Behavioural Risk Factors of Non-Communicable Diseases Among Adult Women in Kathmandu

TABLE OF CONTENT

ABSTRACT

ACKNOWLEDGEMENT

LIST OF TABLES AND FIGURES

CHAPTER I: INTRODUCTION
1.1. Background of the Study
1.2. Need for the Study
1.3. Objectives of the Study
1.4. Significance of the Study
1.5. Conceptual Framework
1.6. Hypothesis/ Research questions
1.7. Operational Definitions
1.8. Delimitation

CHAPTER II: REVIEW OF LITERATURE
2.1. Introduction
2.2. Review of Literature
2.3. Summary of Reviewed Literature

CHAPTER III: METHODOLOGY
3.1. Research Design
3.2. Research Setting and Population
3.3. Sampling
3.4. Instrumentation
3.5. Data Collection Procedure
3.6. Ethical Considerations
3.7. Data Analysis Procedure

CHAPTER IV: FINDINGS OF THE STUDY

CHAPTER V: DISCUSSION, CONCLUSION AND
3.1. Discussion
3.2. Conclusion
3.3. Limitations
3.4. Implications
3.5. Recommendations for Further Study

REFERENCES

APPENDICES
Appendix A: Consent Form (English Version)
Appendix B: Consent Form (Nepali Version)
Appendix C: Research Instrument (English Version)
Appendix D: Research Instrument (Nepali Version)
Appendix E: Categorization of Physical Activity, BMI, Hypertension,
Fruit and Vegetable serving and Alcohol drink

LIST OF TABLES AND FIGURES

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LIST OF FIGURES

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ABSTRACT

Non Communicable Diseases are the leading cause of death worldwide causing nearly Abbildung in dieser Leseprobe nicht enthalten80% of death in low and middle-income countries. World Health Organization has Abbildung in dieser Leseprobe nicht enthaltenidentified certain risk factors that are associated with an increase in the occurrence of Abbildung in dieser Leseprobe nicht enthaltenNon Communicable Diseases they are Physical inactivity, tobacco use, alcohol use Abbildung in dieser Leseprobe nicht enthaltenand unhealthy diets.

A cross sectional descriptive research design was used to assess the status of Abbildung in dieser Leseprobe nicht enthaltenbehavioural risk factors regarding Non communicable Diseases among the adult Abbildung in dieser Leseprobe nicht enthaltenwomen of Gothatar Village Development Committee, Kathmandu. A total of 156 Abbildung in dieser Leseprobe nicht enthaltenwomen were taken by using cluster random sampling technique. A semi-structured Abbildung in dieser Leseprobe nicht enthaltenquestionnaire developed on the basis of Non Communicable Diseases Risk Factors: Abbildung in dieser Leseprobe nicht enthaltenSTEPS Survey Nepal 2013 was used and face to face interview was done to collect Abbildung in dieser Leseprobe nicht enthaltenthe data. The analysis was done by using descriptive statistics (frequency, percentage, Abbildung in dieser Leseprobe nicht enthaltenmean, standard deviation) and inferential statistics (Chi Square test, Fisher's exact test Abbildung in dieser Leseprobe nicht enthaltenand Odds ratio).

The finding of the study revealed that 91.9% of women were taking inadequate fruit Abbildung in dieser Leseprobe nicht enthaltenand vegetables as recommended by World Health Organization. Current smoking was Abbildung in dieser Leseprobe nicht enthaltenpresent in 7.7% respondents, where older people were more likely to be current Abbildung in dieser Leseprobe nicht enthaltensmoker (p=<0.001), current alcohol consumption was present in 7.1 % and was higher Abbildung in dieser Leseprobe nicht enthaltenin underprivileged (p=0.020). Physical inactivity was found in 6.4% with 6 time Abbildung in dieser Leseprobe nicht enthaltenhigher prevalence among older age group. Nearly half (51.9%) of women were found Abbildung in dieser Leseprobe nicht enthaltento be overweight and obese. Systolic hypertension was present in 9% and diastolic Abbildung in dieser Leseprobe nicht enthaltenhypertension in 13.5% of the respondent.

The finding of study concluded that the use of smoking was higher among older women and among those women with education level below primary level. Alcohol consumption was found to be more among women of underprivileged group. The study highlighted the poor dietary habit among women indicating the need of education and awareness raising programs on diet and nutrition.

ACKNOWLEDGEMENT

This study has been completed with the suggestions, guidance and help from many Abbildung in dieser Leseprobe nicht enthaltenindividuals. In fact it would not have been possible to meet the target without their Abbildung in dieser Leseprobe nicht enthaltenhelp and assistance and it may therefore be unfaithful if it is missed to mention them.

I would like to express sincere thanks and deep sense of gratitude towards TU, IOM, Abbildung in dieser Leseprobe nicht enthaltenMaharajgunj Nursing Campus for providing me an opportunity and facilities to Abbildung in dieser Leseprobe nicht enthaltenconduct this study for the partial fulfillment of Masters Degree in Nursing (Adult Abbildung in dieser Leseprobe nicht enthaltenNursing).

With great respect and deep sense of gratitude, I owe my sincere indebtedness to Abbildung in dieser Leseprobe nicht enthaltenSupervisor, Mss. Kamala Upreti, Associate Professor, Maharajgunj Nursing Campus Abbildung in dieser Leseprobe nicht enthaltenfor her consistent encouragement, guidance, moral support, motivation and valuable Abbildung in dieser Leseprobe nicht enthaltensuggestions which has helped me to pass through critical phase successfully.

