related physical activity is very important. It asks and helps the participant to now think about how they travel around getting from place-to-place. This statement should not be omitted.
Doyouwalkoruseabicycle(pedal cycle)foratleast10minutescontinuouslytogettoandfromplaces?
Select the appropriate response.
Yes 1
P7No 2 If No, go to P 10
Inatypicalweek,onhowmanydaysdoyouwalkorbicycleforatleast10minutescontinuouslytogettoandfromplaces?
“Typical week” means a week when the participant is engaged in his/her usual activities. Valid responses range from 1-7.
Numberofdays └─┘ P8
Howmuchtimedoyouspendwalkingorbicyclingfortravelonatypicalday?
Ask the participant to think of a typical day he/she can recall easily in which he/she engaged in transport-related activities. The participant should only consider those activities undertaken continuously for 10 minutes or more. Probe very high responses (over 4 hrs) to verify.
Hours:minutes└─┴─┘:└─┴─┘hrsmins
P9 (a-b)
Recreational activities
Thenextquestionsexcludetheworkandtransportactivitiesthatyouhavealreadymentioned.
NowIwouldliketoaskyouaboutsports,fitnessandrecreationalactivities(leisure) [Insert relevant terms].
This introductory statement directs the participant to think about recreational activities. This can also be called discretionary or leisure time. It includes sports and exercise but is not limited to participation in competitions. Activities reported should be done regularly and not just occasionally. It is important to focus on only recreational activities and not to include any activities already mentioned. This statement should not be omitted.
121
Doyoudoanyvigorous-intensitysports,fitnessorrecreational(leisure) activities that cause large increases in breathingorheartrate like[running or football] forat least10minutescontinuously?
[INSERT EXAMPLES] (USE SHOWCARD)
Ask the participant to think about recreational vigorous-intensity activities only. Activities are regarded as vigorous intensity if they cause large increases in breathing and/or heart rate.
Yes 1
No 2 If No, go to P 13
P10
In a typical week, on how many days do you do vigorous-intensitysports,fitnessorrecreational(leisure)activities?
“Typical week” means a week when the participant is engaged in his/her usual activities. Valid responses range from 1-7.
Numberofdays└─┘ P11
Howmuchtimedoyouspenddoingvigorous-intensitysports,fitnessorrecreationalactivitiesonatypicalday?
Ask the participant to think of a typical day he/she can recall easily in which he/she engaged in recreational vigorous-intensity activities. The participant should only consider those activities undertaken continuously for 10 minutes or more. Probe very high responses (over 4 hrs) to verify.
Hours:minutes└─┴─┘:└─┴─┘hrsmins
P12
(a-b)
Do you do any moderate-intensity sports, fitness orrecreational (leisure) activities that cause a small increasein breathing or heart rate such as brisk walking, [cycling, swimming, and volleyball] foratleast10minutescontinuously?
[INSERT EXAMPLES] (USE SHOWCARD)
Ask the participant to think about recreational moderate-intensity activities only. Activities are regarded as moderate intensity if they cause small increases in breathing and/or heart rate.
Yes 1
No 2 If No, go to P 16
P13
In a typical week, on howmany days do you do moderate-intensitysports,fitnessorrecreational(leisure)activities?
“Typical week” means a week when the participant is engaged in his/her usual activities. Valid responses range from 1-7.
Numberofdays└─┘P14
Howmuchtimedoyouspenddoingmoderate-intensitysports,fitnessorrecreational (leisure) activitiesonatypicalday?
Ask the participant to think of a typical day he/she can recall easily in which he/she engaged in recreational moderate-intensity activities. The participant should only consider those activities undertaken continuously for 10 minutes or more. Probe very high responses (over 4 hrs) to verify.
Hours:minutes└─┴─┘:└─┴─┘hrsmins
P15 (a-b)
Sedentary behaviour
Thefollowingquestionisaboutsittingorrecliningatwork,athome,gettingtoandfromplaces,orwithfriendsincludingtimespentsittingatadesk,sittingwithfriends,travelingincar,bus,train,reading,playingcardsorwatchingtelevision,butdonotincludetimespentsleeping.
