MSc International Development Studies
Master Thesis
PREVALENCE, PERCEPTIONS, AND
PRACTICES OF NON-COMMUNICABLE
DISEASE RISK FACTORS IN RURAL AND
URBAN SOMALILAND
by
Zamzam Elmi
12790435
Supervisor: Dr. Nicky Pouw
Second reader: Dr. Olga Nieuwenhuis
ABSTRACT
The majority of adults living in Sub-Saharan Africa (SSA) are exposed to non-communicable disease (NCD) risk factors, namely tobacco smoking, harmful use of alcohol, an unhealthy diet, physical inactivity, obesity, or high blood pressure. Rapid, unplanned urbanization in SSA has been linked to the changes in lifestyle habits. Somalia is experiencing some of the highest rates of urbanization in SSA, with Somaliland undergoing even more rapid rates of urban growth due to the de-facto state’s relative stability in the region. This, coupled with Somaliland having one of the worst health indicators in SSA, means that the human toll and socio-economic costs of inaction against NCD risk factors can be substantial. However, a gap remains in research on the prevalence of NCD risk factors and the health beliefs and practices that may perpetuate NCD risk factors in rural and urban Somaliland. Therefore, this research first aims to address this knowledge gap by examining the extent to which NCD risk factors are prevalent in rural and urban Somaliland. This is done by using a modified version of the World Health Organization (WHO) STEPwise approach to noncommunicable disease risk factor surveillance (STEPS) survey. Secondly, the research aims to understand the reasons behind NCD prevalence by exploring the perceptions and practices that surround NCDs and their risk factors in rural and urban Somaliland by means of in-depth interviews and a focus group discussion with local health professionals and a rural village elder. The quantitative study found that although certain diet related NCD risk factors, such as low fruit and vegetable intake and high sugar and salt intake, were prevalent in both rural and urban areas, the dietary risk factors were more prevalent in rural areas. However, abdominal obesity and hypertension was more common in urban populations, with urban women being particularly affected by abdominal obesity. The principal findings of the qualitative study were that diets are homogenising and becoming increasingly carbohydrate and oil rich in both rural and urban Somaliland. Moreover, traditional Islamic healing practices remain common place. The lack of NCD risk factor information in the general public has also meant that people affected by an NCD do not continue their medications as prescribed and delay seeking medical treatment.
Keywords: Non-communicable disease risk factors, STEPS Instrument, Prevalence, Health perceptions, health practices, Somaliland
ACKNOWLEDGEMENTS
I would first like to sincerely thank my thesis supervisor, Nicky Pouw, for her patience and understanding during the writing of this thesis.
I thank all of the team members who worked with me to collect survey data in Somaliland, Ibrahim Elmi (translator), Shukri Bandare (Director of Non-Communicable Disease, Ministry of Health Development), Hamda Hassan Mohamed (graduate nurse), Khaalid Awil Hussein (graduate nurse), Mohamed Ismail Jama (graduate nurse), and Umkhair Omar Chama (graduate nurse), and Nimo Mursal Hussein (Director of Hargeisa Institute of Health Science). Without their extensive help and expertise, the content of this thesis would not have been as extensive.
I give my heartfelt thank you to Ian Vermeer, who encouraged and cheered me up during the process of writing this thesis.
My dearest thank you goes to my parents, Tuula and Mohamed, and my brother Dalmar, who have never failed to support me in all of my endeavours.
TABLE OF CONTENTS
ABSTRACT ... 2
ACKNOWLEDGEMENTS ... 4
LIST OF ACRONYMS AND ABBREVIATIONS ... 7
LIST OF FIGURES ... 8
LIST OF TABLES ... 9
CHAPTER 1. INTRODUCTION ... 10
1.1 Background ... 10
1.2 Research Relevance and Aim ... 13
1.3 Research Questions ... 14
1.4 Outline of Thesis ... 14
CHAPTER 2. LITERATURE REVIEW AND THEORETICAL FRAMEWORK ... 16
2.1 The Scope of Non-Communicable Disease Burden ... 16
2.1.1 Global Non-Communicable Disease Burden ... 16
2.1.2 Regional Non-Communicable Disease Burden: Eastern Mediterranean and Africa ... 17
2.1.3 National Non-Communicable Disease Burden: Somaliland ... 20
2.2 Global Perspective and Political Commitments on NCDs ... 21
2.3 The Role of Health Risk Factors: Prevalence, Perceptions, and Practices ... 23
2.3.1 Definition of a Health Risk Factor ... 23
2.3.2 Unhealthy Diet ... 24
2.3.3 Tobacco Smoking ... 25
2.3.4 Harmful Use of Alcohol ... 25
2.3.5 Khat Chewing ... 26
2.3.6 Physical Inactivity ... 27
2.4. Urbanization in Sub-Saharan Africa and the Emergence of Noncommunicable Diseases ... 28
2.5 Epidemiological Transition Theory ... 30
2.6 Comparison of the Biomedical Model and Social Model for the Study of Non-Communicable Diseases ... 32
2.7 Global NCD Assessment Method: STEPwise Approach ... 35
2.7 Conceptual Scheme ... 37
2.8 Conclusion ... 39
CHAPTER 3. METHODOLOGY ... 40
3.1 Research Design ... 40
3.2 Ontology and Epistemology ... 41
3.4.1 Quantitative Health and Lifestyle Survey ... 42
3.4.2 Qualitative In-depth Interviews and Focus Group Discussion ... 46
3.5 Methodological Reflection ... 47 3.5.1 Validity ... 47 3.5.2 Reliability ... 47 3.5.3 Credibility ... 47 3.5.4 Dependability ... 48 3.5.5 Transferability ... 48 3.6 Ethical Reflection ... 48 3.7 Conclusion ... 49
CHAPTER 4. RESEARCH SETTING: THE SOMALILAND CONTEXT ... 50
4.1 Location ... 50
4.2 Culture ... 50
4.3 Drought and Food Insecurity ... 51
4.4 Conclusion ... 52
CHAPTER 5. INDIVIDUAL NON-COMMUNICABLE DISEASE RISK FACTOR PREVALENCE IN RURAL AND URBAN SOMALILAND ... 53
5.1 Results ... 54
5.1.1 Demographic Characteristics ... 54
5.1.2 Behavioural Risk Factor Findings ... 59
5.1.3 Physical Risk Factor Findings ... 66
5.2 Comparison of Rural and Urban Results ... 68
5.3 Conclusion ... 71
6.1 Results ... 72
6.1.1 Perceptions on Lifestyle Transformation ... 72
6.1.2 Practices and Beliefs Surrounding Non-Communicable Diseases ... 74
6.1.3 Perceptions on Khat, Tobacco, and Alcohol Use ... 76
6.1.4 Health Professionals’ Perception on Non-Communicable Disease Prevalence, Prevention, and Control in Somaliland ... 78 6.2 Conclusion ... 79 CHAPTER 7. CONCLUSION ... 80 7.1 Summary of Findings ... 80 7.2 Theoretical Reflection ... 81 7.3. Research Recommendations ... 82 7.4 Policy Recommendations ... 82 REFERENCES ... 84 APPENDIX ... 93
LIST OF ACRONYMS AND ABBREVIATIONS
BMI Body mass index
CMNN Communicable, maternal, neonatal, and nutritional diseases DBP Diastolic blood pressure
MoHD Ministry of Health Development NCDs Non-communicable diseases SBP Systolic blood pressure
SDGs Sustainable Development Goals SSA Sub-Saharan Africa
STEPS STEPwise approach to noncommunicable disease risk factor surveillance UN United Nations
UNICEF United Nations Children’s Fund WC Waist circumference
WHeR Waist-to-height-ratio WHiR Waist-to-hip ratio
LIST OF FIGURES
FIGURE 1. Age standardized noncommunicable disease mortality rate per 100 000
population in the Eastern Mediterranean Region by country group, 2015. ...…. 18 FIGURE 2. The proportionate mortality rates of noncommunicable diseases, communicable
diseases, and injuries by country group in the Eastern Mediterranean Region (EMR), 2015 (WHO/EMRO 2019, p. 17). Somalia is included in Group 3. … 19 FIGURE 3. A simplified model of epidemiological transition. According to the model, as Sub-Saharan African countries move from the upper left corner to the bottom right, the region will face a so called “double burden” of disease. ……… 31 FIGURE 4. Model of the broad determinants of health, also known as the social determinants
