CommunityBased Study of Risk Factors for Stroke in Da Nang, Viet Nam

To assess the situation of stroke and its risk factors in Da Nang • To enhance the capacity of health staff in stroke care, treatment, and research. Designed and conducted a household survey to evaluate risk factors of stroke: approx. 900 households – 1621 participants 35 yrs and older • Develop a stroke registry patients hospitalized in Da Nang Hospital (using WHO STEPS questionnaire) 497 cases were collected from Mar – Nov. 2010. Lists of stroke patients from other hospitals will also be collected to evaluate the burden of the disease.

Community-Based Study of Risk Factors for

Stroke in Da Nang, Viet Nam

Annette L Fitzpatrick, PhD Dept of Epidemiology, Adjunct Global Health

University of Washington

Quang Van Ngo, MD, MPH

Da Nang Department of Health

Da Nang, Vietnam

Da Nang Department of Health

Kiet A Ly, MD, MPH, Northwest Center To Reduce Oral Health Disparities

Thanh G N Ton, PhD, Department of Neurology David L Tirschwell, MD, Department of Neurology W.T Longstreth, MD, MPH, Department of Neurology Tung T Vo, MD, Department of Health, Da Nang Chien H Pham, Director, Department of Health, Da Nang

Da Nang Department of Health

Contents of Presentation

Why Study CVD in Developing

Countries?

relative terms worldwide

older adults

course across gender, age, ethnicity, geography

disease as measured by DALYs

Not Just an Issue in High Income

Countries

Projected Global Distribution

of Chronic Disease Deaths

By World Bank Income Group, 2005

Low Income Countries 35%

Lower Middle Income Countries

Impact of Stroke Globally

•1:3 persons will experience a stroke, dementia or both

• Stroke is a costly disease:

– Large numbers of premature deaths,– Ongoing disability in many survivors,– Impact on families or caregivers

– Impact on health services (WHO Stroke STEPS)

Stroke in Vietnam

Disease

Scand J Pub Health; Hoang 2006, Prev Chron Dis)

Stroke in Vietnam

Results for adults aged

25-64 years (incl 95% CI)

Step 1 Tobacco Use

Percentage who currently

smoke tobacco 29.7(± 1.1) 60.0(± 1.8) 1.7(± 0.3)

Percentage who currently

smoke tobacco daily 28.4(± 1.1) 57.3(± 1.9) 1.6(± 0.3)

Mean number of

manufactured cigarettes

smoked per day

11.1(± 0.4) 11.2(0.4) 7.0(± 1.3)

Stroke in Vietnam

Results for adults aged 25-64 years

(incl 95% CI)

Step 2 Physical Measurement

Percentage with raised BP (SBP ≥140

FIC R21 Grant: 06/99 – 05/11 Collaborated between UW and DOH

Evaluation of stroke risk factors in Da Nang, Viet Nam

OBJECTIVES

• To assess the situation of stroke and its risk factors in Da Nang

• To enhance the capacity of health staff in

stroke care, treatment, and research

A Evaluate stroke and its risk factors in Da Nang

2 Projects

• Designed and conducted a household survey to evaluate risk factors of stroke: approx 900 households – 1621 participants

35 yrs and older

• Develop a stroke registry patients hospitalized in Da Nang Hospital (using WHO STEPS questionnaire)

497 cases were collected from Mar – Nov 2010

Lists of stroke patients from other hospitals will also be collected to evaluate the burden of the disease

B Building capacity:

• Established a local Advisory Committee to provide guidance on

methodological approaches and other issues of importance in conducting research on stroke in Da Nang and potentially other chronic diseases in the future;

• Organized training courses to enhance capacity for local health staff in stroke care and research (6 courses: Clinical Stroke, Imaging,

Epidemiology, EpiInfo, Field Data Collection, Stroke Registry Training).

• Organized meetings between experts from the UW and local staff to

exchange idea on establishing a better stroke care system/ unit at Da

Nang hospital.

• Provided equipment (computers, projector, books) to Da Nang Hospital and DN Health Staff Training Center.

Maps of Viet Nam & Da Nang

Geographic information of Da Nang

DA NANG HEALTH NETWORK

7 District Health Centers

Da Nang

Health

Department

56 commune Health Stations

(CHS) Each has 5-7 staff

Provide primary health care, first aid, and basic treatment

-Each DHC has from 50 to 100 in-patient beds and also supervise primary health care activities of CHSs in the district

Provincial Institutes Main functions

Da Nang Hospital The biggest central hospital in Da Nang with about 1,200 in-patient beds Training Center for Medical Staff Organize continuing training courses for medical staff

Health Information & Education Center Design and conduct health information and education programs Center for Reproductive Health Treatment, management mother and child health care programs Mental hospital Treatment, management of the national program of mental care Rehabilitation Center Treatment, management of Community Based Rehabilitation program Preventive Medical Center National vaccination programs, nutritional program, epidemic controls, etc HIV/AIDS Control Center HIV/ AIDS control programs

Eye Hospital Treatment, management of community eye care programs Dental Care Center Treatment, management of dental care programs in school & communities Tuberculosis Hospital Treatment, management of the national tuberculosis program

Dermatological Hospital Treatment, management of the national leprosy program Food Safety and Hygiene Agency Food and hygiene inspection

Forensic Medicine Center Provide forensic examination Traditional Medicine Hospital Treatment

Da Nang Pharmaceutical company

Beside the treatment functions, provincial institutes also provide their accordant specialty support and

supervision to primary health care programs conducted

at DHCs and CHSs (for ex: the community mental care program, CBR, child malnutrition, prenatal care, etc.)

