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Part 6: Templates and Forms Overview

1. physical activity Instrument questions activity at work e travel to and from places e recreational activities Men N Women N Both Sexes N Work Transport Recreation Work Transport Recreation Work Transport Recreation Age Group Median inter Median inter Median inter Median inter Median inter Median inter Median inter Median inter Pee quartile range quartile range quartile range quartile range quartile range quartile range quartile range quartile range ngs 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier Work P1 P2 P3 P4 P5 P6 Transport P7 P8 P9 Recreation P10 P11 P12 P13 P14 P15 e Fpi Info programme name Psetspecific unweighted PsetspecificWT weighted Part 6 Templates and Forms 6 3D 44 Section 3D Data Book Template WHO STEPS Surveillance No physical Description percentage of participants classified as doing no work transport or recreational related physical activity activity by setting Instrument questions activity at work e travel to and from places e recreational activities Men N Women N Both Sexes N Work Transport Recreation Work Transport Recreation Work Transport Recreation Age Group N N N N N N N N N
2. 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier C7 e Epi Info programme name Cworknotpaid unweighted Part 6 Templates and Forms 6 3D 15 Section 3D Data Book Template WHO STEPS Surveillance Unpaid work Description proportion of participants in unpaid work and unemployed Instrument question continued e Which of the following best describes your main work status over the last 12 months Both Sexes N Unemployed Non Home l Age Group paid Student faaker Retired Able to Notable work to work n n n n n n 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier C7 e Epi Info programme name Cworknotpaid unweighted Part 6 Templates and Forms 6 3D 16 Section 3D Data Book Template WHO STEPS Surveillance Income Description mean reported household earnings per year of participants in local currency presented only for both sexes because results are for the household not individuals Instrument question e Taking the past year can you tell me what the average earning of the household have been Both Sexes Age Group N Mean 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier C9a o
3. District District District District District Age Group 1 2 3 4 5 n n n n n 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years e Questions used uses coding column as identifier I1 e Epi Info programme name District unweighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D 7 WHO STEPS Surveillance Demographic Information Results Age group by gender Description summary information by age group and gender of the participants sample Instrument question e Sex e What is your date of birth Men Women Both Sexes Age Group N N N n n n 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier C1 C2 or C3 e Epi Info programme name Cagesex unweighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D 8 WHO STEPS Surveillance Ethnicity Description summary results for the ethnicity of the participants Instrument Question e What is your insert relevant ethnic group racial group cultural subgroup others background Men N Women N Both Sexes N Ethnic Ethnic Ethnic Other Ethnic Ethnic Ethnic Other Ethnic Ethnic Ethnic Other Age Group group group group ethnic group group group ethnic group group group ethnic Ruani Aano aas group Giai asad Sedai group ma ee PRT group
4. 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier Work P1 P4 Transport P7 Recreation P10 P13 e Epi Info programme name Pnoactivitybyset unweighted PnoactivitybysetWT weighted Part 6 Templates and Forms 6 3D 45 Section 3D Data Book Template WHO STEPS Surveillance Sedentary Description total time spent in sedentary activities per day Instrument question e sedentary behaviour Men N Women N Both N mean median mean median mean median Age Group mean median inter median inter median inter mean mean quartile range quartile range quartile range 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier P16 e Epi Info programme name Psedentary unweighted PsedentaryWT weighted Part 6 Templates and Forms 6 3D 46 Section 3D Data Book Template WHO STEPS Surveillance Work related Description median time of work related moderate and vigorous intensity physical activity per day physical activity Instrument questions e activity at work Men N Women N Both N Moderate Vigorous Moderate Vigorous Moderate Vigorous Age Group median inter median int
5. Part 6 Templates and Forms Section 2 Interview Blood Collection and Data Entry Forms 6 2 17 WHO STEPS Surveillance STEPS Data Entry Folder Coversheet Tracking Information Computer C Phase of data entry Ist Key Entry First key second key entry or complete 2nd Key Entry Cirde one Complete Instrument section entered and template being used Location Tracking Cirde only one Survey Consent Biochemical Data entry staff name or ID number BP Start Date SS End Date OOOO Part 6 Templates and Forms 6 2 18 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Section 3 Reporting Templates Fact Sheet and Data Book Overview Introduction This section includes two templates that can be used to report both the comprehensive and summary results of the STEPS survey In this section This section contains the following Report Templates Fact Sheet Analysis Guide 6 3B 1 Fact Sheet Template 6 3C 1 Data Book Template 6 3D 1 Part 6 Templates and Forms 6 3 1 Section 3A Reporting Templates WHO STEPS Surveillance lt Site Country gt STEPS Survey lt year gt Fact Sheet Analysis Guide PLEASE use this as a guide when you are altering your instrument as it will provide you with a guideline for which questions are needed in order to calculate these basic indicators To calculate the basic indicators that are presented on the fact sheet refer to the Data Analysis section