I would also like to extend my warm thanks to Prof Dr. Sarala Shrestha (Chairperson Abbildung in dieser Leseprobe nicht enthaltenof research committee) and Prof. Dr. Sarala Joshi (HOD, Research and Education) for Abbildung in dieser Leseprobe nicht enthaltentheir insight comments, valuable suggestions and guidance at every stage of this Abbildung in dieser Leseprobe nicht enthaltenstudy. I am grateful to Associate Prof. Nira Pandey, Campus Chief and Associate Abbildung in dieser Leseprobe nicht enthaltenProf. Sulochana Shrestha, Assistant Campus Chief, Maharajgunj Nursing Campus for Abbildung in dieser Leseprobe nicht enthaltentheir administrative support in the study. My sincere gratitude goes to all the faculties Abbildung in dieser Leseprobe nicht enthaltenof Maharajgunj Nursing Campus who provided me with their valuable suggestions Abbildung in dieser Leseprobe nicht enthaltenregarding this study.

I am also grateful towards Assoc. Prof. Dr Amod Poudel, Mr. Bibhav Adhikari (Statistician), Mr. Prem Panta (Statistician) and Mr. Sushan Shrestha (Statistician) and for providing their guidance and valuable suggestion in the statistical analysis.

I would like to express thanks to all the library staff of Maharajgunj Nursing Campus for making the literature available through different ways.

My sincere gratitude goes to Assoc. Prof. Krishna Paudel, College of International Abbildung in dieser Leseprobe nicht enthaltenLanguage and Mrs Bhawana Karki, the English teacher of Brisahpati Vidhyasadan Abbildung in dieser Leseprobe nicht enthaltenSchool for their great help in translation and back to back translation of the Abbildung in dieser Leseprobe nicht enthaltenquestionnaire.

I would like to extend my heartfelt thanks to Mr Laxmi Sundar Abaal the Secretary of Gothatar VDC and all the respondents without whom this study could not be done. Their co-operation will always be remembered with appreciation.

I owe a special debt of thanks to my colleagues who kept me motivated and helped me through difficult stages. At last but not the least, I would like to express my sincere gratitude and graceful thanks to my family members and well-wishers who directly and indirectly helped to carry out this study.

Bibhuti Katel

CHAPTER I INTRODUCTION

1.1 Background of the Study

Non Communicable Diseases (NCDs) are the biggest cause of death worldwide. A total of 57 million deaths occurred in the world during 2008, 36 million (63%) were due to NCDs mainly cardiovascular diseases (48%), cancers (21%), chronic respiratory diseases (12%) and diabetes (3%). In Nepal, the estimated death in 2008 by NCDs was 50% of all death with 48.8% in male and 42.8% in female (Alwan, Armstrong, Cowan, & Riley, 2011).

Low- and lower-middle-income countries have the highest proportion of deaths under Abbildung in dieser Leseprobe nicht enthaltenthe age of 60 years from NCDs. Premature deaths under age of 60 years for high-Abbildung in dieser Leseprobe nicht enthaltenincome countries were 13% and 25% for upper-middle-income countries. In lower-Abbildung in dieser Leseprobe nicht enthaltenmiddle-income countries the proportion of premature NCD deaths under 60 years rose Abbildung in dieser Leseprobe nicht enthaltento 28%, more than double the proportion in high-income countries. In low-income Abbildung in dieser Leseprobe nicht enthaltencountries, the proportion of premature NCD deaths under 60 years was 41%; which is Abbildung in dieser Leseprobe nicht enthaltenthree times the proportion in high-income countries (Alwan et al., 2011).

Non communicable diseases (NCDs) cause 63% of deaths globally and nearly 80% of deaths in low and middle income countries(Alwan, 2010). In Nepal, 42% of deaths are caused by NCDs and nearly 35% of deaths are caused by four particular NCDs -Abbildung in dieser Leseprobe nicht enthaltencardiovascular diseases (CVDs), cancer, chronic obstructive pulmonary diseases and diabetes mellitus (Aryal et al., 2014).

WHO has identified certain risk factors (personal behavior of lifestyle, an environmental exposure, hereditary characteristic) that is associated with an increase in the occurrence of NCDs. Physical inactivity, tobacco use, alcohol use and unhealthy diets are the four prioritized behavioral risk factors associated with occurrence of four leading NCDs.

The four NCDs diseases are preventable. Up to 80% of heart disease, stroke, and type 2 diabetes and over a third of cancers could be prevented by eliminating shared risk factors, mainly tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol (Alwan, 2010).

1.2. Need for the Study

Use of tobacco and alcohol consumption among adults is higher in Nepal as compared Abbildung in dieser Leseprobe nicht enthaltento other South Asian neighbors. According to report of 2011, the number of female Abbildung in dieser Leseprobe nicht enthaltensmokers is higher in Nepal compared to other countries with the prevalence of 25% Abbildung in dieser Leseprobe nicht enthaltencurrent smoker followed by Pakistan and Myanmar with prevalence of 7% each. Abbildung in dieser Leseprobe nicht enthaltenSimilarly in India the prevalence of current smoking among women was 4% while Abbildung in dieser Leseprobe nicht enthaltenChina and Pakistan had prevalence of 2% each (Riley & Cowan, 2014).

According to Vaidya, Oli, Aryal, Karki, and Krettek (2014) low fruit and vegetable Abbildung in dieser Leseprobe nicht enthaltenintake is a public health problem in the Nepalese context. A community based study Abbildung in dieser Leseprobe nicht enthaltenshowed fruit and vegetable intake in the community was low with only 2.1% of the Abbildung in dieser Leseprobe nicht enthaltenstudy population consuming the WHO-recommended five servings per day. Low fruit Abbildung in dieser Leseprobe nicht enthaltenand vegetable intake was present among them 98.3% of the male and 97.8% of the Abbildung in dieser Leseprobe nicht enthaltenfemale respondents. While in Gujarat, low fruits and vegetables consumption was Abbildung in dieser Leseprobe nicht enthaltenpresent among 91.6% male and 93.8% female (Aroor, Trivedi, & Jain, 2013).

Physical inactivity causes 6% of the burden of disease from coronary heart disease, 7% of type 2 diabetes, 10% of breast cancer, and 10% of colon cancer. The elimination of physical inactivity would increase the life expectancy of the world’s population by 0·68 years (Lee et al., 2012).

