Prevalence of non-communicable diseases risk factors and their determinants: Results from STEPS survey 2019, Nepal
Bihungum Bista, Meghnath Dhimal, Saroj Bhattarai, Tamanna Neupane, Yvonne Yiru Xu, Achyut Raj Pandey, Nick Townsend, Pradip Gyanwali, Anjani Kumar Jha
PLOS ONE · 2021 · DOI: 10.1371/journal.pone.0253605
Countries: Nepal
What Was Studied
This nationally representative cross-sectional survey used the WHO STEPwise approach to NCD risk factor surveillance (STEPS instrument v3.2) to assess the distribution and determinants of behavioural (tobacco, alcohol, diet, physical activity) and biological (overweight, raised blood pressure, raised blood glucose, raised cholesterol) NCD risk factors among Nepali adults aged 15-69. Data were collected face-to-face between February and May 2019 using a multistage cluster sampling design: 259 wards (37 per province) were selected as primary sampling units across all 7 provinces, 25 households were sampled per ward, and one adult was randomly selected per household. Of 6,475 eligible participants approached, 5,593 completed the survey (86% response rate). Analysis used Stata 15 with survey-weighted estimation and Poisson regression to calculate adjusted prevalence ratios (APR) for each risk factor and adjusted relative risk ratios (ARR) for clustering of multiple risk factors, by socio-demographic covariates including age, sex, education, province, ecological belt, wealth quintile, and residence.
What They Found
Nearly all participants (97%, 95% CI 94.3–98.0) had insufficient fruit and vegetable intake. Current smoking was found in 17% (95% CI 15.2–19.2), harmful alcohol use in 6.8% (95% CI 5.5–8.4), and physical inactivity in 7.4% (95% CI 5.7–10.1). On biological risk factors, 24.3% (95% CI 21.6–27.2) were overweight/obese, 24.5% (95% CI 22.4–26.7) had raised blood pressure, 5.8% (95% CI 4.3–7.3) had raised blood glucose, and 11% (95% CI 9.6–12.6) had raised total cholesterol. On average, each participant carried 2.04 risk factors (95% CI 2.02–2.08). Men had far higher adjusted odds of smoking (APR 4.49, 95% CI 3.70–5.46) and harmful alcohol use (APR 9.09, 95% CI 5.38–15.35) than women. Adults in the richest wealth quintile had significantly higher odds of accumulating multiple risk factors than the poorest (ARR 1.17, 95% CI 1.07–1.28), while those with more than secondary education had fewer risk factors (ARR 0.86, 95% CI 0.78–0.95). Compared with the 2013 STEPS survey, harmful alcohol use increased roughly three-fold (2.2% to 6.8%) and physical inactivity roughly doubled (about 3% to 7.4%).
What This Means for Nepal
These findings should directly guide where Nepal channels WHO's Package of Essential NCD Interventions (PEN), now expanding at primary-care level, and where the ~98-item Free Essential Drug List needs strengthening. Sudurpashchim (26% smoking) and Karnali (22% smoking) carry the heaviest tobacco burden, yet Karnali has 0% of its sanctioned physician and consultant posts filled (2021) — so scaling up PEN-based screening there will require task-shifting blood-pressure/glucose measurement and brief tobacco-cessation counselling to Nepal's ~50,400 Female Community Health Volunteers (FCHVs) rather than assuming physician-led delivery. Because richer, more urban populations (Bagmati, Gandaki) show the highest risk-factor clustering (ARR 1.17 for the richest quintile) while poorer, less-educated, mountain-belt populations show higher smoking, MoHP's 2014 Multisectoral Action Plan for NCD Prevention and Control should set differentiated, province-specific targets rather than a single national approach — leveraging the federal structure in which provincial health directorates (Schedule 6) and local governments (Schedule 8) already hold health-service responsibilities that could be aligned to this survey's province-level baseline.
Contextualisation
This STEPS 2019 survey was designed to monitor Nepal's 2014 Multisectoral Action Plan for the Prevention and Control of NCDs, and its province-level data exposes a critical mismatch between risk and capacity: Sudurpashchim (26% current smoking) and Karnali (22%) carry the country's highest tobacco burden, yet Karnali has 0% of its sanctioned physician and consultant posts filled, leaving the province least able to screen for or treat the NCDs this survey documents. With NCDs already responsible for 66% of Nepal's deaths and WHO's Package of Essential NCD Interventions (PEN) being rolled out at primary-care level, these disaggregated findings should directly inform where PEN services and the ~98-item Free Essential Drug List are prioritised, rather than NCD care remaining concentrated in urban tertiary hospitals.