of health. ……… 34 FIGURE 5. NCD STEPwise framework for global chronic disease surveillance. ………… 36 FIGURE 6. Conceptual scheme. ………. 38
LIST OF TABLES
TABLE 1. Age group distribution and marital status of participants (18-69 years) in
Somaliland, by rural-urban location. ………. 55 TABLE 2. (In)formal school attendance, completed education level, and work status of
participants (18-69 years) in Somaliland, by rural-urban location. ………. 56 TABLE 3. Estimated daily income of participants (18-69 years) in Somaliland, by
rural-urban location. ………. 57 TABLE 4. Source of drinking water, toilet ownership status, and type of toilet used by
participants (18-69 years) in Somaliland, by rural-urban location. ………. 58 TABLE 5. Fuel source, household livestock ownership and first healthcare contact of
participants (18-69 years) in Somaliland, by rural-urban location. ………. 59 TABLE 6. A summary of the associated links between modifiable risk factors studied and the
four major noncommunicable diseases. ……… 59 TABLE 7. Prevalence of tobacco smoking and khat chewing among 18–69-year-old
participants in Somaliland, by gender and rural-urban location. ……… 60 TABLE 8. Prevalence of perceived regular weekly intake of fruit and vegetables among 18–
69-year-olds in Somaliland, by gender and rural-urban location. ……….. 62 TABLE 9. Prevalence of salt intake and perception of proportion of salt intake in diet for
participants among 18–69-year-olds in Somaliland, by gender and rural-urban location. ………... 64 TABLE 10. Prevalence of sugar intake and perception of proportion of sugar intake in diet
for participants among 18–69-year-olds in Somaliland, by gender and rural-urban location. ………... 65 TABLE 11. Prevalence of physical activity and leisure sports participation for participants
among 18–69-year-olds in Somaliland, by gender and rural-urban location. ….. 66 TABLE 12. Prevalence of physical risk factors for men (n= 81) in Somaliland, by rural-urban
location and age category. ……… 67 TABLE 13. Prevalence of physical risk factors for women (n= 106) in Somaliland, by
CHAPTER 1. INTRODUCTION
1.1 Background
Non-communicable diseases (NCDs), also known as chronic diseases, are the leading cause of death worldwide (WHO 2013a, para. 2).NCDs are non-transmissible, slowly progressive diseases that are the result of a combination of factors, including one’s genetic predisposition, physiological and environmental conditions as well as behavioural characteristics (WHO 2018a, para. 6). In 2016, 71% (40.5 million) of all preventable deaths worldwide were due to NCDs. Moreover, 85% of these premature deaths (under the age of 70) happened in low- and middle-income countries (WHO 2018a, paras. 1–2). The four main types of NCDs, which account for over 80% of all NCD related deaths annually, are cardiovascular disease (17.9 million), cancers (9.0 million), chronic respiratory disease (3.9 million), and diabetes (1.6 million) (WHO 2018a, para. 3). The prevalence of these four NCDs can be drastically decreased by reducing the four major modifiable risk factors, namely tobacco use, harmful use of alcohol, unhealthy diets and physical inactivity (WHO 2018a, para. 5).
Global concern has steadily increased regarding the growing challenges posed by NCDs (WHO 2018b, p. 10). This concern has been reflected in the relatively recent addition of NCDs in the global health agenda. The group of diseases were first prioritized in 2011, when World Health Organization (WHO) member states agreed on a political declaration for the prevention and control of NCDs (WHO 2018b, p. 10). Nine voluntary targets were agreed to be attained by 2025, which included a “25% relative reduction in total mortality for cardiovascular diseases, cancer, diabetes, or chronic
respiratory diseases” (WHO 2014, pp. xii). Moreover, since the first declaration, the United Nations
(UN) member states agreed to the Sustainable Development Goals (SDGs) in 2015. This included the health goal (SDG target 3): “ensure healthy lives and promote well-being for all at all ages” 1 (WHO
1 The SDG health goal also encompasses targets 3.5, 3.a and 3.b, which respectively call upon states to “strengthen the prevention and
treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol,” “strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate,” and “support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries […]”. (WHO 2014, p. 10)
2014, p. 10). Incorporated in target 3 is the specific NCD target (SDG target 3.4): “by 2030, reduce
by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being” (WHO 2014, p. 10).
However, thus far, several countries have not lived up to these agreements. In a follow-up resolution by Member States at the UN High-Level Meeting on NCDs in 2018, it was acknowledged that not enough action has been taken since 2011 to reach the targets by 2030 (UNGA 2018, p. 2). The 2018 resolution also highlighted that there was great concern for the health implementation challenges faced by developing countries, especially as developing countries were due to face a disproportionate increase of NCDs compared to the rate of increase in the rest of the world (UNGA 2018, p. 2).
In Sub-Saharan Africa (SSA), infectious diseases remain commonplace (Gouda et al. 2019, p. 1375). However, the region is now having to deal with a simultaneous rise in NCD prevalence (Kushitor and Boatemaa 2018, p. 1). This double phenomenon has been characterised as Africa’s double burden of disease (Kushitor and Boatemaa 2018, p. 1). Communicable diseases such as malaria, tuberculosis, and HIV have historically been, and continue to be the largest contributors to the region’s disease burden (Gouda et al. 2019, p. 1375). However, it is projected that SSA will have one of the largest increases in NCD mortality globally (Gouda et al. 2019, p. 1375). NCDs such as chronic respiratory diseases, chronic kidney disease, cardiovascular diseases, diabetes, cancers as well as mental illnesses and substance abuse disorders are all indicated to be on the rise in several countries across SSA (Gouda et al. 2019, p. 1375). Alarmingly, the region already has the highest age-specific rates of hypertension worldwide (46%). In contrast, the lowest rates are in the Americas (36%) (Kushitor and Boatemaa 2018, p. 1). Furthermore, surveillance measures for NCD risk factors done in the past decade have found that a majority of adults in SSA are exposed to risk factors for NCDs, namely tobacco smoking, harmful use of alcohol, an unhealthy diet, physical inactivity, obesity, or high blood pressure (Gouda et al. 2019, p. 1375).
Rapid, unplanned urbanization has been found to create an environment which intensifies the burden of NCDs and their risk factors in SSA (Ahmed et al. 2019, p. 2). The region has the highest urbanization rate in the world (OECD and Sahel and West Africa Club 2020, p. 4). What is more, the region’s urban populations are expected to double in the next 25 years from its current population size of 472 million (World Bank 2017, para. 2). This rate of change is concerning as urbanization has the power to fundamentally change peoples’ way of life (Allender et al. 2010, p.
297). Poor dietary habits, physical inactivity, and substance use may be dramatically amplified as people move into cities (Juma et al. 2019, p. 1). These changes can generate socioeconomic problems that cut into developing countries’ scarce funding, and thus, undermine their social as well as economic development (WHO/AFRO 2014, para. 4).