A study conducted in Nagpur among 1964 men and 1807 women concluded that Abbildung in dieser Leseprobe nicht enthaltenamong men, overweight and obesity was present in 5.7% and 0.3% respectively while Abbildung in dieser Leseprobe nicht enthaltenin women overweight and obesity was found in 7.2% and 0.7% respectively Abbildung in dieser Leseprobe nicht enthalten(Bhardwaj, Shewte, Bhatkule, & Khadse, 2012). But in contrast the prevalence of Abbildung in dieser Leseprobe nicht enthaltenoverweight and obesity among women is 1.8% and 24.5% respectively. The Abbildung in dieser Leseprobe nicht enthaltenprevalence of obesity is higher in women having less frequency of fruit in comparison Abbildung in dieser Leseprobe nicht enthaltento women who took fruits frequently (Shahi, Rai, Adhikari, & Sharma, 2013).

The step survey conducted by NHRC on NCDs Risk Factors reveals that the percent Abbildung in dieser Leseprobe nicht enthaltenof women who ate less than 5 servings of fruit and/or vegetables on average per day Abbildung in dieser Leseprobe nicht enthaltenhas increased from 63.5% in 2008 to 98.9% in 2013. The percentage of women who Abbildung in dieser Leseprobe nicht enthaltenare obese (BMI >30kg/m² ) has increased from 2.4 in 2008 to 4.8 in 2013. Similarly Abbildung in dieser Leseprobe nicht enthaltenpercentage of women with raised BP (SBP > 140 and/ or DBP > 90 mmHg, who are Abbildung in dieser Leseprobe nicht enthaltennot currently on medication for raised BP) was 18.1% in 2008 and 20.6% in 2013 Abbildung in dieser Leseprobe nicht enthalten(Aryal et al., 2014).

The available data and literature review shows that the behavioural risk factors of non-communicable disease are in increasing trends in Nepal. The number of female smokers is higher in Nepal compared to other countries similarly fruit and vegetables consumption is lower in women of Nepal and the prevalence high among them in compared to other countries which are the major causative risk of the four NCDs. However by eliminating behavioural risk factors the four NCDs can be prevented up to 80 percent. Hence the researcher aims to assess the status of behavioral risk factors regarding non-communicable disease among the women.

1.3. Objective of the Study

General objective

The general objective of the study was to find out the status of the behavioral risk Abbildung in dieser Leseprobe nicht enthaltenfactors regarding non communicable diseases among adult women of Gothatar VDC, Abbildung in dieser Leseprobe nicht enthaltenKathmandu.

Specific Objectives

The specific objectives of the study were:

To find out the status of tobacco consumption among adult women. To assess the status of alcohol consumption among adult women. To identify dietary habit of adult women.

To assess the physical activity of adult women.

To assess BMI and blood pressure of adult women.

To find out the association between selected socio-demographic variables (i.e. age, ethnicity, education, economic status) and behavioural risk factors of Noncommunicable Diseases.

1.4 Significance of the Study

This study will help to identify the prevalence of behavioural risk factors in the concerned locality.

The finding of the study may be helpful for the local policy maker to develop plan and execute health program.

The study will also help the respondents to be aware of their risk behavior and make necessary change or modification of their behavior.

1.5 Conceptual Framework

The Conceptual Framework has been developed in order to achieve clear and in depth understanding of the study being conducted. This conceptual framework was developed on the basis of extensive literature review and consultation with experts. This framework highlights the behavioural risk factors regarding non communicable diseases among adult women. The behavioural risk factors have been categorized into use of tobacco, alcohol consumption, physical inactivity and poor dietary habit. The socio-demographic factors include age, ethnicity, education, marital status, occupation and economic status.

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Fig 1: Conceptual Framework on Behavioural Risk Factors of Non communicable diseases among Adult Women of Gothatar VDC, Kathmandu.

(Note: The broken lines were not studied).

1.6 Research Questions

What is the prevalence of behavioural risk factors regarding non communicable diseases among adult women?

Is there any association between selected socio-demographic variables and the status of behavioural risk factors of non - communicable diseases?

1.7 Operational Definition

Behavioral risk factors: Physical inactivity, unhealthy dietary habits, tobacco use and alcohol consumption.

Non Communicable Diseases: The four leading NCDs (Non Communicable Diseases) i.e. Cardiovascular Diseases (CVDs), Diabetes, Cancer and Chronic Respiratory Diseases.

Adult women: Adult women refer to the women of the age group of 20-60 years and residing in Gothatar VDC, Kathmandu Physical inactivity: Any women who will not meet the criteria of vigorous or moderate activity as given in the WHO steps manual i.e. less than 600 MET minutes per week.

Poor dietary habits: Consumption of less than 5 servings of fruits and vegetables Abbildung in dieser Leseprobe nicht enthaltenper day.

Tobacco users: Those adult women who consume both smoking products and smokeless tobacco products (i.e. khaini and gutkha).

Alcohol consumption: Respondents taking any form of alcohol such as beer, jaand, tongba, local raksi, whisky, vodka (spirits), rum, wine (red and white).

Hypertension: It includes those who self-reported as having hypertension or those Abbildung in dieser Leseprobe nicht enthaltenwho had high blood pressure according to JNC-VII classification during the time Abbildung in dieser Leseprobe nicht enthaltenof survey.

Overweight and obesity: Overweight BMI between 25-29.9 and obesity as BMI 30 or higher. Combined Risk Factors: Presence of more than one behavioural risk factors, obesity and hypertension.

1.8 Delimitation

Study was conducted only among women of age group 20 -60 years of age.

CHAPTER II LITERATURE REVIEW

2.1 Introduction

During the course of literature review many books, journals, internet, news, bulletin and articles were searched. The literature review has been arranged systematically covering each component of behavioural risk factors.

2.2 Review of Literature

2.2.1 Overview of Non Communicable Disease

Non-communicable diseases (NCDs), also known as chronic diseases, are not passed from person to person. They are of long duration and generally slow progression. The four main types of non- communicable diseases are cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary diseases and asthma) and diabetes (WHO, 2013).