(USE SHOWCARD)
122 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
Howmuch time do you usually spend sitting or reclining onatypicalday?Ask the participant to consider total time spent sitting at work, in an office, reading, watching television, using a computer, doing hand craft like knitting, resting etc. The participant should not include time spent sleeping.
Hours:minutes└─┴─┘:└─┴─┘hrsmins
P16
(a-b)
History of Raised Blood Pressure
Question Response Code
Haveyoueverhadyourbloodpressuremeasuredbyadoctororotherhealthworker?
Ask the participant to only consider measurements done by a doctor or other health worker.
Yes 1
No 2 If No, go to H6H1
Haveyoueverbeentoldbyadoctororotherhealthworkerthatyouhaveraisedbloodpressureorhypertension?
Select the appropriate response.
Yes 1
No 2 If No, go to H6H2a
Haveyoubeentoldinthepast12months?
Only for those that have previously been diagnosed with raised blood pressure.
Yes 1
No 2 H2b
Inthepasttwoweeks,haveyoutakenanydrugs(medication)for raised blood pressure prescribed by a doctor or otherhealthworker?
Ask the participant to only consider drugs for raised blood pressure prescribed by a doctor or other health worker.
Yes 1
No 2H3
Whichofthefollowingdoyoucurrentlydoformanagingyourhypertension?
(select one or more)?
Regularmedication1
Irregularmedication2
Herbalmedication3
Physicalactivity4
Diet 5
Nothing6
Other7
HX1
History of Diabetes
Question Response Code
Haveyoueverhadyourbloodsugarmeasuredbyadoctororotherhealthworker?
Ask the participant to only consider measurements done by a doctor or other health worker.
Yes 1
No 2 If No, go to H12H6
Haveyoueverbeentoldbyadoctororotherhealthworkerthatyouhaveraisedbloodsugarordiabetes?
Select the appropriate response.
Yes 1
No 2 If No, go to H12H7a
Haveyoubeentoldinthepast12months?
Only for those that have previously been diagnosed with diabetes.
Yes 1
No 2 H7b
123
Whatisyourdiabetestype?
Type11
Type22
Other(gestational,etc.)3
Don’tknow4
HX2
Inthepasttwoweeks,haveyoutakenanydrugs(medication)fordiabetesprescribedbyadoctororotherhealthworker?
Ask the participant to only consider drugs for diabetes prescribed by a doctor or other health worker.
Yes 1
No 2 H8
Areyoucurrentlytakinginsulinfordiabetesprescribedbyadoctororotherhealthworker?
Ask the participant to only consider insulin that was prescribed by a doctor or other health worker.
Yes 1
No 2 H9
Whichofthefollowingcurrentlydoyoudoformanagingyourdiabetes?
(select one or more)
Regularmedication1
Irregularmedication2
Herbalmedication3
Physicalactivity4
Diet 5
Nothing6
Other7
HX3
WhatistheresultofyourlatestHbA1ctestdoneinthelast3months?
Notmeasured1
Lessthan6%2
Between6-8%3
Between8-10%4
10%andabove5
Measuredbutdonot6remember
HX4
History of Raised Total Cholesterol
Questions Response Code
Haveyoueverhadyourcholesterol (fat levels in yourblood)measuredbyadoctororotherhealthworker?
Ask the participant to only consider measurements done by a doctor or other health worker.
Yes 1
No 2 If No, go to H17H12
Haveyoueverbeentoldbyadoctororotherhealthworkerthatyouhaveraisedcholesterol?
Select the appropriate response.
Yes 1
No 2 If No, go to H17H13a
Haveyoubeentoldinthepast12months?
Only for those that have previously been diagnosed with raised total cholesterol.
Yes 1
No 2 H13b
124 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
In the past two weeks, have you taken any oral treatment(medication)forraisedtotalcholesterolprescribedbyadoctororotherhealthworker?
Ask the participant to only consider drugs for raised total cholesterol prescribed by a doctor or other health worker.
Yes 1
No 2 H14
Whichofthefollowingdoyoucurrentlydoformanagingyourhighcholesterol?
(select one or more)
Regularmedication1
Irregularmedication2
Herbalmedication3
Physicalactivity4
Diet 5
Nothing6
Other7
HX5
History of Cardiovascular Diseases
Question Response Code
Have you ever had a heart attack or chest pain from heartdisease (angina) or a stroke (cerebrovascular accident orincident)?