6. Step 2 or Step 3 plus coverage of core expanded and optional items Identify the sample size and sample frame that will be used Identify geographical coverage of the survey Describe resources that e are required e have already been committed and e are expected including support from WHO Describe any aspects of the survey that might raise specific cultural or ethical issues Describe e To whom and how the results will be reported and disseminated e Any restrictions on results e Confidentiality of personal identification information e Use of results once the survey is complete e Methods for informing and involving community leaders and community groups in the STEPS surveillance project Continued on next page 6 1 8 WHO STEPS Surveillance Part 3 Survey Scope Continued Budget Provide a detailed budget that includes e total funds required for each year planned to implement all STEPS activities as identified in the Scope e source of funds and e funding gap USD pf Part 6 Templates and Forms 6 1 9 Section 1 Planning and Set Up Templates WHO STEPS Surveillance Part 4 Declarations Introduction Declaration by principal investigator Declaration by head of department The information supplied in this application is to the best of my knowledge and belief accurate I have considered the ethical issues involved in this research and believe that I have adequately addressed them in this a
7. Step 3 Centre Village Cluster Number Technician ID Date Participant ID Time of last meal drink Time of collection Fasting blood sugar If did not fast properly appointment of next visit Part 6 Templates and Forms Section 2 Interview Blood Collection and Data Entry Forms 6 2 15 WHO STEPS Surveillance Biochemical Measurement Form Step 3 Centre Village Cluster Number Technician ID Date Partici Fasting Blood Hgb Total Chol HDL LDL TRIG Analyzed pant ID Sugar Strip Lab Part 6 Templates and Forms 6 2 16 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Data Entry Tracking Form Computer Label 1 Key 2 Key Participant ID Date received Date finished Date received Date finished Error on Instrument Supervisor s decision Individual Comment Checked out by supervisor Date checked out Date checked in Note This form is available electronically in excel and can be downloaded with the data entry templates available from www who int chp steps
8. n n n n n n n n n n n n 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier C5 e Epi Info programme name Cethnic unweighted Part 6 Templates and Forms 6 3D 9 Section 3D Data Book Template WHO STEPS Surveillance Household Description mean number of adults over 18 years old in each household presented only for both sexes because results are for the composition household not individuals Instrument question e How many people older than 18 years including yourself live in your household Both Sexes Age Group N n 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier C8 e Epi Info programme name Chousehold18 unweighted Part 6 Templates and Forms 6 3D 10 Section 3D Data Book Template WHO STEPS Surveillance Education Description mean number of years of education in population of the participants Instrument question e In total how many years have you spent at school or in full time study excluding pre school Both Men Women Sexes Age Group N N N n n n Mean Mean Mean 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier C4 e Epi Info programme name Ceduyears unweighte
9. 0 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier M3 M4 e Epi Info programme name Mbmiclass unweighted MbmiclassWT weighted Part 6 Templates and Forms 6 3D 56 Section 3D Data Book Template WHO STEPS Surveillance Waist Description mean waist circumference results excluding pregnant women circumference Instrument question e Waist circumference measurement Waist circumference Men Women Age Group N N mean mean 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier M7 e Epi Info programme name Mwaist unweighted MwaistWT weighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D 57 WHO STEPS Surveillance Hip Description mean hip circumference results excluding pregnant women circumference Instrument question e Hip circumference measurement Hip circumference Men Women Age Group N N mean mean 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier M15 e Epi Info programme name Mhip unweighted MhipWT weighted Part 6 Templates a