2.2.2 Tobacco Use

Tobacco is the single largest agent implicated in a number of diseases and is a risk Abbildung in dieser Leseprobe nicht enthaltenfactor for the six of the eight leading causes of death in the world. It has killed an Abbildung in dieser Leseprobe nicht enthaltenestimated 100 million people in the 20th century and continues to kill 5.4 million Abbildung in dieser Leseprobe nicht enthaltenpeople every year and this figure is expected to rise to 8 million per year by 2030, Abbildung in dieser Leseprobe nicht enthalten80% of which will occur in the developing countries (WHO, 2008). (Pham et al., Abbildung in dieser Leseprobe nicht enthalten2009).

Cigarette smoking is a popular method of tobacco consumption worldwide. In Nepal, Abbildung in dieser Leseprobe nicht enthaltentobacco used in various forms such as beedi smoking, a most popular form in tarai Abbildung in dieser Leseprobe nicht enthaltenregion followed by cigarette smoking and use of various smokeless tobacco Abbildung in dieser Leseprobe nicht enthaltenpreparations in hilly and urban areas. The prevalence of tobacco use is considerably Abbildung in dieser Leseprobe nicht enthaltenhigher in rural areas than in urban areas, particularly in youth population. Males consume more tobacco products than females. The prevalence of tobacco products Abbildung in dieser Leseprobe nicht enthaltenusers is the highest (68.2%) in the high mountain region followed by the tarai region Abbildung in dieser Leseprobe nicht enthalten(42.4%) and mid hilly region (40.9%). In Nepal, chronic non-communicable diseases Abbildung in dieser Leseprobe nicht enthaltenof respiratory, cardio-vascular and, nervous systems, including cancers of oral cavity, Abbildung in dieser Leseprobe nicht enthaltenrespiratory and digestive organs, as well as premature deaths cause around 42% Abbildung in dieser Leseprobe nicht enthaltenmortality. Tobacco is the most common risk factor, which became the world’s leading Abbildung in dieser Leseprobe nicht enthaltenkiller, responsible for many cancers. Lung cancer is the commonest tobacco-attributed Abbildung in dieser Leseprobe nicht enthaltencancer in both genders, which is one of the common causes of death from cancers in Abbildung in dieser Leseprobe nicht enthaltenNepal. The major part of population in Nepal is not aware of risk factors leading to Abbildung in dieser Leseprobe nicht enthaltencancers and other diseases (Subedi, D.M.R.D, & Sharma, 2013).

Tobacco use is a serious public health problem in the South East Asia Region where Abbildung in dieser Leseprobe nicht enthaltenuse of both smoking and smokeless form of tobacco is widely prevalent. The region Abbildung in dieser Leseprobe nicht enthaltenhas almost one quarter of the global population and about one quarter of all smokers Abbildung in dieser Leseprobe nicht enthaltenin the world. Out of 5.1 million tobacco attributable deaths in the world, more than 1 Abbildung in dieser Leseprobe nicht enthaltenmillion are in South East Asia Region (SEAR) countries. Smoking among men is high Abbildung in dieser Leseprobe nicht enthaltenin the region and women usually take to chewing tobacco. The prevalence across Abbildung in dieser Leseprobe nicht enthaltencountries varies significantly with smoking among adult men ranges from 24.3% Abbildung in dieser Leseprobe nicht enthalten(India) to 63.1% (Indonesia) and among adult women from 0.4% (Sri Lanka) to 15% Abbildung in dieser Leseprobe nicht enthalten(Myanmar and Nepal). The prevalence of smokeless tobacco use among men varies Abbildung in dieser Leseprobe nicht enthaltenfrom 1.3% (Thailand) to 31.8% (Myanmar), while for women it is from 4.6% (Nepal) Abbildung in dieser Leseprobe nicht enthaltento 27.9% in Bangladesh (Thakur, Garg, Narain, & Menabde, 2011).

The prevalence of smoking among female tea pluckers in Srilanka is 7.27%. Among Abbildung in dieser Leseprobe nicht enthaltenthe smokers, most smoked cigar (55%), followed by beedi (39%) and cigarette (6%). Abbildung in dieser Leseprobe nicht enthaltenAmong them 92.8% has never smoked or used tobacco products while 16.5% uses Abbildung in dieser Leseprobe nicht enthaltentobacco occasionally and the regular (current) user of smoking and smokeless tobacco Abbildung in dieser Leseprobe nicht enthaltenwere 7.2% and 70 % respectively. The study further showed a significant positive Abbildung in dieser Leseprobe nicht enthaltenassociation between smoking and illiteracy (p<0.05) There was positive association of Abbildung in dieser Leseprobe nicht enthaltensmoking and age more than 35 years (p<0.01) (Weerakoon et al., 2009).

Smoking increases the risk of breast cancer among women. Compared with never Abbildung in dieser Leseprobe nicht enthaltensmokers, women who smoke for at least 20 years and who smoke 10 cigarettes or Abbildung in dieser Leseprobe nicht enthaltenmore daily have the higher risk. Women who initiate smoking prior to their first birth or before age of 15 have an increased risk. Women who start smoking as teenagers and continue to smoke for at least 20 years may increase their breast cancer risk (Gram et al., 2005).

A study finding showed that the current smokers with breast cancer have higher mortality. Compared with never smokers, current smokers at diagnosis had a slightly higher breast cancer-specific mortality, but not statistically significant. Among current smokers, breast cancer-specific mortality increased with total exposure to, intensity and duration of smoking .Compared to never smokers, breast cancer-specific mortality was 32 to 56% higher among heavy smokers (more than 30 pack years of smoking, more than 20 cigarettes per day or more than 30 years of smoking). Smoking at diagnosis was associated with an increased all-cause mortality rate (Bérubé, Lemieux, Moore, Maunsell, & Brisson, 2014).