Select the appropriate response.
Yes 1
No2SkiptoH18H17
Atwhatagedidyoufirsthavetheheartattackorchestpainfrom heart disease (angina) or a stroke (cerebrovasculardisease)?
Years]---------- HX6
Areyoucurrently takingaspirin regularly topreventor treatheartdisease?
“Regularly” means on a daily or almost daily basis.
Yes 1
No 2 H18
Are you currently taking statins (Lovastatin/Simvastatin/Atorvastatinoranyotherstatin)regularlytopreventortreatheartdisease?
“Regularly” means on a daily or almost daily basis.
Yes 1
No 2 H19
125
Family History of Chronic Diseases
Question Response Code
Doanyofyourparentsorsiblingshavea known diagnosed chronic diseasethatrequiresmedication?
Yes 1
FH1No
2 SKIP to next section
Doyourparentsorsiblingshavewhichof thediagnosedchronicdisease thatrequiresmedication?
(checkalltheapply)
Type2Diabetes
Hypertension
Hypercholesterolemia
heartattack
chestpainfromheartdisease(angina)
stroke(cerebrovascularaccidentorincident)
Cancer
Other(pleasespecify)
No
1
2
3
4
5
6
7
8
9
FH2
Doanyofyourparentsorsiblingshaveexperiencedanyheartattackorchestpainfromheartdisease(angina)beforetheageforman55andforwoman65?
Yes 1
FH3No 2
Asthma, Chronic Obstructive Pulmonary Disease (COPD), Cancer History
Code Response Code
Haveyoubeendiagnosedwithasthma(includingallergicasthma)byadoctor?
Yes 1CD1
No 2
HaveyoubeendiagnosedwithChronicObstructivePulmonaryDisease(COPD/emphysema/chronic bronchitis by adoctor)?
Yes 1
CD2No 2
In the past 12months, have you beendiagnosedwithanytypeofcancer?
Yes 1CD3
No 2skiptonextsection
Couldyoupleasespecifywhichkindofcancerhaveyoubeendiagnosedwith?
SpecifythenameofthecancerCD4
CORE: Lifestyle Advice
Questions Response Code
Howdoyoufeelaboutyourweight?
Thin(lowweight)
Normalweight
Overweight
Obese
Morbidobese
1
2
3
4
5
BW1
126 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
Duringthepasttwelvemonths,hasadoctororotherhealthworkeradvisedyoutodoanyofthefollowingspecificforyourhealthcondition?
(RECORDFOREACH)
Selecttheappropriateresponse.Asktheparticipanttoonlyconsideradvicefromadoctororotherhealthworker.
Quitusingtobaccoordon’tstartYes 1
H20aNo 2
Reducesaltinyourdiet Yes 1H20b
No 2
Eatatleastfiveservingsoffruitand/orvegetableseachday
Yes 1H20c
No 2
ReducefatinyourdietYes 1
H20dNo 2
StartordomorephysicalactivityYes 1
H20eNo 2
Maintainahealthybodyweightorloseweight
Yes 1H20f
No 2
Adverse Effects of Risk Factors on Health
Notefortheinterviewer:oneormoreoptionscanbeselected
Questions Response Code
Basedonwhatyouknoworbelieve,smokingtobaccocauseswhichthefollowinghealthproblems
Morethanoneresponsepossible
Lungdisease
Cancer
Heartattack
Stroke
Highbloodpressure
None
Don’tknow/Havenoidea
1
2
3
4
5
6
77
RF1
Basedonwhatyouknoworbelieve,usingtoomuchsaltorsaltysauces/tomatopasteinyourdietcauseswhichofthefollowinghealthproblems
Hypertension
Heartattack
Renaldisease
Stroke
Stomachcancer
None
Don’tknow/Havenoidea
1
2
3
4
5
6
77
RF2
Basedonwhatyouknoworbelieve,doesconsuminglessfruitsorvegetablescausewhichofthefollowinghealthproblem?