10. 34 years 35 44 years 45 54 years 55 64 years 25 44 years 45 64 years 25 64 years Part 6 Templates and Forms Section 3D Data Book Template 6 3D 68 WHO STEPS Surveillance Section 4 Archiving Archiving your STEPS Materials Introduction Once the survey is completed and before the team is disbanded all records need to be properly stored in order to prevent loss Policies and Most governments and large organisations will have their own established systems archival systems in which case their facilities are likely to be your best long term storage option Investigate storing your data at e Ministry of Health e WHO country office e WHO regional office Archival period Decide on the archival period The duration may have been specified by your ethics authority If not consider twelve years This is long enough for data to be available for further STEPS surveys and long enough to investigate query from the results Checklist Use the checklist below to help ensure all necessary steps have been completed Decide on the duration of storage e Names and contact details of site coordinator and one other member of the coordinating committee 2 Box up all e Questionnaires e Manuals e Interviewing materials e Printed versions of all file m 5 Determine who is entitled to have access to the archive 6 Place a copy of the form to apply for access in each box T Provide copies of electronic files without
11. 60 WHO STEPS Surveillance Raised blood Description raised blood pressure pressure Instrument question e Reading 1 3 systolic and diastolic blood pressure SBP 2 140 and or DBP 2 90 mmHg SBP 2 160 and or DBP 2 100 mmHg Both Both AgeiGioup Men Women Sexes Men Women Sexes N N N N N N 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier M11la M11b M12a M12b M13a M13b e Epi Info programme name Mraisedbp unweighted MraisedbpWT weighted Part 6 Templates and Forms 6 3D 61 Section 3D Data Book Template WHO STEPS Surveillance Treatment for Description percentage of participant treated with drugs for raised blood pressure during the last 2 weeks raised blood pressure Instrument question e During the past two weeks have you been treated for high blood pressure with drugs medication prescribed by a doctor or other health worker Treatment with drugs for raised blood pressure during the last 2 weeks Age Group Men Women hail N N N 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier M14 e Epi Info programme name Mbptreatment unweighted MbptreatmentWT weighted Part 6 Templates and Forms 6 3D 62 S
12. Blood pressure diagnosis and treatment Description raised blood pressure diagnosis and treatment results Instrument questions e During the past 12 months have you been told by a doctor or other health worker that you have elevated blood pressure or hypertension e Are you currently receiving any of the following treatments advice for high blood pressure prescribed by a doctor or other health worker e Are you currently taking any herbal or traditional remedy for your high blood pressure Raised blood pressure diagnosed Currently taking blood pressure by doctor or health worker in last 12 drugs prescribed by doctor or months health worker Age Group Men Women babes Men Women fale N N N N N N 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier H1 H2 H3a e Epi Info programme name Hraisedbpadvice unweighted HraisedbpadviceWT weighted 6 3D 49 Part 6 Templates and Forms WHO STEPS Surveillance Section 3D Data Book Template Blood pressure Description percentage of population with raised blood pressure who received lifestyle advice lifestyle advice Instrument question e Are you currently receiving any of the following treatments advice for high blood pressure prescribed by a doctor or other health worker Advised or trea
13. Cl 95 Cl 95 Cl Age Group N 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier D5 e Epi Info programme name Doil unweighted DoilWT weighted Part 6 Templates and Forms 6 3D 39 Section 3D Data Book Template WHO STEPS Surveillance Physical Activity Introduction Analysis physical activity data can be very complicated and the result confusing The following guidelines will help clarify the results of the physical activity and will also provide valuable information on the classifications Make sure you use some of these guidelines when you report physical activity data e MET values are applied to vigorous and moderate intensity variables in the work and recreation settings These have been calculated using an average of the typical types of activity undertaken Different types of activities have been grouped together and given an MET value based on the intensity of the activity Applying MET values to activity levels allows us to calculate total physical activity For more information regarding MET values go the STEPS website at www who int chp steps e The calculations below use multiple questions in the physical activity section To simplify this a bit the questions have been clustered into four groups as they appear in the Instrument In the Instrument questions section of the table only the group label appear