A cross sectional study conducted in Nagpur shows that the prevalence of daily Abbildung in dieser Leseprobe nicht enthaltensmoked tobacco was 20.5 % for men while all females were lifetime abstainer. Daily Abbildung in dieser Leseprobe nicht enthaltensmokeless tobacco users were 62.6 % and 32.8 % in men and women Abbildung in dieser Leseprobe nicht enthaltenrespectively(Bhardwaj et al., 2012). While in Gujarat the prevalence of daily smoking Abbildung in dieser Leseprobe nicht enthaltenis 0.4% and 0.5% of the women in urban and rural area respectively. Similarly daily Abbildung in dieser Leseprobe nicht enthaltenuse of smokeless tobacco in the urban and rural women is 5.5% and 19.8% Abbildung in dieser Leseprobe nicht enthaltenrespectively (Aroor et al., 2013).

Similarly the rate of smoking and lung cancer among women is rising in Europe. Abbildung in dieser Leseprobe nicht enthaltenSmoking is significantly associated with older age, being divorced, having Abbildung in dieser Leseprobe nicht enthaltenfriends/family who smoke and having parents who smoke. The most frequently Abbildung in dieser Leseprobe nicht enthaltenreported reason for initiation smoking was friend smoking, with 62.3% of ever Abbildung in dieser Leseprobe nicht enthaltensmokers. Education and income measures were not significantly associated with Abbildung in dieser Leseprobe nicht enthaltensmoking (Oh et al., 2010).

Tobacco use is a serious public health problem in the central developmental region of Abbildung in dieser Leseprobe nicht enthaltenNepal. 42.1% male and 18.4% female were currently using tobacco. 25.26% of male Abbildung in dieser Leseprobe nicht enthaltenand 7.47% of female were currently using chewing tobacco. The highest proportion of Abbildung in dieser Leseprobe nicht enthaltencurrent tobacco users falls under the age group of 55-64 years closely followed by 54. Of the total smoking tobacco users, majority (98.9%) consume cigarette followed Abbildung in dieser Leseprobe nicht enthaltenby beedi (37.4%). Only 4% of total current smokers use hukka (pipes). Of the total smokeless tobacco users, highest percentage i.e. 93.0% consume chewing tobacco which is commonly known as surti or tamakhu in Nepal, which is, followed by chewing battle which is consumed nearly half of the smokeless tobacco users. Majority of tobacco users were influenced by friends for using tobacco (48.4%) followed by parents (24.9%). More percentages of female were influenced by friends (53.8%) than their male counterpart (Adhikari & Gupta, 2014).

The mean number of years of current tobacco use in female of West Bengal was 18.0 years (Basu, Biswas, & Chatterjee, 2013). Similarly the study of Adhikari and Gupta (2014) reveals that the mean age of initiation of smoking in women was 17.38 years. Likewise the mean age of smoking among European women was 18.2 years with over 80% beginning smoking by the age of 20 (Oh et al., 2010).

2.2.3Alcohol Consumption:

Alcohol remains a major contributor to cancer mortality and years of potential life lost Abbildung in dieser Leseprobe nicht enthalten(YPLL). Alcohol consumption resulted in an estimated 3.2% to 3.7% of all US cancer Abbildung in dieser Leseprobe nicht enthaltendeaths. The majority of alcohol-attributable female cancer deaths were from breast Abbildung in dieser Leseprobe nicht enthaltencancer (56% to 66%), whereas upper airway and esophageal cancer deaths were more Abbildung in dieser Leseprobe nicht enthaltencommon among men (53% to 71%). Alcohol-attributable cancers resulted in 17.0 to 19.1 YPLL for each death. Daily consumption of up to 20 grams of alcohol (≤ 1.5 drinks) accounted for 26% to 35% of alcohol-attributable cancer deaths. Reducing alcohol consumption is an important and underemphasized cancer prevention strategy (Nelson et al., 2013).

Alcohol is the most prevalent addictive substance used in Sri Lanka and this practice has been in existence for centuries. About 24 percent of the adult female tea pluckers are current alcohol users, 65.3 percent has never used alcohol while 10.8 percent are occasional user. Among those who take alcohol majority of the females' reason for taking alcohol is to forget their worries (Weerakoon et al., 2009).

A case control study conducted by Qian et al. (2014) shows positive relationship Abbildung in dieser Leseprobe nicht enthaltenbetween alcohol consumption and breast cancer risk, suggesting that this modifiable Abbildung in dieser Leseprobe nicht enthaltenrisk factor should be addressed in breast cancer prevention programs in Africa. Abbildung in dieser Leseprobe nicht enthaltenCompared with non-drinkers, women who had drunk for <10 years had 41% higher risk of having breast cancer, and those who had drunk for 10-19 years had 71% risk where as those who drink for ≥20 years had 82% higher risk of having breast cancer. Every 10-year increase in the duration of drinking was associated with a 54% increase in breast cancer risk. Alcohol consumption was associated with breast cancer risk, regardless of alcohol amount; breast cancer risk increase was shown even in the category of women who consume 0.1-4.9 g/day.

Similarly, Peter and Paolo (2009) concluded that alcohol consumption increases the risk of breast cancer. There is consistent evidence from large, prospective studies that even moderate alcohol consumption increases the risk of breast cancer. Most studies have confirmed a gradient of increasing risk of breast cancer associated with increasing levels of alcohol consumption, even at moderate levels of consumption. In France, 9.4% of breast cancer is attributable to alcohol consumption; and 7.7% of all breast cancers in Europe are attributable to alcohol consumption

In regard to Nepal, Aryal et al. (2014) reported that the prevalence of alcohol consumption (current drinkers) among Nepalese women is 7.1 percent. Among those who drank in the past 12 months, 17.5 percent drank daily. Among the current drinkers, 13.2% of were heavy drinkers (≥ 40 grams on a single occasion).

2.2.4 Dietary Habit

Fruit and vegetable intake is crucial in health promotion and disease prevention. Findings of research studies shows fruit and vegetables consumption are one of the several important protective factors against non-communicable diseases such as several cancers, cardiovascular diseases, diabetes and obesity. Inadequate intake of fruit and vegetable is found among adult populations worldwide. WHO recommends adults to consume at least five serving of fruits or 400 grams of fruits and vegetables daily (Lock, Pomerleau, Causer, Altmann, & McKee, 2005).