Somalia has one of the highest rates of urbanization in the SSA region (UN Habitat n.d., para. 2). Somaliland (a de facto state in northern Somalia) is experiencing an even more rapid rate of urbanization than the rest of Somalia due to the de-facto state’s relative political stability (UN Habitat n.d., para. 2). With a population of 4.3 million, over half (53%) of Somaliland’s population is now estimated to be living in urban areas (UN Habitat n.d., para. 2). Moreover, the country is expecting a 4 million increase to its urban population by 2025 (UN Habitat n.d., para. 2). Somaliland is unique in that its urban population increase is in part due to returnees from neighbouring countries, and internally displaced populations fleeing famine and the effects of climate change (Kilcullen 2019, pp. 17, 20). In addition, Somaliland has one of the worst health indicators in the SSA region, with the main issues being the de-facto state’s poor governance, scarce financial resources, and an inadequate number of qualified health professionals (Leather et al. 2006, p. 1120).
It is particularly important for developing nations with minimal health infrastructure and constrained budgets to be pro-active and prioritize relatively inexpensive preventive public health measures for NCDs, rather than rely on more costly medical solutions (Juma et al. 2019, p. 10). The human toll of NCDs is reason enough to justify urgent action, however, the impact extends far beyond health. The socio-economic cost of inaction against NCDs are substantial for low-income countries (WEF and WHO 2011, p. 5). It has been estimated that the continued underinvestment in NCD control and prevention will result in a loss of more than USD 310 billion in gross domestic product for low-income countries between 2011 and 2025 (WEF and WHO 2011, p. 5). Cost-effective measures, or “best buys,” specifically designed by the WHO for developing countries are available (WHO 2017a, p. 2). However, the effective implementation of these “best buy” measures requires the collection of epidemiological data on NCDs and NCD risk factor prevalence on a national level (WHO 2011a, para. 10). Gathering quantitative epidemiological data for risk factor prevalence helps policymakers and health professionals form evidence-based strategies, while qualitative data on risk factors ensures that the most appropriate, context-specific tools are chosen for NCD prevention (Juma et al. 2019, p. 10). Additionally, the recent COVID-19 pandemic has highlighted the importance of researching, preventing and controlling NCDs as people with NCDs are particularly vulnerable to the effects of the COVID-19 virus (WHO 2020, para. 2).
1.2 Research Relevance and Aim
Historically, the academic focus and international aid has been assigned to more pressing issues in SSA, namely communicable diseases, and maternal, neonatal, and nutritional conditions (CMNN) (Dalal et al. 2011, p. 886). Therefore, despite NCDs soon dominating the disease landscape in SSA, the overall epidemiological understanding of NCDs in SSA is still low (Dalal et al. 2011, p. 886). Similarly, data concerning NCDs and their risk factors are limited for Somaliland (Ahmed et al. 2019, p. 2). The first study known to the author on NCD risk factors in Somaliland was conducted by Ahmed et al. in 2019. Their study took a quantitative look at selected NCD risk factor prevalence in Hargeisa, the capital of Somaliland, for women and men among 20 to 69-years (Ahmed et al. 2019, p. 1). However, there were no studies looking at the differences in NCD risk factor prevalence between rural and urban areas for Somaliland. Moreover, no studies for Somaliland have taken a qualitative approach to NCD risk factor studies, nor combined qualitative and quantitative methods.
Therefore, the objective of this thesis is to understand the prevalence of selected NCD risk factors in rural versus urban Somaliland. In other words, this study aims to quantitatively understand how widespread NCD risk factors are in rural and urban Somaliland, but crucially to also qualitatively understand why NCD risk factors may be widespread. Ultimately, it is hoped that this thesis serves as part of the foundation for future national level research in Somaliland. In addition, by taking on a mixed-method approach, it is hoped that this thesis influences the formation of more holistically informed cross-sectoral measures to tackle the imminent, yet complex problem of NCDs.
1.3 Research Questions
To achieve the objective of this thesis, the following question is examined:
How does the prevalence, perceptions, and practices of non-communicable disease risk factors differ between rural and urban Somaliland?
The main research question is explored by the aid of two sub-research questions:
(A) To what extent does the prevalence of individual risk factors for non-communicable diseases differ between rural and urban Somalilanders?
(B) What are the perceptions and practices surrounding noncommunicable disease risk factors in rural and urban Somaliland?
1.4 Outline of Thesis
The thesis comprises of seven chapters which feature different components of the research topic.
Chapter 2 focuses on the existing literature on NCDs and their risk factors and describes the theoretical framework, which underpins this thesis. More specifically, the chapter underlines what is known about extent of the problem posed by NCDs, globally, regionally and in Somaliland. Chapter 2 highlights the existing global political commitments made on the prevention and control of NCDs. Then, individual health risk factors for NCDs and the literature on the health perceptions and practices surrounding them in relevant regions are discussed. Moreover, urbanization in SSA and its ties to NCDs is investigated. This is followed by an examination of the epidemiological transition theory, and the comparison of the biomedical model and social model as bases for the framework of this thesis. Afterwards, the STEPwise approach to noncommunicable disease risk factor surveillance (STEPS), and its flaws and merits are outlined. Chapter 2 concludes with the presentation of the conceptual scheme used in this thesis.
Chapter 3 clarifies the methodological approach used in the thesis. The chapter includes the overall research design, epistemological and ontological stances, the data collection and analysis research techniques, and the methodological and ethical reflections. Chapter 4 explores the context
within which the research is conducted, namely Somaliland. It gives an overview of the research location and provides a brief summary of the cultural, political, and environmental contexts.
Chapter 5 and 6 outline the findings made in this study. Chapter 5 focuses on the quantitative findings and answers the first sub-research question, which investigates the extent to which the prevalence of individual risk factors for NCDs are different in rural and urban Somaliland. Chapter 6 focuses on the qualitative findings and answers the second sub-research question on the type of perceptions and practices surrounding NCDs that are found in rural and urban Somaliland. Chapter 7 provides an overall conclusion, suggests areas for further research, and recommends policies for NCD prevention and control in Somaliland.
CHAPTER 2. LITERATURE REVIEW AND
THEORETICAL FRAMEWORK
This chapter first details what is meant and what is known about NCDs and its related risk within the research context (see 2.1). More specifically, the chapter first contextualises the scope of the NCD burden, globally (see 2.1.1), on relevant regional levels (see 2.1.2), and in Somaliland (see 2.1.3). Next, an explanation is given on where NCDs fit in the global public health agenda and what international goals and agreements have already been made to prevent and combat them (see 2.2). This is followed by a detailed explanation of individual health risk factors and how they relate to NCDs. The section also reviews what is known about the particular risk factor prevalence in SSA and the Eastern Mediterranean region and how these risk factors are practiced and perceived (see 2.3). Afterwards, the literature on urbanization’s links to NCDs and their risk factors, particularly in SSA, are described (see 2.4). This is followed by the theoretical portion, which begins with the assessment of the well-known and far-reaching epidemiological transition theory and its applicability for the African context (see 2.5). After this examination, a comparison is made between the biomedical model and social model as theoretical bases for this thesis (see 2.6). Following the comparison, a brief exploration of the benefits and drawbacks of the global NCD survey mechanism (WHO STEPwise Instrument) is presented (see 2.7). Finally, the concepts, themes, and models in the literature review and theoretical framework are summarized in a conceptual scheme (see 2.8).
2.1 The Scope of Non-Communicable Disease Burden
2.1.1 Global Non-Communicable Disease BurdenThe contemporary global burden of NCDs can be characterised by the immensely disproportionate likelihood of dying prematurely due to an NCD in developing countries, rather than the developed countries (Kostova et al. 2017, p. S1). Although NCDs are often associated with older age, in most low- and middle-income countries NCDs have slowly become the primary cause of early death and disability, albeit not yet in Africa (Kostova et al. 2017, p. S1; WHO 2011b, p. 1). In stark contrast to developed countries, most NCD related deaths in developing countries happen before the age of 70 (Kostova et al. 2017, p. S1). In populations younger than 60 years, death due to NCDs account for 40% of all deaths in low-income countries. In contrast, the
premature NCD death rate is 12% for high-income countries (Kostova et al. 2017, p. S1). In other words, the chance of dying due to an NCD as an adult is quadrupled for people living in the developing world (Kostova et al. 2017, p. S1). This disparity is made worse by the fact that the growth of NCDs in developing countries has not meant a comparative decline in the prevalence of communicable diseases, creating what is known as the “double burden” of diseases (Kostova et al. 2017, p. S1; Boutayeb 2010, p. 532).