14. Disease Risk Factor Surveillance Key personnel A STEPS coordinating committee has been set up to oversee and manage the planning preparation and implantation of the proposed survey and includes the following people Organisation and qualifications Dates The proposed survey dates are Start Date oo o Completion Date O O Part 6 Templates and Forms 6 1 6 Section 1 Planning and Set Up Templates WHO STEPS Surveillance Part 2 Scientific Assessment Introduction Scientific basis Summary of report Part 6 Templates and Forms Section 1 Planning and Set Up Templates 6 1 7 WHO STEPS Surveillance Part 3 Survey Scope Introduction Goals Objectives Overview of scope Sample size Geographical coverage Resources Cultural ethical issues Reporting and use of results Part 6 Templates and Forms Section 1 Planning and Set Up Templates Identify the planned goals or use for the information gathered For example as a contribution to ongoing data collection to e Describe the current levels of risk factors for chronic diseases in this population e Track the direction and magnitude of trends in risk factors e Plan or evaluate a health promotion or preventive campaign e Collect data from which to predict likely future demands for health services Specify objectives that support gathering essential information only Specify the scope of surveillance to be conducted over time ie Step 1
15. a Dail 5 6 days 1 4 days 1 3days lt once a Age Group y per wk per wk per month month y per wk per wk per month month 95 Cl 95 Cl 95 Cl 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier Al A2 e Epi Info programme name Afrequency unweighted AfrequencyWT weighted Part 6 Templates and Forms 6 3D 31 Section 3D Data Book Template WHO STEPS Surveillance Largest Description largest number of drinks consumed during a single occasion in the last 12 months number of drinks in last 12 Instrument question mantis e In the past 12 months what was the largest number of drinks you has on a single occasion counting all types of standard drinks together Maximum number of drinks during a single day in last 12 months Kae Gia Men Women Both Sexes g p N N N mean mean mean 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier Al A6 e Epi Info programme name Alargestnum unweighted AlargestnumWT weighted Part 6 Templates and Forms 6 3D 32 Section 3D Data Book Template WHO STEPS Surveillance Heavy drinking Description number of standard drinks consumed in the last 7 days grouped into three categories Instrument questi
16. and year to insert month and year country site name carried out Step 1 Step 2 and Step 3 if applicable Socio demographic and behavioural information was collected in Step 1 Physical measurements such as height weight and blood pressure were collected in Step 2 If applicable biochemical measurements were collected to assess blood glucose and cholesterol levels in Step 3 The STEPS survey in insert site country was a population based survey of adults aged 25 64 adjust as necessary A insert type of sampling design sample design was used to produce representative data for that age range in insert country site name A total of 2 000 adjust as necessary adults participated in the country site name STEPS survey The overall response rate was x A repeat survey is planned for insert year if funds permit Results for adults aged 25 64 years incl 95 Cl adjust if necessary Both Sexes Males Females Step 1 Tobacco Use 77 1 29 49 Percentage who currently smoke tobacco daily 66 2 88 1 Pi r e 1 E Hafe 1 For those who smoke tobacco daily Average age started smoking years Average years of smoking Percentage smoking manufactured cigarettes For smokers of manufactured cigarettes Mean number of manufactured cigarettes smoked per day Step 1 Alcohol Consumption Percentage of abstainers who did not drink alcohol in the last year Percentage of current drinkers who
17. arm to test for sugar and fat levels in your blood This may cause some mild pain Timeframe It is estimated that Step 1 and 2 of the survey will take approximately 1 hour Community The results of this study will be used to assist the Ministry of Health in benefits developing public health programmes that target efforts to lower the risk factors that lead to chronic non communicable diseases Your rights It is your right to e decline to take part in the study e withdraw your consent at any time and e decline to answer any questions in the interview that you do not wish to answer Continued on next page Part 6 Templates and Forms 6 2 4 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Participant Information Form Step 1 2 amp 3 Continued Confidentiality You will provide your name and contact information so that you can be contacted if there is any need to follow up with you after the survey is conducted Your participation and data provided will be completely confidential Your name will not be used in any report of the study Results The results of this survey will be used to help plan strategies in reducing the risk factors that contribute to chronic non communicable diseases in your community The results will be published in research publications media briefings fact sheets and reports and can be made available to you through the local researchers Ethical This study ha