A higher intake of fruits and vegetables has been associated with a lower risk of Abbildung in dieser Leseprobe nicht enthaltenischemic heart disease (IHD). The burden IHD and ischemic stroke can be reduced by 31 and 19 percentage respectively, if the individual daily intake of fruit and vegetables can be increased up to 600 grams (Lock et al., 2005).

A study done among Portuguese mothers showed that the mean intake of fruit and Abbildung in dieser Leseprobe nicht enthaltenvegetables was below the WHO recommendations of ≥ 400 g/day. Only 46% of the Abbildung in dieser Leseprobe nicht enthaltenmothers met this recommendation. Educational level was positively associated with Abbildung in dieser Leseprobe nicht enthaltendaily vegetable intake. Mothers belonging to higher educational levels were more Abbildung in dieser Leseprobe nicht enthaltenlikely to have a daily vegetable intake. Similarly mothers belonging to higher social Abbildung in dieser Leseprobe nicht enthaltenclasses were more likely to eat fruit and vegetables daily (Franchini, Poínhos, & Abbildung in dieser Leseprobe nicht enthaltenKlepp, 2013).

The consumption of fruit and vegetable is low in Nepalese people. When compared to Abbildung in dieser Leseprobe nicht enthaltenother South-Asian countries such as India (approximately 74 percent inadequate fruit Abbildung in dieser Leseprobe nicht enthaltenand vegetable intake), Sri Lanka (68 percent) and Bangladesh (47 percent), Nepal Abbildung in dieser Leseprobe nicht enthaltenwith prevalence of 97.9% stands next to Pakistan (99 percent) when it comes to the Abbildung in dieser Leseprobe nicht enthaltenoverall insufficient fruit and vegetable consumption (Vaidya et al., 2014).

Similarly a study in conducted in China by Li, Wang, Jiang, Zhang, and Wang (2013) shows that 51.7% women were consuming less than 400 grams of fruits and vegetables. While in Gujarat the prevalence of low fruits and vegetables consumption among women was 93.8% and 97.1% of the women in urban and rural areas respectively (Aroor et al., 2013).

The burden of low fruit and vegetable intake as a cardio metabolic risk factor is a Abbildung in dieser Leseprobe nicht enthaltenpublic health problem in the Nepalese context. The study conducted by Vaidya et al. Abbildung in dieser Leseprobe nicht enthalten(2014) shows that the average intake of fruit and vegetables is half the recommended Abbildung in dieser Leseprobe nicht enthaltenamount. The burden of low fruit and vegetable in the population is alarmingly high at 97.9 percent. In comparison to male, females consumed more fruits in terms of both Abbildung in dieser Leseprobe nicht enthaltendays/week and serving/day. Females consumed vegetables on more number of days Abbildung in dieser Leseprobe nicht enthaltenthan males. The average number of serving of vegetables was also higher in women. Abbildung in dieser Leseprobe nicht enthaltenHowever 97.8 percent of the females had low fruit and vegetables intake. Newar Abbildung in dieser Leseprobe nicht enthaltenwomen had less fruit intake compared to other ethnic groups. Occupation wise those Abbildung in dieser Leseprobe nicht enthaltendoing government jobs, took fruits on more number of days. Similarly insufficient Abbildung in dieser Leseprobe nicht enthaltenfruit and vegetables intake by women has also been shown by other study conducted Abbildung in dieser Leseprobe nicht enthaltenin Sindhuli where 96.5% females were having insufficient fruit and vegetables intake Abbildung in dieser Leseprobe nicht enthalten(Dhungana et al., 2014).

Regarding the consumption of dietary salt 91.0% consumed powdered salt from the Abbildung in dieser Leseprobe nicht enthaltenpacket with two children on its logo. Around 4.7 percent of the respondents always or Abbildung in dieser Leseprobe nicht enthaltenoften added salt before eating or while eating. Similarly, 11.5 percent of respondents Abbildung in dieser Leseprobe nicht enthaltenalways or often consumed processed food containing high amounts of salt. Around

10.9 percent thought that they consumed far too much or too much salt, 42.2 percent ate meals without adding salt (Aryal et al., 2014).

Eating a high-salt diet for several years may damage blood vessels. People with this Abbildung in dieser Leseprobe nicht enthaltentype of blood vessel damage who eat a high-salt diet are more likely to develop Abbildung in dieser Leseprobe nicht enthaltenhypertension; therefore, the impact of a high-salt diet is greater on this group of Abbildung in dieser Leseprobe nicht enthaltenpeople (Scheven, Jong, Bakker, Curhan, & Gansevoort, 2012). This is further Abbildung in dieser Leseprobe nicht enthaltensupported by a large scale study conducted in Japan by among 10,422 participants Abbildung in dieser Leseprobe nicht enthalten(4585 men and 5837 women) concluded a positive relationship of dietary salt intake Abbildung in dieser Leseprobe nicht enthaltento BP (Miura et al., 2009).

2.2.5 Physical Inactivity:

Insufficient physical activity can be defined as less than five times 30 minutes of moderate activity per week, or less than 20 minutes of vigorous activity per week or equivalent (Mendis, Puska, & Norrving, 2011).

Insufficient physical activity is the fourth leading risk factor for mortality. Abbildung in dieser Leseprobe nicht enthaltenApproximately 3.2 million people die each year due to physical inactivity. People Abbildung in dieser Leseprobe nicht enthaltenwho have insufficient physical activity have a 20% to 30% increased risk of all-cause Abbildung in dieser Leseprobe nicht enthaltenmortality. Regular physical activity reduces the risk of cardiovascular disease Abbildung in dieser Leseprobe nicht enthaltenincluding high blood pressure, diabetes, breast and colon cancer, and depression Abbildung in dieser Leseprobe nicht enthalten(Alwan et al., 2011).