From a global health security and disease control perspective, the higher prevalence of NCDs and NCD risk factors hinder infectious disease control operations (Kostova et al. 2017, p. S1). This is due to NCDs increasing the susceptibility or severity of certain infectious diseases (Kostova et al. 2017, p. S1). For example, the ongoing COVID-19 pandemic has shown how patients with existing conditions such as obesity (including in young people), diabetes, or cardiovascular disease have an increased chance of severe medical outcomes, including death (WHO/EURO 2020, paras. 1–3; WHO/UNDP 2020, pp. 1–2). Moreover, if poorly controlled, the high prevalence of NCDs in a population can place a heavy burden on already strained healthcare systems and drain national healthcare funding, therefore losing the opportunity to use funds on other important health issues (Kostova et al. 2017, p. S1).
2.1.2 Regional Non-Communicable Disease Burden: Eastern Mediterranean and Africa
The Eastern Mediterranean Region, which is a classification of countries established by the WHO, includes Somalia and countries from North Africa and the Middle East (WHO/EMRO 2019, pp. 14, 16). Similar to global trends, data from 2015 found that the leading cause of death was due to NCDs in most of the countries in the region (WHO/EMRO 2019, p. 14). However, relative to other countries in the Eastern Mediterranean Region, Somalia has the lowest rate of age standardized NCD related mortalities per 100 000 population at 22% (see Figure 1.) (WHO/EMRO 2019, p. 14). In contrast, the highest NCD death rate in the region is in Lebanon (89%) (WHO/EMRO 2019, p. 14). Moreover, according to the WHO Noncommunicable Diseases Country Profiles (2018c, p. 187), CMNNs account for the vast majority of the disease burden in Somalia. CMNNCs accounted for 64% (40 000 people) of overall deaths in the country (WHO 2018c, p. 187).
FIGURE 1.
Age standardized noncommunicable disease mortality rate per 100 000 population in the Eastern Mediterranean Region (EMR) by country group, 2015. (WHO/EMRO 2019, p. 17)
NCDs accounted for more than 60% percent of deaths in the Eastern Mediterranean Region in 2015 (WHO/EMRO 2019, p. 14). The Figure 2 illustrate the proportion of the NCD mortality rate in the Eastern Mediterranean Region. The lowest NCD rate is in Group 3 followed by Group 1 and Group 2 with Somalia belonging to Group 3. According to the WHO, the Eastern Mediterranean Region has the second highest NCD age-standardized death rate in the world, only surpassed by the WHO African Region (WHO/EMRO 2019, p. 14).
62 61 50 22 57 43 43 85 48 78 76 89 78 54 89 83 76 72 6670 77 85 0 10 20 30 40 50 60 70 80 90 100 Total YemenSudan Somalia Pakistan Djibouti Afghanistan TunisiaSyria MoroccoLibya LebanonJordan Iraq Iran Egypt United Arab EmiratesSaudi Arabia Qatar Oman Kuwait Bahrain EM R Gr ou p 3 Gr ou p 2 Gr ou p 1
FIGURE 2.
The proportionate mortality rates of noncommunicable diseases, communicable diseases, and injuries by country group in the Eastern Mediterranean Region (EMR), 2015 (WHO/EMRO 2019, p. 17). Somalia is included in Group 3.
The age standardized NCD mortality rate reveals that people living in SSA countries encounter NCD risk factors more often throughout their life-course than people living in developed regions and therefore the increasing rate of NCDs in SSA cannot be solely attributed to an ageing population (Dalal et al. 2011, p. 886). This is because age, while it has a significant influence on the likelihood of developing an NCD, is not as significant as the accumulated rate of risk factors gathered throughout a person’s life (Dalal et al. 2011, p. 886). Therefore, although communicable diseases and poverty driven diseases still prevail in the WHO Africa Region, when looking at age-standardized death rates, rather than absolute death rates, many African countries are highly impacted by NCDs (Dalal et al. 2011, p. 886; Maher et al. 2010, p. 944). For example, the Democratic Republic of Congo, Nigeria, Ethiopia, and South Africa already have a higher age standardized NCD death rate than developed countries (Dalal et al. 2011, p. 886). NCD death rates were also found to be higher in all age groups from 15 to 59 years in Tanzania than in the developed countries (Dalal et al. 2011, p. 886). In addition, the estimated cardiovascular disease
11 11 37 25 73 75 52 62 16 14 11 12 0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 % Group 1 Group 2 Group 3 EMR
Communicable, maternal, prenatal, and nutritional conditions NCDs Injuries 0 10 20 30 40 50 60 70 80 90 100
death rate is triple as high in some African countries than in some European ones (Maher et al. 2010, p. 944).
The WHO expects that the Africa Region will have the greatest increase in the absolute rate of NCD prevalence over the next decade, an estimated 27% (Maher et al. 2010, p. 944). At this rate, it is likely that NCDs will take over communicable diseases as the leading cause of death on the continent as soon as 2030 (WHO 2011b, p. 1; Mudie et al. 2019, pp. 1–2). Hypertension, a major risk factor for cardiovascular disease and stroke, is already highly widespread at 48% occurrence rate in the region (Mudie et al. 2019, p. 1). In addition, diabetes has been found to occur in about 5.1% and obesity in about 20% of the SSA population (Mudie et al. 2019, p. 1). In the Africa Region, NCDs have been found to be linked to urbanization, decreased air quality, and behavioural risk factors (smoking, physical inactivity, unhealthy diet, harmful use of alcohol, and obesity) (Dalal et al. 2011, pp. 886–887).
Nevertheless, it is important to note that comparisons between the burden of NCDs in the SSA region to the burden in other regions may not always be appropriate (Mudie et al. 2019, p. 2). This is because certain infectious diseases as well as the life-long effects of under-nutrition are risk factors of NCDs (Mudie et al. 2019, p. 2). The higher prevalence of these conditions in SSA, namely HIV, hepatitis B virus, human papillomavirus, and tuberculosis, contribute to a higher risk of cancers, cardiovascular diseases and diabetes (Mudie et al. 2019, p. 2; Coates et al. 2020, e1490).
2.1.3 National Non-Communicable Disease Burden: Somaliland
Data on NCD risk factors is scarce in Somaliland (Ahmed et al. 2019, p. 1). Only one previous quantitative study, conducted by Ahmed et al. in 2019, has been done on NCD risk factors in Hargeisa, Somaliland. Ahmed et al. determined the prevalence of risk factors (smoking, low fruit and vegetable consumption, physical inactivity, raised blood pressure, overweight and obesity, and abnormal blood lipid levels) for a participant population of total 1100 people in Hargeisa, Somaliland. The participants ranged from 20 to 69 years and the study included both men and women (Ahmed et al. 2019, p. 1).
The study found that most risk factors were high in Somaliland (Ahmed et al. 2019, p. 1). For example, Somalilanders had very low quantities of fruits vegetables in their diets with more
than 97% of participants having less than one serving of either fruit or vegetable per day. Moreover, Somalilander women were more likely to be overweight and have low physical activity levels. However, hypertension was high among men and women, which corresponds with findings from the rest of Africa. In addition, it was found that risk factors increased with age for both genders (Ahmed et al. 2019, p. 1).