Heartattack
Stroke
Cancer
Diabetes
None
Don’tknow/Havenoidea
1
2
3
4
5
77
RF3
127
Basedonwhatyouknoworbelieve,beingphysicallyinactivecauseswhichofthefollowinghealthproblem?
Heartattack
Stroke
Cancer
Diabetes
None
Don’tknow/Havenoidea
1
2
3
4
5
77
RF4
Basedonwhatyouknoworbelieveconsumingtoomuchfatcauseswhichofthefollowinghealthproblem?
Heartattack
Stroke
Cancer
Diabetes
None
Don’tknow/Havenoidea
1
2
3
4
5
77
RF5
Basedonwhatyouknoworbelievealcoholconsumptioncauseswhichofthefollowinghealthproblem?
Heartattack
Stroke
Cancer
Livercirrhosis
Psychologicaldamageandaddiction
No
Don’tknow/Havenoidea
1
2
3
4
5
6
77
RF6
Basedonwhatyouknoworbelieveaddictivedrugs(substances)consumptioncauseswhichofthefollowinghealthproblem?
Liverfailure
Braindamage
Psychiatricdiseases(depression,schizophreniaetc.)
Sexualimpotence
None
Don’tknow/Havenoidea
1
2
3
4
5
77
RF7
Cancer Screening Tests
Question Response Code
HaveyouheardthattheCancerScreeningsareavailableforfreeinFamilyHealthCentersandCancerEarlyDiagnosisScreeningandTrainingCenters(KETEM)?
Yes
No
1
2CA1
Whenyouwerelasttestedforguaiacfaecaloccultbloodtest?
Notefortheinterviewer:Foragesbetween50-70
Inthelast12months
Morethan1,lessthan2yearsago
Morethan2,lessthan5yearsago
Morethan5yearsago
Never
1
2
3
4
5
CA2
HaveyouhadacolonoscopyInthelast10years?
Yes
No
1
2CA3
128 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
Whendidyoulasthaveamammogram?
Notefortheinterviewer:X-raysofbreasts,Forfemalesagedbetween40-69
Inthelast12months
Morethan1,lessthan2yearsago
Morethan2,lessthan5yearsago
Morethan5yearsago
Never
1
2
3
4
5
CA4
Whendidyoulasthaveacervicalsmeartest?
Notefortheinterviewer:Forfemalesagedbetween30-65)
Inthelast12months
Morethan1,lessthan3yearsago
Morethan3,lessthan5yearsago
Morethan5yearsago
Never
1
2
3
4
5
CA5
Accidents and Injuries
Question Response Code
Inthelast12month,wereyouinjuredasaresultofanaccident?
Yes
No
Don’tknow
Refused
1
2 If No, go to TRT1
77 If don’t know, go to TRT1
88 If Refused, go to TRT1
AC1
Pleaseindicatewhichofthefollowingwasthecauseofthisinjury.
Notefortheinterviewer:IncludingpoisoningandinjuriescausedbyanimalorinsectbitesExcludingtheinjuriesstemmingfromothers’deliberateactions
Traffic
Household
Occupational-work
Other(pleasespecify)
1
2
3
4
AC2
Ifyouhadanyaccidentdidyouneedmedicalcare?
Notefortheinterviewer:Iftherearemorethanoneoccurrencesinthetypeconsidered,thequestioncoversthemostseriousone(seriousinjuriesthatrequireseriousmedicalattention).
Yes,anambulatorycare
Yes,inpatienttreatment
No,didnotneedmedicalhelp
1
2
3
AC3
129
Ambulatory or Inpatient CareNotefortheinterviewer:TheinterventionsinscopeofOne-DayTreatmentaretreatmentslastinglessthan24hourswithouthavinginpatientanddischargeprocedures.Theseinterventionsarechemotherapytreatment;radiotherapytreatment;alldiagnosticandoperational treatmentsdonebygeneraland localanesthesia, intravenousor inhalationsedation;capsuleendoscopy;dialysistreatments;intravenousinfusionofblood,bloodproductofmedicationetc.(MinistryofHealth,MedicalEnforcementDeclaration)
ThisquestionshouldonlybeaskedoftheparticipantswhohavesaidyestoH2a,H7a,H13a,H17,CD1,CD2,CD3.