18. drank alcohol in the past 30 days For those who drank alcohol in the last 30 days Percentage of women who had 4 or more drinks on any day in the last week Percentage of men who had 5 or more drinks on any day in the last week Percentage who drank alcohol on 4 or more days in the last week Step 1 Fruit and Vegetable Consumption in a typical week Mean number of servings of fruit consumed per day Mean number of servings of vegetables consumed per day Percentage who ate 5 or more combined servings of fruit amp vegetables per day Step 1 Physical Activity Percentage with low levels of activity defined as lt 600 MET minutes week Median time spent in work related physical activity per day minutes Median time spent in transport related physical activity per day minutes Median time spent in recreational physical activity per day minutes WHO STEPS chronic disease risk factor surveillance fact sheet www who int chp steps Country gt STEPS Survey lt year gt Fact Sheet D o or aqd aged 64 yea 9 O aq ecessa DO Step 2 Physical Measurements Mean body mass index BMI kg m Percentage who are overweight or obese BMI 2 25 kg m Percentage who are obese BMI 30 kg m Average waist circumference cm Mean systolic blood pressure SBP mmHg Mean diastolic blood pressure DBP mmHg Percentage wit
19. indicated below If this is not convenient please contact us to make a suitable time for the survey lt site gt Ministry of Health lt address gt World Health Organization Notification of WHO STEPS Surveillance Visit Today Ministry of Health employees visited your household to conduct a survey of people between the ages of 25 to 64 on health issues We will try and return on the date indicated below If this is not convenient please contact us to make a suitable time for the survey Day Date Time lt site gt Ministry of Health lt address gt Part 6 Templates and Forms 6 2 2 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Participant Information Form Step 1 2 amp 3 Introduction Title of survey Aim of the survey Data collection methods What s involved This form describes what participation in the WHO STEPS survey means The title of this survey is the STEPS Surveillance of Risk Factors for Chronic Non Communicable Diseases NCDs This survey will determine the extent in name of the site of several of the major risk factors for major chronic non communicable diseases e g diseases not caused by infections These diseases and their risk factors include e Tobacco use e Alcohol consumption e Low intake of fruit and vegetable e Physical inactivity e Raised blood pressure e Raised fasting blood glucose e Obesity e High levels of fat in th
20. me or contact name of institution and contact details or Principal Investigator at site Signing this consent indicates that you understand what will be expected of you and are willing to participate in this survey Read by Participant Interviewer o do Agreed Refused i O i I hereby provide INFORMED CONSENT to take part in Steps 1 and 2 of the Risk Factors Study For participants under 21 years old a parent or guardian must also sign this form Name Sign Parent Guardian Sign Witness Sign Part 6 Templates and Forms 6 2 6 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Consent Form 2 Step 3 Dear Participant Random selection Confidentiality Voluntary participation What s involved Consent to participate Signatures You have been randomly selected to be part of this survey and this is why we would like to interview you This survey is conducted by the World Health Organization in collaboration with the Ministry of Health and the WHO Regional Office and will be carried out by professional interviewers from name of institution This survey is currently taking place in several countries around the world The information you provide is totally confidential and will not be disclosed to anyone It will only be used for research purposes Your name address and other personal information will be removed from the instrument and only a code will be used to co
21. you currently taking any of the following treatments advice for diabetes prescribed by a doctor or other health worker Advised or treated by doctor or Advised or treated by doctor or Advised or treated by doctor or health health worker to lose weight health worker to stop smoking worker to start or do more exercise Both Both Both Age Group Men Women Sexes Men Women Sexes Men Women Sexes N N N N N N N N N 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier H8d H8e H8f e Epi Info programme name Hdiabeteslifestyle unweighted HdiabeteslifestyleWT weighted 6 3D 53 Part 6 Templates and Forms Section 3D Data Book Template WHO STEPS Surveillance Diabetes advice by traditional healer treatment Instrument questions Description percentage of population with diabetes who are seeking advice with traditional healers and receiving traditional e During the past 12 months have you seen a traditional healer for diabetes e Are you currently taking any herbal or traditional remedy for your diabetes Age Group Counselling by Traditional Healer for Diabetes during last 12 months Current Herbal or traditional treatment for Diabetes Both Both Men Women Sexas Men Women Sexes N N N N N N 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 C