2.2 Global Perspective and Political Commitments on NCDs
The WHO was arguably the main driver in bringing NCDs to the forefront of the global health agenda, and thus solidifying “NCDs” as a common term within global public health terminology (Adjaye-Gbewonyo and Vaughan 2019, p. 2). Although the WHO started pushing for the categorisation and recognition of NCDs as a distinct group of non-infectious conditions and as a prominent global health problem in the 1970s, it was not until 1993 when the term NCDs took off. This happened as a result of the WHO participating in the World Bank’s milestone 1993 publication titled Global Burden of Disease (GBD) (Adjaye-Gbewonyo and Vaughan 2019, p. 2).
The GBD greatly facilitated the WHO in acquainting stakeholders with the term NCDs (Adjaye-Gbewonyo and Vaughan 2019, p. 2). It helped to emphasise the importance of NCDs as a distinct public health issue by categorising it as one of three major global disease burdens. The disease categories in the GBD were: (1) communicable diseases, neonatal, maternal conditions and malnutrition; (2) non-communicable diseases; and (3) injuries (Murray and Lopez 1996, p. 14).
This recognition further sparked the use of the term NCDs since it made apparent that conditions which were previously viewed as infectious can also be typed as chronic (Adjaye-Gbewonyo and Vaughan 2019, p. 2). Therefore, this research uses the term NCDs instead of chronic diseases as the former term is a well-established disease category in the international health development field (Weisz and Vignola-Gagné 2015, p. 507). When using the term NCDs in the analysis within this research, unless explicitly stated otherwise, the thesis refers to the four main types of NCDs, namely cardiovascular disease, cancer, respiratory illnesses and diabetes.
It took until 2011 for NCDs to be recognised by an international declaration as a significant global health threat (Reddy 2020, p. e456). NCDs were not mentioned in the Millennium
concern in the 2011 Political Declaration of the high-level meeting of the General Assembly on the prevention
and control of non-communicable diseases (Reddy 2020, p. e456; Chestnov et al. 2014, p. 623). Following
the first UN High-Level Meeting on NCDs in 2011, the WHO created the first global road map for tackling NCDs known as the Global action plan for the prevention and control of NCDs 2013–2020 (Chestnov et al. 2014, p. 623). The global action plan on NCDs included nine voluntary targets to be achieved by 2025. These targets were as follows (WHO 2013b, p. 5):
1. 25% relative reduction in total mortality for cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases.
2. At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context.
3. A 10% relative decrease in pervasiveness of deficient physical action. 4. A 30% relative decrease in mean populace admission of salt/sodium.
5. A 30% relative decrease in the pervasiveness of current tobacco use in people matured 15+ years.
6. A 25% relative decrease in the pervasiveness of raised circulatory strain, or regulation of predominance of raised pulse, as indicated by national conditions.
7. Stop the rise in diabetes and overweigh/obesity.
8. At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes.
9. An 80% accessibility of the moderate fundamental innovations and essential drugs, including generics, required to treat major NCDs in both open and private offices.
Moreover, NCDs finally found their way into the successor of the Millennium Development Goals as the disease group can now be found in the 2015 Sustainable Development Goals (SDGs) (Reddy 2020, p. e456).
By 2013, there was a significant increase in the number of member states that had placed the basic foundations for NCD control and prevention (Chestnov et al. 2014, p. 623). In a follow-up survey conducted by the WHO in 2013 on the 2011 NCD targets, some noteworthy strides had been achieved in the NCD field. For example, 95% out of the 172 WHO member states that signed the 2011 political declaration had implemented an NCD department in their Ministry of Health (Chestnov et al. 2014, p. 623). Half of the member states have an NCD prevention and control plan in place, which includes budgetary allotment for the cause (Chestnov et al. 2014, p. 623). In addition, the number of states which had conducted NCD risk factor surveys increased from 30% in 2011 to 63% in 2013 (Chestnov et al. 2014, p. 623).
Despite these noteworthy steps towards the right direction, there have been several setbacks in the implementation of the NCD targets. In the second UN High Level-Meeting on NCDs in 2014, it was observed that many member states, especially developing countries, lacked the capacity to act and the required expertise to combat NCDs effectively (Chestnov et al. 2014, p. 623). Therefore, the resolution made by the UN at the 2014 General Assembly set forth an agenda which stressed the need for international cooperation (Chestnov et al. 2014, p. 623).
However, by the third UN High-Level Meeting on NCDs held in 2018, inadequate action to tackle NCDs globally remained a serious issue. The 2018 NCD political declaration largely disappointed organizations working in the NCD field, such as the NCD Alliance and The United Nations Children’s Fund (UNICEF) (Newman 2018, paras. 1, 7). The disappointment largely stemmed from the fact that the political declarations made since 2011 had not rendered any significant progress in terms of additional funding or action on the four major non-communicable diseases, namely cardiovascular disease, diabetes, cancer, and chronic respiratory disease (Newman 2018, para. 2). The next UN High Level-Meeting on NCDs is scheduled for 2025 (Newman 2018, para. 15).
2.3 The Role of Health Risk Factors: Prevalence, Perceptions, and Practices
2.3.1 Definition of a Health Risk FactorFrom an epidemiological standpoint, a risk factor (also known as a determinant) is a variable, which is linked to an increased likelihood of developing a disease or infection (AIHW 2017, para. 1). The WHO defines a health risk factor as “a factor that raises the probability of adverse health outcomes” (WHO 2009, p. v). Risk factors are used in public health to measure population level risk for diseases rather than describe the possible health outcome for a specific individual (WHO 2003, p. 10). Risk factor data can then be used to alter the distribution of these diseases on a population level (WHO 2003, p. 10).
Due to the quantity of factors influencing a populations’ health being countless and interrelated, it is difficult to be comprehensive. Therefore, the WHO argues that priority in a surveillance system for NCDs in particular should be given to those risk factors which: (a) have
measures; (c) have a proven valid means of measurement; and (d) the measurements can be attained by means of proper ethical standards (WHO 2003, p. 11).
Hence, global NCD surveillance focuses significantly on relatively few, easily obtainable, yet important data on behavioural risk factors (WHO 2003, p. 12). Behavioural risk factors can be defined as lifestyle habits that an individual has the most ability to modify (Linardakis et al. 2015, para. 6). The WHO highlights the four major behavioural risk factors for NCDs as being an unhealthy diet, tobacco smoking, harmful use of alcohol, and physical inactivity (WHO 2018a, para. 5). These behavioural risk factors are examined more extensively in the following sub-sections (see 2.3.2– 2.3.6) with the addition of khat use.
2.3.2 Unhealthy Diet
Having a significant portion of one’s diet containing trans fats, saturated fats, added sugar or salt increases the risk of cardiovascular diseases and diabetes (Kassa and Grace 2020, p. 6). Eating an ample amount of fruit and vegetables, conversely, has a protective affect against coronary heart disease and stroke (Kassa and Grace 2020, p. 6). It has been found that socio-economic status has a significant influence on the quality of individuals’ diets (Kassa and Grace 2020, p. 6). The more economically affluent have healthier diets, while high-calorie diets with low nutritional value were found to be associated with individuals with lower socio-economic standing.
In some SSA countries, culturally bound body-image ideals play a role in driving the unhealthily high intake of calories (Adeboye et al. 2012, p. 517). Having a large waist circumference can be a sign of beauty, health, charisma, fame, fertility or power (Adeboye et al. 2012, p. 517; Kassa and Grace 2020, p. 7). In parts of Africa, for example, women are customarily fattened up before marriage (Adeboye et al. 2012, p. 517). It has also been found that African men tend to prefer larger, overweight women to thin women (Adeboye et al. 2012, p. 517). Therefore, in several African countries, obesity is commonly not considered as a serious health issue in need of intervention (Adeboye et al. 2012, p. 517).