Physical inactivity (lack of physical activity) has been identified as the fourth leading Abbildung in dieser Leseprobe nicht enthaltenrisk factor for global mortality (6% of deaths globally). Moreover, physical inactivity Abbildung in dieser Leseprobe nicht enthaltenis estimated to be the main cause for approximately 21-25% of breast and colon Abbildung in dieser Leseprobe nicht enthaltencancers, 27% of diabetes and approximately 30% of ischemic heart disease (WHO, Abbildung in dieser Leseprobe nicht enthalten2015).

Physical inactivity is a leading risk factor for cardiovascular and other non-Abbildung in dieser Leseprobe nicht enthaltencommunicable diseases in high, low and middle-income countries. Nepal, a low- income country in South Asia, is undergoing an epidemiological transition. Although the reported national prevalence of physical inactivity is relatively low, studies in urban and peri-urban localities have always shown higher prevalence. Furthermore, women and housewives and older, more educated and self-or government-employed respondents showed a greater prevalence of physical inactivity. Respondents with hypertension, diabetes or overweight/obesity reported less physical activity than individuals without those conditions (Vaidya & Krettek, 2014).

Physical inactivity causes 6% of the burden of disease from coronary heart disease, Abbildung in dieser Leseprobe nicht enthalten7% of type 2 diabetes, 10% of breast cancer, and 10% of colon cancer. Inactivity is Abbildung in dieser Leseprobe nicht enthaltenresponsible for 9% of premature mortality (5.1% to 12.5%), or >5.3 of the 57 million Abbildung in dieser Leseprobe nicht enthaltendeaths that occurred worldwide in 2008. The elimination of physical inactivity would Abbildung in dieser Leseprobe nicht enthaltenincrease the life expectancy of the world’s population by 0.68 years (Lee et al., 2012).

Warburton, Nicol, and Bredin (2006) conclude that there is irrefutable evidence of the effectiveness of regular physical activity in the primary and secondary prevention of several chronic diseases (e.g., cardiovascular disease, diabetes, cancer, hypertension, obesity, depression and osteoporosis) and premature death. There is a linear relationship between physical activity and health status.

Low physical activity was present in 22.3% of the urban women and 13.6% of the Abbildung in dieser Leseprobe nicht enthaltenrural women of India(Aroor et al., 2013). Similarly the prevalence of physical Abbildung in dieser Leseprobe nicht enthalteninactivity among Chinese women was 18.3%(Li et al., 2013). While in Nepal, 2.4% of Abbildung in dieser Leseprobe nicht enthaltenwomen is having low physical activity i.e. less than 600 MET (Aryal et al., 2014).

2.2.6 Biological risk of Non communicable Diseases

Obesity

Overweight and obesity are defined as abnormal or excessive fat accumulation that Abbildung in dieser Leseprobe nicht enthaltenpresents a risk to health. Body or equal mass index (BMI) is a simple index of weight-Abbildung in dieser Leseprobe nicht enthaltenfor-height that is commonly used to classify overweight and obesity in adults. A Abbildung in dieser Leseprobe nicht enthaltenperson with a BMI of 30 or more is generally considered obese. A person with a BMI Abbildung in dieser Leseprobe nicht enthaltenequal to or more than 25 is considered overweight (WHO, 2015b). (WHO, 2015).

In Srilanka, the prevalence of obesity among women was 36.5 percent (Wijewardene Abbildung in dieser Leseprobe nicht enthaltenet al., 2005). The prevalence of overweight and obesity among the urban women was 29.7% and 54.1% respectively while among rural women was 13.4% and 24.7% in Abbildung in dieser Leseprobe nicht enthaltenGujarat (Aroor et al., 2013).Similarly the study of Pham et al. (2009) among 1978 Abbildung in dieser Leseprobe nicht enthaltenrespondents showed that 8.8% of men and 12.6% of women were overweight (body Abbildung in dieser Leseprobe nicht enthaltenmass index (BMI) ≥ 25 kg/m2) and 2.3% of men and 1.5% of women were obese Abbildung in dieser Leseprobe nicht enthalten(BMI ≥ 30 kg/m2).

Likewise in Nepal, the prevalence of overweight among women was 24.5% and Abbildung in dieser Leseprobe nicht enthaltenprevalence of obesity was 1.8%. Overweight and obesity of women was not Abbildung in dieser Leseprobe nicht enthaltenassociated with physical activities, whether women were vegetarian or non-vegetarian Abbildung in dieser Leseprobe nicht enthaltenand frequency of food they usually took. But the women who took fruits frequently in Abbildung in dieser Leseprobe nicht enthaltentheir diet had low body mass index than women who took fruits less frequently. In Abbildung in dieser Leseprobe nicht enthaltenother word, overweight and obesity among women was associated with fruits intake Abbildung in dieser Leseprobe nicht enthaltenless frequently (Shahi et al., 2013).

According to P.Aacharya, Prasad, and P.Gupta (2006) the finding of retrospective Abbildung in dieser Leseprobe nicht enthaltenstudy among the clients attending General Health Check-up Clinic at TUTH, Abbildung in dieser Leseprobe nicht enthaltenKatmandu revealed that 5.8% were underweight, 52.2% normal, 37.9% overweight Abbildung in dieser Leseprobe nicht enthaltenand 4.1% to be obese. Out of those obese cases, 73.7% had hypertension, 10.5% had Abbildung in dieser Leseprobe nicht enthaltendiabetes mellitus and 5.3% had Ischemic Heart Disease (IHD). Similarly, out of the Abbildung in dieser Leseprobe nicht enthaltenoverweight cases 46.0% had hypertension, 6.8% had diabetes mellitus and 3.4% had Abbildung in dieser Leseprobe nicht enthaltenIHD. The cases with normal weight or underweight had significantly lower incidence Abbildung in dieser Leseprobe nicht enthaltenof these diseases; 21.1% had hypertension, 5.4% had diabetes mellitus and 2.9% had Abbildung in dieser Leseprobe nicht enthaltenIHD. Out of 27 underweight cases, 3.7% had hypertension, 3.7% had diabetes Abbildung in dieser Leseprobe nicht enthaltenmellitus and none had IHD.