4 private hospitals:

50-150 patient beds /each

Detail Sampling Schema

Number of Hamlets in selected Commune

Hamlets x Households

Number of households

Hai Chau = 13C 1C =56H 5H x 30hh 150hh Thanh Khe = 10C 1C =32H 5H x 30hh 150hh Son Tra = 7C 1C =73H 5H x 30hh 150hh

NHSon = 4C 1C =53H 5H x 30hh 150hh

Hoa Vang = 11C

1C =15H 5H x 30hh 150hh 1C =13H 5H x 30hh 150hh

Sampling: Community Survey

• Sampling: Stratified 50% Urban, 50% rural

• Randomly Selected: 3 (of 30) urban communes

2 (of 11 ) rural

1 (of 4) rural/urban

• Randomly Selected 5 hamlets in each commune

• Randomly Selected 30 HH in each hamlet

• Interviewed Adults 35+ in each HH

Data Collection

• Verbal Informed Consent

• Home Interview – WHO Steps

– Demographics (age, education, religion, SES ownership questions

– Medical History (CVD, hypertension, diabetes,

hyperlipidemia, cancer, arthritis, COPD

– MI Chest Pain (derived from Rose Angina Q)

– Questionnaire for Verifying Stroke-Free Status

– Health Behaviors (Tobacco, Alcohol, PA, Limited Diet)– Cognitive Function

– Stress and Anxiety

Data Collection

• Examination

– Vital Signs : Seated BP, Heart rate

– Anthropometry: Height, Weight, Waist, Hips, Knee-Heel Length

– Spirometry (Peak Flow and FEV)

• Finalized From based on Feed-back

• Pre-test using Community Volunteers

• Follow-up Monitoring at Each Site

• Visits Completed at 883 Households

• N = 1621 Adults

• 712 (43.9%) Men, 909 (56.1 %) Women

• Mean Age: 51.8 years ( + 12.5)

• Minimum: 35 years, maximum: 93 years

• 838 (51.7%) urban, 492 rural (30.4%) and 291 (18.0%) urban/rural

General Characteristics of Sample

Characteristic Men

(N=712)

Women (N=909)

Total (N=1621) p

General Characteristics of Sample

Characteristic Men

(N=712)

Women (N=909)

Total (N=1621) p

General Characteristics of Sample

Characteristic

Urban (N=838)

Rural (N=492)

Mixed Urban-rural (N=291)

Total (N=1621) p

Self-Reported Disease

Hypertension

101 (14.2%)

131 (14.4%)

14 (5.6%)

44 (8.3%) (17.2%)81 (26.1%)47 (24.7%)46

Diabetes 26

(3.7%)

37 (4.1%)

6 (2.4%)

8 (1.5%) (5.6%)26 (8.0%)14 (4.9%)9

Heart Attack 2 

(0.2%)

2  (0.3%)

0 (0.0%)

1 (0.2%) (0.0%)0 (1.1%)2 (0.0%)0

Severe

Chest Pain

30 (4.2%)

48 (5.3%)

11 (4.4%)

21 (3.9%) (5.5%)26 (7.8%)14 (3.2%)6

Stroke 2

(0.3%)

2 (0.2%)

0 (0.0%)

0 (0.0%) (0.2%)1 (1.1%)2 (0.5%)1

High

cholesterol

41 (5.8%)

58 (6.4%)

8 (3.2%)

18 (3.4%) (8.5%)40 (13.3%)24 (4.8%)9

Red indicates p <.01

Risk Factors for CVD

Unaware of Hypertension

Measured hypertension Self-reported

hypertension

No (N=1177)

Yes (N=443)

Reported HTN and Taking Medications

*Told had HTN in past 12 months

** Reported taking antihypertensive med in last 2 weeks

Self-Reported Hypertension*

Took HTN

Medications**

No (N=23)

Yes (N=206)

AHA Q for Verifying Stroke-Free Status

HAVE YOU EVER HAD…

• Sudden painless weakness on one side of your body?

• Sudden numbness or a dead feeling on one side of your

body?

• Sudden painless loss of vision in one or both eyes?

• Suddenly lost one half of your vision ?

• Suddenly lost the ability to understand what people are

Stroke Symptoms by Gender

Number of Stroke Symptoms

* p< 05

** p < 001

Any Stroke Symptoms by

Next Steps: Community Surveillance

• Have submitted Follow-up R01

• Longitudinal Follow-up of Community Cohort

• Community Education

– Hypertension

– Stroke Symptoms

• Intervention of Educational Materials

– Interactive Educational Tool vs Written Material

Next Steps: Stroke Registry

• Develop and Implement Standards of Care for Stroke

THANK YOU FOR YOUR ATTENTION

Are there any questions?

Da Nang Department of Health