Furthermore, Adeboye et al. (2012, p. 517) argue that historic food insecurity on the African continent may be a major contributing factor behind over-eating in women. The authors argue that although the effects of urbanization and affluence heavily influence over-eating for part of the population in Africa, at the poorer end of the socio-economic range, food insecurity is a
larger reason for excessive caloric intake. Studies by Townsend et al. and Chaput et al. (as cited in Adeboye et al. 2012, p. 517) found links between food insecurity and women while Chaput found that that link was only found in women and not men in Uganda. Adeboye et al. (2012, p. 517) therefore conclude that women in particular, regardless of socioeconomic standing, are at greater risk of developing obesity in Africa.
2.3.3 Tobacco Smoking
Tobacco smoking is the number one leading cause of preventable early death worldwide (WHO/AFRO n.d., para. 1). Hence, the WHO calls tobacco smoking the largest threat to global public health (WHO/EMRO n.d., para. 2). Around 5 million people die from direct tobacco smoking, while more than 600 000 people die from second-hand smoke yearly (WHO/EMRO
n.d., para. 2). Tobacco smoking is a risk factor for all four major NCDs – cardiovascular disease,
diabetes, chronic respiratory disease, and cancer (Eriksen et al. 2015, p. 2). In addition, it is a risk factor for infectious diseases such as tuberculosis and lower respiratory infections, thus tobacco smoking creates an immense health burden on societies (Eriksen et al. 2015, p. 7).
In the Eastern Mediterranean Region, which encompasses Somalia, the projected 2020 tobacco smoking prevalence rate is 18.6% (Tobacco Tactics 2020, para. 2). However, this rate is expected to decline to 17% by the year 2025 (Tobacco Tactics 2020, para. 2). In real numbers, the Eastern Mediterranean Region had an estimated 90 million tobacco smokers in 2015 and will have 94 million smokers in 2025 (largely driven by demographic increases) (Tobacco Tactics 2020, para. 2). Moreover, the region is unique in that there is a significant disparity between the number of male and female tobacco smokers (Tobacco Tactics 2020, para. 4). Tobacco smoking was found to be prevalent at 33.3% for men, while only 3.9% of women smoked.
2.3.4 Harmful Use of Alcohol
As one of the top causes of disability, illness, and death worldwide, the excessive use of alcohol continues to have disastrous implications for societies at large and on heavy drinkers and people associated with them in particular (WHO/EMRO n.d., paras. 1–2). Around 3.3 million die from alcohol use yearly and alcohol can be said to be responsible for almost 5% of the global disease and injury burden (WHO/EMRO n.d., paras. 2–3). Alcohol is associated with an estimated 10%
of the global NCD burden (WHO/EMRO n.d., para. 3). The long-term over-use of alcohol is linked to NCDs such as liver cirrhosis, numerous cancers, stroke, and hypertension. Additionally, alcohol can lead to more imminent health conditions, such as injuries, mental disorders, depression, and loss of memory (WHO/EMRO n.d., paras. 3–4).
Conversely, it is estimated that the Eastern Mediterranean Region has the lowest alcohol related disease burden in the world (WHO/EMRO 2006, p. i). About 90% in the region are life-time abstainers (i.e., never had an alcoholic drink), compared to the global average of 48% (WHO/EMRO, para. 6). It should be noted that the overall extent to which harmful alcohol consumption is prevalent in the region is relatively unclear (WHO/EMRO 2006, p. 1; WHO 2018d, p. 57). This is due to alcohol use being stigmatized and therefore a taboo topic, and that is also illegal in some countries in the region. Nevertheless, with data from 12 out of 21 countries in the region, the WHO has estimated in 2004 that “The Eastern Mediterranean Region displays a steady
low consumption”. Ten, including Somalia, out of 20 countries in the region have a total ban on the
service and sale of all forms of alcohol (WHO 2018d).
Therefore, the WHO states that the Eastern Mediterranean region’s cultural and religious constraints on alcohol have had a protective effect, which has kept the disease burden of alcohol relatively low compared to the global average (WHO/EMRO 2006, p. 2). However, binge drinking, which the excessive use of alcohol with the intent of becoming intoxicated, is a particularly large problem among adolescents in developing countries. Seven countries in the region, including Somalia, have reported that the use of alcohol is most common among youths who are under the age of 20 years, despite alcohol consumption being illegal (WHO/EMRO 2006, p. 2).
2.3.5 Khat Chewing
Although khat (Catha edulis Forsk, in Somali qaad or jaad) is not included as one of the four main behavioural risk factors for NCDs by the WHO, khat is a commonly used psychoactive stimulant in East Africa and the Arabian Peninsula (Teklie et al. 2017, p. 321; Elmi 1983, p. 163). Consequently, the psychoactive substance has a distinct yet significant impact on overall health and NCD burden in the region (Mihretu et al. 2020, pp. 1–2). Khat is associated with cardiovascular dysfunctions, hypertension and increased likelihood of diabetes as well as insomnia, oral conditions, gastritis, haemorrhoids, psychotic states and depression (Mihretu et al. 2020, p. 2).
It’s estimated that khat use is around 59% in Somalia, with the vast majority of users being men (around 75% of Somali men chew khat versus 7–10% of women) (Mihretu et al. 2020, p. 1; Rampes 2003, p. 457). It is a culturally accepted custom in East Africa and the Arabian Peninsula, including Somalia and Somaliland (Mihretu et al. 2020, pp. 1–2). However, it should be noted that there remains a great gap in literature on the margins between normative (acceptable) and problematic use of khat and at what quantities and frequencies the negative health effects of khat use start to emerge (Mihretu et al. 2020, p. 2).
2.3.6 Physical Inactivity
The WHO ranks physical inactivity as one of the leading causes of death and disability in the world (WHO 2002, para. 1). On a global scale, industrialization and the expansion of the service sector has made it easier to remain sedentary while also reducing work related physical activity (Kassa and Grace 2020, p. 5). This has led to an alarming proportion of the world’s population (estimated at 60%) to live a predominantly sedentary lifestyle (Kassa and Grace 2020, p. 5). In addition, on a global scale, 23% of adult and 81% of adolescents in 2010 (aged between 11–17 years) were not getting sufficient amounts of physical activity (WHOa n.d., para. 2). Being adequately physically active has major benefits as it lowers the risk of numerous NCDs, including cardiovascular disease, stroke, diabetes, hypertension, colon and breast cancer (Guthold et al. 2011, p. 52). Moreover, physical activity benefits an individual’s overall mental and physical well-being as high levels of physical activity lowers the rate of depression, controls weight and metabolic energy balance (Guthold et al. 2011, p. 52).
In the African region, physical activity levels differ greatly between countries from 46.8% in Mali engaging in regular physical activity to 96.0% in Mozambique (Guthold et al. 2011, p. 54). However, Guthold et al. (2011, pp. 52, 57) found that although there was no clear pattern found in overall physical activity levels in Africa, leisure-time activity was consistently low in all 22 countries studied in the region.
2.4. Urbanization in Sub-Saharan Africa and the Emergence of Noncommunicable
Diseases
In the developing world, the future of urbanization and what it will mean for overall health for its populations remains largely unclear (Van de Poel 2009, p. 11). Current available literature suggests that generally, urban populations tend to be healthier than their rural equivalents. Yet, as Van de Poel (2009, pp. 11–12) argues, this data may be hiding huge inequalities within urban populations. Although populations living in urban areas can benefit from the proximity of health services, information, education, and job opportunities, these benefits often do not extend to the poorest populace living in urban slums (Smith et al. as cited in Van de Poel 2019, pp. 11–12). In addition to not having access to basic services and opportunities, slum dwellers are burdened with living conditions that are detrimental to their health (Smith et al. as cited in Van de Poel 2019, pp. 11– 12).