Question Response Code
Inthepast12months,didyouvisitahospitalforyourtreatmentofhypertension,cardiovasculardisease,stroke,diabetes,cancer,chronicobstructiverespiratorydiseaseorasthma?
Yes
No
1
2skiptonextsectionTRT1
Whatkindoftreatmentdidyouhave?
Notefortheinterviewer:oneormoreoptionscanbeselected
anambulatorycare
acarelastinglessthan24hours
acarelastinglongerthan24hours
1
2
3
TRT2
Ambulatory Diagnosis, Treatment and Home Care The following questionswill be asked to you for hypertension, cardiovascular disease, stroke, diabetes, cancer, chronicobstructiverespiratorydiseaseorasthma
Note to interviewer: Home care is examination, tests, analysis, treatment, medical care, monitoring and rehabilitationservicesincludingsocialandpsychologicalcounsellingservicesathomeinfamilyenvironmentprovidedtoindividualswhoneedhomecareduetovariousdiseases(MinistryofHealthofferedhomeApplicationProceduresandPrinciplesonHealthServicesDirective)
Question Response Code
When did you last go to the dentist foryourself (apart from accompanying yourchildrenorrelatives)?
Withinthelastonemonth
Lessthan6monthsago
Morethan6,lessthan12monthsago
12monthsormoretimeago
Never
1
2
3
4
5
ACH1
When did you last visit a generalpractitioner or your family doctor, foryourself?
Withinthelastonemonth
Lessthan6monthsago
Morethan6,lessthan12monthsago
12monthsmoretimeago
Never
1
2
3
4
5
ACH2
Inthelast4weeks,howmanytimeshaveyou visited a general practitioner or yourfamilydoctor,foryourself?
└─┴─┘ times ACH3
130 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
When did you last visit a specialistphysicianforyourself?
Withinthelastonemonth
Lessthan6monthsago
Morethan6,lessthan12monthsago
12monthsagoormore
Never
1
2
3
4
5
ACH4
Inthelast4weeks,howmanytimeshaveyou visited a specialist physician foryourself?
└─┴─┘ times ACH5
Have you visited any health personnelotherthanmedicaldoctorsforyourselfinthelast4weeks?
Yes
No
1
2ACH6
Whichofthefollowinghealthpersonnelotherthanmedicaldoctorshaveyouvisitedforyourselfwithinthelast4weeks?
Physicaltherapist
Psychologist
Dietician
Other
1
2
3
4 ifotherthengotoACH7other
ACH7
Other(pleasespecify) └─┴─┴─┴─┴─┘ ACH7other
Haveyoureceivedmedicalcareathomeoverthelast12months?
Yes
No
1
2ACH8
Step 2 Physical Measurements
Blood PressureInterviewerID
Record interviewer ID (in most cases interviewer would be the same as for behavioural measurements).
└─┴─┴─┘ M1
DeviceIDforbloodpressure
Record device ID.└─┴─┘ M2
Cuffsizeused
Select cuff size used.
Small
Medium
Large
1
2
3
M3
Reading1
Record first measurement after the participant has rested for 15 minutes. Wait 3 minutes before taking second measurement.
Systolic(mmHg) └─┴─┴─┘ M4a
Diastolic(mmHg) └─┴─┴─┘M4b
Reading2
Record second measurement. Ask the participant to rest for another 3 minutes before taking the third measurement.
Systolic(mmHg) └─┴─┴─┘ M5a
Diastolic(mmHg)
└─┴─┴─┘
M5b
Reading3
Record third measurement.
Systolic(mmHg) └─┴─┴─┘ M6a
Diastolic(mmHg) └─┴─┴─┘ M6b
131
Duringthepasttwoweeks,haveyoubeentreatedforraisedbloodpressurewithdrugs(medication)prescribedbyadoctororotherhealthworker?
Select appropriate response.
Yes
No
1
2M7
Height and Weight
Question Response Code
For women: Areyoupregnant?
Pregnant women skip over height, weight, waist and hip measurements.
Yes
No
1 If Yes, go to M16
2 M8
InterviewerID
Record interviewer ID (in most cases interviewer would be the same as for behavioural and blood pressure measurements).