Hypertension

A cross sectional study conducted in Kathmandu concluded Hypertension is an Abbildung in dieser Leseprobe nicht enthaltenemerging public health challenge in urban areas of Nepal. Most importantly, it may be Abbildung in dieser Leseprobe nicht enthaltenincreasing among young population. Moreover, awareness, treatment and control rates Abbildung in dieser Leseprobe nicht enthaltenare not satisfactory. The study revealed that the prevalence of hypertension was 23.7%, pre-hypertension was 30% and 46.3% had ideal blood pressure. Prevalence of Abbildung in dieser Leseprobe nicht enthaltenhypertension was higher among male (30.39% vs. 10%). Almost two third of the hypertensive subjects were less or equal to 40 years (64.35%). Awareness, treatment Abbildung in dieser Leseprobe nicht enthaltenand control of hypertension were 39.13%, 18.26% and 7.38% respectively (Shakya et Abbildung in dieser Leseprobe nicht enthaltenal., 2012).

Similarly there is high prevalence of hypertension and pre-hypertension among Abbildung in dieser Leseprobe nicht enthaltenpopulation of Puducherry in South India. Among 856 participants27.6 percent were Abbildung in dieser Leseprobe nicht enthaltenhypertensive and 57% pre-hypertensive; the magnitude of both stage 1 and stage 2 Abbildung in dieser Leseprobe nicht enthaltenhypertension increased with the age. Of the hypertensive, 26.3% and 28.7% were Abbildung in dieser Leseprobe nicht enthaltenfrom rural and urban area respectively, whereas in pre-hypertension the corresponding Abbildung in dieser Leseprobe nicht enthaltenfigures were 61 and 53.4 percent. Significantly increased risk of hypertension was Abbildung in dieser Leseprobe nicht enthaltennoted among adults with increasing age, having less than six members in the family, Abbildung in dieser Leseprobe nicht enthaltensuffering from obesity (general and abdominal obesity) and living sedentary life. On Abbildung in dieser Leseprobe nicht enthaltenthe other hand, the probability of having increased risk of pre-hypertension was Abbildung in dieser Leseprobe nicht enthaltensignificantly higher among adults living in the rural areas, having non-vegetarian Abbildung in dieser Leseprobe nicht enthaltendietary habit, suffering from obesity (general and abdominal obesity), living sedentary Abbildung in dieser Leseprobe nicht enthaltenlife and having family history of hypertension (Bharati, Pal, Rekha, & Yamuna, Abbildung in dieser Leseprobe nicht enthalten2011).

In Srilanka, the prevalence of hypertension as defined was 18.8% (CI 14.5-23.1) for Abbildung in dieser Leseprobe nicht enthaltenmen and 19.3% (CI= 12.2 -26.4) for women (Wijewardene et al., 2005). Likewise a Abbildung in dieser Leseprobe nicht enthaltenstudy conducted in Vietnam with total sample of 1978 showed that the prevalence of Abbildung in dieser Leseprobe nicht enthaltenhypertension (systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, or taking Abbildung in dieser Leseprobe nicht enthaltenmedication for hypertension) was 27.3% for men and 16.2% for women (Pham et al., Abbildung in dieser Leseprobe nicht enthalten2009).

Similarly the prevalence of hypertension among rural women in India was 27.8% Abbildung in dieser Leseprobe nicht enthalten(Bansal et al., 2012). Similarly the study conducted to assess the prevalence among Abbildung in dieser Leseprobe nicht enthaltenrural Nepali women showed that 3.3% had hypertension and 14.4% had pre-Abbildung in dieser Leseprobe nicht enthaltenhypertension. Hypertension and prehypertension was higher among women of age 46 Abbildung in dieser Leseprobe nicht enthaltenyears than women of age below 46. The study concluded that although the prevalence Abbildung in dieser Leseprobe nicht enthaltenof hypertension was low in this cohort, it was more prevalent among the poorer Abbildung in dieser Leseprobe nicht enthaltenwomen and was strongly associated with other cardiovascular risks (Khan et al., Abbildung in dieser Leseprobe nicht enthalten2013).

2.3 Summary

Non -communicable diseases are of long duration and generally slow progression. Abbildung in dieser Leseprobe nicht enthaltenThey are the leading cause of death worldwide with low and lower middle income Abbildung in dieser Leseprobe nicht enthaltencountries having the highest proportion of death under 60 years of age. WHO has Abbildung in dieser Leseprobe nicht enthaltenidentified certain risk factors (personal behaviour of lifestyle, an environmental Abbildung in dieser Leseprobe nicht enthaltenexposure, and hereditary characteristics) that are associated with an increase in the Abbildung in dieser Leseprobe nicht enthaltenoccurrence of NCDs. The prioritized behavioural risk factors associated with Abbildung in dieser Leseprobe nicht enthaltenoccurrence of NCDs are tobacco use, use of alcohol, unhealthy diets and physical Abbildung in dieser Leseprobe nicht enthalteninactivity. Nearly 80% of the NCDs can be prevented by eliminating these Abbildung in dieser Leseprobe nicht enthaltenbehavioural risk factors.

Several research studies shows that the prevalence of smoking among women in Nepal is higher compared to other South Asian countries. On average women initiate smoking before the age of 20 years. Regarding dietary habit studies shows that majority of the women do not consume adequate fruit and vegetables as recommended by WHO. Similarly in Nepal the adequate consumption of fruit and vegetable is very low among women.

Many research studies shows high prevalence of obesity and hypertension among women. Therefore there is need to estimate the prevalence of behavioural risk factors of non-communicable diseases among women and plan preventive action to reduce non-communicable disease among them.

Literature review shows that there have been studies among Nepalese women regarding smoking habit, obesity, hypertension, fruit intake, but the study that includes all the four behavioural risk factors among women is lacking, so this study aims to assess the status of behavioural risk factor among women.

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