This is often further exacerbated by external factors present near or in slums such as air pollution, dangerous traffic, and isolation from the rest of society. Popkin (as cited in Van de Poel 2009, p. 12) argues that the combination of fast economic, environmental and social changes produced by urbanisation leads to the growth in the prevalence rates of NCDs in cities. Moreover, urban growth which is rapid and unplanned can lead to a scenario where the demands of the urban population severely surpass the environmental capacity of the area (Moore as cited in Van de Poel 2009, p. 12). This can further expose the urban populations to NCDs and therefore weaken NCD intervention measures.
In SSA countries, a substantial disparity remains between the rich and poor urban residents (Juma et al. 2019, p. 3). SSA remains mostly rural, however, the region is experiencing one of the most rapid rates of urbanization in the world (Juma et al. 2019, p. 2). This fast rate means that by 2035, 50% of SSA populations are expected to live in urban areas. Yet, urbanization in SSA can be largely characterised as “rapid, unplanned and unmanaged”. This is because SSA urbanization is mainly driven by demographic increases that have not been coupled with proportionate increases in socioeconomic development (Juma et al. 2019, pp. 2–3).
Of the SSA urban populations, 62% live in informal urban settlements (Juma et al. 2019, p. 1). SSA informal settlements, or urban slums, are associated with poor living conditions, urban
poverty, inequality, lack of social amenities, and lack of physical activity space (Juma et al. 2019, p. 1). This combination of an adverse physical environment as well as psychological stress predisposes the urban poor to NCDs as deprived urban environments may facilitate the adoption of adverse health behaviours, including physical inactivity, unhealthy diets, tobacco use and the harmful use of alcohol (Juma et al. 2019, p. 1).
Several studies suggest that the link between urbanization and increased NCD prevalence in SSA is quite clear. Studies done in Ougadougou, Burkina Faso have shown that urban dwellers had higher rates of hypertension, while studies done in the slums of Nairobi, Kenya found substantial links between the risk of second-hand smoking and low socio-economic status (Soubeiga et al. 2017, p. 1; Juma et al. 2019, p. 3). Studies in Kenya, Ghana, and South Africa have indicated that city living was associated with a higher risk of obesity (Juma et al. 2019, p. 3). Studies in Cape Verdean, Ghanaian, and Senegalese cities found that there was a significant increase in urban dwellers’ consumption of calorie-dense foods with added sugar (Juma et al. 2019, p. 7). The urban dwellers in these studies consumed processed food and drink with sugar seven times more frequently than fruits and vegetables (Juma et al. 2019, p. 7). Moreover, in South Africa, urban environments were found to correspond with several behavioural risk factors for NCDs, namely tobacco smoking, harmful use of alcohol, low physical activity, as well as low fruit and vegetable intake (Juma et al. 2019, p. 3).
Nevertheless, numerous SSA scholars argue that the unique mode of urbanization in SSA and its links to NCD risk needs to be studied further (BeLue 2009, p. 2; Khorrami 2017, p. 470). For example, Bikler et al. (2018, p. 1618) contend that the link between urbanization and NCD rise in SSA is still relatively unexplored. The authors state that, “An important, yet poorly explained
epidemiological feature of NCDs is their low incidence in underdeveloped areas of low-income countries and rising rates in urban areas” (Bikler et al. 2018, p. 1617). The scholars add that the asymmetrical and rapid
urbanization of SSA therefore presents a unique chance to examine how environment influences disease epidemiology (Bikler et al. 2018, p. 1618).
2.5 Epidemiological Transition Theory
The theory of the epidemiological transition has played one of the greatest roles in shaping the discussion surrounding NCDs (Reubi et al. 2016, p. 181). The epidemiologist, Abdel Omran, published an article in 1971, which first mentions the concept of an “epidemiological transition” (Adjaye-Gbewonyo and Vaughan 2019, p. 3). Omran used the phrase to refer to a shift he was seeing in the Western world, namely a shift from an abundance of infectious diseases to primarily chronic ones (Adjaye-Gbewonyo and Vaughan 2019, p. 3).
Omran posited that the West had in the past transitioned from conditions of undernutrition and infectious disease (times of pestilence and famines) and gradually headed towards an age where such conditions declined (Adjaye-Gbewonyo and Vaughan 2019, p. 3). He argued that Western countries had reached an age where life expectancies had risen and chronic diseases were the primary cause of death, which he referred to as the “age of degenerative and man-made diseases” (Adjaye-Gbewonyo and Vaughan 2019, p. 3). The theory’s notable effect on NCD framing is largely owed to Omran’s reasoning that this shift would also become evident in developing regions as their economies developed (Adjaye-Gbewonyo and Vaughan 2019, p. 3).
The epidemiological transition theory can be illustrated through a simplified model (see Figure 2) (Stewart-Wilson et al. 2018, p. 29). Countries on the left-hand side have high levels of communicable disease and low levels of NCDs. As countries develop, they reach a tipping point in the middle where communicable diseases and NCDs occur at similar rates (Stewart-Wilson et al. 2018, p. 29). Finally, highly developed countries reach a point where there is a high level of NCDs and low level of communicable diseases, seen on the right-hand side (Stewart-Wilson et al. 2018, p. 29).
FIGURE 3.
A simplified model of epidemiological transition. According to the model, as Sub-Saharan African countries move from the upper left corner to the bottom right, the region will face a so called “double burden” of disease. (Modified
by author, Stewart-Wilson et al. 2018, p. 29).
Omran’s work remained in relative obscurity for 20 years after its initial publication, however, it quickly became a citation classic in the 1980s when his predictions about the rise of chronic diseases in developing countries became evident (Weisz and Vignola-Gagné 2015, p. 507). Consequently, the epidemiological transition theory became a convenient analytical tool for NCDs and has particularly been used to explain NCD trends in developing countries (Adjaye-Gbewonyo and Vaughan 2019, p. 3).
However, the epidemiological transition theory has often been understood to insinuate that NCDs come about as a consequence of economic development in general, and industrialization in particular (Adjaye-Gbewonyo and Vaughan 2019, p. 3). It can be argued that this interpretation has resulted in the dichotomisation of NCDs and infectious diseases in Western medical understanding. In other words, the epidemiological transition theory implies that there is a distinct pattern and quantifiable separation between where (space) and when (time) NCDs occur (Adjaye-Gbewonyo and Vaughan 2019, p. 3).
The epidemiological transition theory has not stood well on a universal scale, particularly in explaining disease prevalence in SSA countries.Defo (2014, p. 2)argues that, apart from island
African nations and perhaps north Africa, the model has shown to be inadequate to explain diseases patterns on the continent:
“[...] the overwhelming evidence indicates that over the past 60 years, African countries have not experienced any sustained shift from one epidemiological regime to another nor seen demographic changes and health improvements as predicted from the perspectives of the demographic, epidemiological, and health transition, in contrast to prevailing situations in other developing countries outside of Africa.”
Due to the epidemiological theory’s inadequacy in explaining the NCD situation in the African region, this research avoids using the epidemiological model as part of its foundational framework. In doing so, this thesis avoids linking NCDs to the rich, urbanized, and more developed as this framing may easily neglect, or belittle NCDs that are highly linked to poverty conditions.
2.6 Comparison of the Biomedical Model and Social Model for the Study of
Non-Communicable Diseases
The major differences between the two models are, (1) the underlying assumptions about the causes of disease, (2) the level of complexity or scope of disease modality, and (3) the methods used to tackle health issues (Adibi 2014, pp. 18–20). Germov (2014 as cited in Adibi 2014, p. 19) explains that the two models differ mainly in terms of when, how, and through whom disease is treated, he asserts that: “While the biomedical model concentrates on treating disease and risk-taking among
individuals, the social model focuses on societal factors that are risk imposing or illness inducing (for example, toxic pollution, stressful work, discrimination, and peer pressure”.