└─┴─┴─┘ M9
DeviceIDsforheightandweight
Record device IDs.Height
Weight
└─┴─┘
└─┴─┘
M10a
M10b
Height
Record participant’s height in cm with one decimal point.
inCentimetres(cm) └─┴─┴─┘. └─┘ M11
Weight
If too large for scale 666.6
Record participant’s weight in kg with one decimal point.
inKilograms(kg) └─┴─┴─┘.└─┘ M12
WaistDeviceIDforwaist
Record device ID.└─┴─┘ M13
Waistcircumference
Record participant’s waist circumference in centimetres with one decimal point.
inCentimetres(cm) └─┴─┴─┘.└─┘ M14
Hip Circumference and Heart RateHipcircumference
Record participant’s hip circumference in centimetres with one decimal point.
inCentimeters(cm) └─┴─┴─┘.└─┘ M15
HeartRateRecord the three heart rate readings.M16a
Reading1 Beatsperminute └─┴─┴─┘
Reading2 Beatsperminute └─┴─┴─┘ M16b
Reading3 Beatsperminute └─┴─┴─┘ M16c
132 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
ANNEX 3
Step 3 Biochemical Measurements
Blood Glucose
Question Response Code
Duringthepast12hourshaveyouhadanythingtoeatordrink,otherthanwater?
It is essential that the participant has fasted.
Yes
No
1
2B1
TechnicianID
Record ID of the person taking the measurement.
└─┴─┴─┘ B2
Device ID
Record device ID.└─┴─┘ B3
Timeofdaybloodspecimentaken(24hourclock)
Enter time measurement started.
Hours:minutes └─┴─┘: └─┴─┘hrsmins B4
Fastingbloodglucose
Double check that the participant has fasted.
mg/dl └─┴─┴─┘.└─┘ B5
Today,haveyoutakeninsulinorotherdrugs(medication)thathavebeenprescribedbyadoctororotherhealthworkerforraisedbloodglucose?
Select appropriate response.
Yes
No
1
2B6
Blood LipidsDevice ID
Record device ID.└─┴─┘ B7
Totalcholesterol
Record value for total cholesterol.mg/dl └─┴─┴─┘.└─┘ B8
Duringthepasttwoweeks,haveyoubeentreatedforraisedcholesterolwithdrugs(medication)prescribedbyadoctororotherhealthworker?
Select appropriate response.
Yes
No
1
2B9
Triglycerides and HDL CholesterolTriglycerides
Record value for triglycerides.mg/dl └─┴─┴─┘.└─┘
B16
HDLCholesterol
Record value for HDL cholesterol.mg/dl └─┴─┴─┘.└─┘
B17
HbA1C
Record value for HbA1Cmmol/mol └─┴─┘.└─┴─┘
B18
133
Urinary sodium and creatinineHadyoubeenfastingpriortotheurinecollection?
It is required that the urine collection should be made while fasting in the morning and after the first urinating
Yes
No
1
2B10
TechnicianID
Record technician ID.└─┴─┴─┘ B11
Device ID
Record device ID. └─┴─┘B12
Timeofdayurinesampletaken(24hourclock)
Record time of day urine sample taken as reported by the participant.
Hours:minutes └─┴─┘: └─┴─┘hrsmins B13
Urinarysodium
Record value for urinary sodium.mmol/l └─┴─┴─┘.└─┘ B14
Urinarycreatinine
Record value for urinary creatinine.mmol/l └─┴─┘. └─┴─┘ B15
134 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
NOTES
135
136 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
NOTES
137
138 National Household Health Survey in Turkey: Prevalence of Noncommunicable Disease Risk Factors, 2017
NOTES
NATIONAL HOUSEHOLD HEALTH SURVEY IN TURKEY PREVALENCE OF NONCOMM
UNICABLE DISEASE RISK FACTORS, 2017
NATIONALHOUSEHOLD HEALTHSURVEY IN TURKEYPREVALENCE OF NONCOMMUNICABLEDISEASE RISK FACTORS2017
Republic of TurkeyMinistry of Health
World Health Organization Regional Office for EuropeUN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark
Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01Email: [email protected]
Website: www.euro.who.int
The WHO Regional Office for EuropeThe World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves.
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