The biomedical model can be said to be the foundation of Western medicine and it has historically made up the epistemology of the public health sphere, including that of the WHO (Adjaye-Gbewonyo and Vaughan 2019, p. 3; Burrows et al. 2005, Chapter 1, p. 6;Hewa 2016, p. 26). The biomedical model focuses on the physical and biological origins of diseases (Adjaye-Gbewonyo and Vaughan 2019, p. 3). It assumes that disease is due to an abnormal deviation from normal biological functioning (Hewa, 2016, p. 26). The model also differentiates between the body and the mind as it emphasises that disease can be treated within the body, irrespective of a person’s state of mind (Hewa, 2016, p. 26). Therefore, the model is considered to be reductionist as it
centres around the individual, reducing the individual into simpler, more solvable units (Adjaye-Gbewonyo and Vaughan 2019, p. 3). Regarding NCDs, the biomedical model is responsible for highlighting the importance of risk factors, namely genetic and biological (for example age, race, gender, and family history) (Adjaye-Gbewonyo and Vaughan 2019, p. 3).
The social model refers to an approach in public health, which centres on the social determinants of health and disease (Gerhardt 1989 as cited in Adibi 2014, p. 19). The WHO (WHOb n.d., para. 1) defines social determinants of health (SDH) as being “[…] the conditions in
which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” In other words, a SDH perspective can be conceptualized as the view that health and
disease is due to the amalgamation of several non-mutually exclusive factors, namely socioeconomic status, structural conditions, and early childhood encounters, as well as gender, ethnicity and disability (Hewa and Liu 2016, p. 4; Marmot and Bell 2019, p. 10). Moreover, the SDH encapsulates the availability and quality of social support networks and interpersonal relationships, also referred to as social capital (Hewa 2016, pp. 4, 14, 15, 20).
Therefore, SDH covers the deeper explanations, or the “causes of the causes” of health inequality (Marmot and Bell 2019, p. 10). In essence, the SDH frames health issues through the central issue of power distribution in a society, and the ways in which power imbalances perpetuate health inequalities (WHO 2010, pp. 5, 20). By using the SDH perspective, one can better grasp the deeper social pathways at play, focusing on both community agency and the responsibility of the state in addressing health inequalities (WHO 2010, p. 5).
One of the most widely cited and influential models for SDH is the Dahlgren-Whitehead rainbow model (Bambra et al. 2009, p. 285). Dahlgren and Whitehead (1991, p. 11) created a multi-layered diagram to illustrate the multi-dimensional factors that influence disease (see Figure 4.). Starting from the outer most layer of the diagram, the over-arching determinant of health is the structural environment. Beneath this layer are the material and social conditions in which people live their lives. This secondary social and material layer includes such aspects as the working conditions, housing, education, health care, and food sources available. Next, social and community networks make up the third layer. Lastly, individual lifestyle factors that influence health are considered, such as diet, tobacco smoking and drinking alcohol (Dahlgren and Whitehead 1991, p. 11).
FIGURE 4.
The broad determinants of health, also known as the social determinants of health (Author’s rendition of the
original diagram by Dahlgren and Whitehead 1991, p. 11).
Although the social model takes on a broader view of disease, it should be explicitly noted that it does not reject the biological properties of diseases, nor does the model negate the importance of medical interventions (Adibi 2014, p. 20). Rather, the social model emphasizes the overarching social context of disease and illness. In doing so, it stresses that effective health interventions can and should be made before disease occurs and that preventive, instead of curative efforts, should be prioritized (Adibi 2014, p. 20). Moreover, Germov (2014 as cited in Adibi 2014, p. 20) argues that, “the social model is not intended as a replacement for the biomedical model but
rather coexists alongside it”. It is within this context that the framework for this thesis was built. The
two perspectives, both biomedical and social, were used in order to create a holistic framework (see 2.7). It places value on both the contextual social nature of disease and the underlying individual, biological causes. The methodology of this thesis is also underpinned by this dualist perspective as a both quantitative and qualitative methods are utilized.
2.7 Global NCD Assessment Method: STEPwise Approach
As NCD prevalence is on the rise worldwide, the international community has sought ways to institutionalise NCD surveillance in order to follow changes and assess appropriate interventions Kroll et al. 2015, p. 2). However, the issue lies in the lack of surveillance capacity in low- and middle-income countries (Kroll et al. 2015, p. 1). The WHO has evaluated that the current surveillance capacity for NCDs is very poor in several countries (Kroll et al. 2015, p. 2). The nature of NCDs being long-term and a complex group of diseases means that data needs to be gathered on a consecutive basis over a long period of time (Kroll et al. 2015, p. 2). Thus, at the 53rd World Health Assembly in 2000, the WHO (Bonita et al. 2001, p. 1), together with the support of its member states, devised and passed a plan for global action on NCDs. This included three main objectives (Bonita et al. 2001, p. 1):
[1.] To map the emerging epidemics of NCDs and to analyse their social, economic, behavioural and political determinants to provide guidance for policy, legislation and finance;
[2.] To reduce the level of exposure of individuals and populations to the common risk factors for NCDs;
[3.] To strengthen health care for people with NCDs
Several scholars agree that the capacity to collect new data and the quality of existing health data is poor in many low- and middle-income countries (Kroll et al. 2015, p. 6). Alawan et al. (2010, as cited in Kroll et al. 2015, p. 6) for instance found that in low- and middle-income countries there were significant gaps in the accuracy and quality of data, the standardisation of risk factors, and in the reporting of NCD outcomes (Kroll et al. 2015, p. 6). The authors also state that socioeconomic information was rarely linked to health data, which severely hindered the evaluation of disparities of health outcomes (Kroll et al. 2015, p. 6).
Therefore, the WHO developed the STEPS framework, which is a standardized, yet flexible method for NCD risk factor monitoring (Bonita et al. 2001, p. 2). The STEPS framework comprises of three “steps” or levels (Bonita et al. 2001, pp. 4–5). These levels allow for lesser or greater degree of detail. The freedom in choosing the comprehensiveness and complexity of data gathering provides flexibility in a low resource setting. Moreover, the levels ensure that
same country) is not compromised (Bonita et al. 2001, pp. 2–3). Being a sequential process, the WHO recommends completing the demographic information questionnaire (Step 1) and the simple physical measurements section (Step 2), before moving onto the more demanding portion (Step 3), which is the collection of blood samples for the biochemical assessment (See Figure 5.) (Bonita et al. 2001, p. 4).
FIGURE 5.
Framework for NCD STEPwise method for global chronic disease surveillance (Author’s modified rendition of the original framework by Bonita et al. 2001, p. 4).
Although there are challenges to the implementation of the STEPwise survey (namely high personnel turnover rate, survey fatigue and weak infrastructure), Riley et al. (2016, p. 77) argue that the STEPwise method for NCD surveillance remains the most relevant approach to global NCD surveillance. The authors note that since the World Health Assembly in 2013 approved the Global
Action Plan for the Prevention and Control of Noncommunicable Diseases, the WHO member states are
expected to “undertake periodic data collection on the behavioural and metabolic risk factors (harmful use of
alcohol, physical inactivity, tobacco use, unhealthy diet, overweight and obesity, raised blood pressure, raised blood glucose, and hyperlipidemia)” (WHO 2013 as cited in Riley et al. 2016, p. 77).
Due to the WHO STEPwise framework’s flexibility, standardisation, and global relevance, this study uses it as part of its framework to understand NCD risk factor prevalence in Somaliland Moreover, the STEPs survey remains valuable, as it aids in the monitoring and reporting of seven out of the nine global targets for NCDs that member states have agreed and signed on to do (Riley