22. Part 6 Templates and Forms Overview In this Part This Part covers the following topics Section 1 Planning and Set Up Templates Section 2 Interview Blood Collection and Data Entry 6 2 1 Forms Section 3 Reporting Templates Fact Sheet and Data 6 3 1 Book Section 4 Archiving 6 4 1 Part 6 Templates and Forms Part 6 Templates and Forms Section 1 Planning and Set Up Templates Overview Introduction This section includes some document templates that can be used during the stage that involves planning and preparing a STEPS survey Intended This section is primarily designed to be used by those fulfilling the following audience roles e STEPS site coordinator e Coordinating committee In this section This section contains the following topics STEPS Implementation Plan Ethical Approval Form Part 6 Templates and Forms 6 1 1 Section 1 Planning and Set Up Templates WHO STEPS Surveillance STEPS Implementation Plan Executive Summary Introduction Current situation Goals Scope Resources Budget Current Situation Introduction Previous risk factor surveys Data availability Infrastructure and capacity Specify if a risk factor survey has already been conducted in this setting Specify risk factor data availability in this setting Specify if there already an infrastructure human capacity equipment other on which STEPS could be built Rationale Specify the rationale f
23. STEPS Surveillance Alcohol Consumption Alcohol Description alcohol consumption status of the population Abstainers have not consumed alcohol in the last 12 months consumption status Instrument questions e Have you consumed alcohol such as beer wine spirits fermented cider or add other local examples within the past 12 months e Have you consumed alcohol such as beer wine spirits fermented cider or add other local examples within the past 30 days Men N Women N Both Sexes N Drank Drank Suren alcohol in paren alcohol in Current prank alcohol drinker drinker in last 12 last 12 Abstainer last 12 Abstainer drinker Abstainer Age Group last 30 month not last 30 Months not last 30 days months not days f days f current current current 95 CI 95 CI 95 CI 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier Al A4 e Epi Info programme name Aconsumption unweighted AconsumptionWT weighted Part 6 Templates and Forms 6 3D 28 Section 3D Data Book Template WHO STEPS Surveillance Number of Description mean number of standard drinks consumed by current drinkers during the last 7 days drinks during last seven days Instrument question e During each of the past 7 days how many standard drinks of any alcoholic drink d
24. aily te Non daily Age Group y smokers y smokers y smokers smokers smokers smokers 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years e Questions used uses coding column as identifier T1 T2 e Epi Info programme name Tsmokefreq unweighted TsmokefreqWT weighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D 21 WHO STEPS Surveillance Amount of tobacco used among smokers Description mean amount of tobacco used by daily smokers by type Instrument question by type e On average how many of the following do you smoke each day Men N Women N Both Sexes N Manu Hand Manu Manu ROEG factured rolled yena Other factured BEAN Riam Other factured prira Reg Other cigarettes cigarettes cigarettes g cigarettes g mean mean mean mean mean mean mean mean mean mean mean mean 95 Cl 95 Cl 95 CI 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 CI 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier T1 T2 T5 a other e Epi Info programme name Tsmoketype unweighted TsmoketypeWT weighted Part 6 Templates and Forms 6 3D 22 Section 3D Data Book Template WHO STEPS Surveillance Initiation and Description average age of initiation and duration in y
25. ate like examples for at least 10 minutes continuously In a typical week on how many days do you do vigorous intensity sports fitness or recreational activities How much time do you spend doing vigorous intensity sports fitness or recreational activities on a typical day Do you do any involve moderate intensity sports fitness or recreational activities that cause large increases in breathing or heart rate like examples for at least 10 minutes continuously In a typical week on how many days do you do moderate intensity sports fitness or recreational activities How much time do you spend doing moderate intensity sports fitness or recreational activities on a typical day Sedentary behaviour How much time do you usually spend sitting or reclining on a typical day Part 6 Templates and Forms 6 3D 41 Section 3D Data Book Template WHO STEPS Surveillance Levels of total Description percentage of participants classified into three categories of total physical activity physical activity Instrument questions activity at work e travel to and from places e recreational activities Men N Women N Both Sexes N Percent Percent Percent High Percent Percent Percent Percent pelea Percent Moderate Moderate Moderate Low level of level of Low level of High level of Low level of High level of Age Grou ey levels of a lt i levels of a3 age levels of ge g p activity cae activi
26. bined servings of fruit amp vegetables D1 D2 D3 D4 DfiveormoreWT Step 1 Physical Activity Percentage with low levels of activity defined as lt 600 MET minutes P1 P15 PtotallevelsWT Median time spent in work related physical activity per day minutes P1 P2 P3 P4 P5 P6 PsetspecificWT Median time spent in transport related physical activity per day minutes P7 P8 P9 PsetspecificWT Median time spent in recreational physical activity per day minutes P10 P15 PsetspecificWT WHO STEPS chronic disease risk factor surveillance www who int chp steps Results for adults aged 25 64 years incl 95 Cl adjust if necessary Questions required to calculate result based on coding column always need C1 C2 or C3 lt Country gt STEPS Survey lt year gt Fact Sheet Analysis Guide Epi Info Programme Name Step2 Physical Measurements Mean body mass index BMI kg m M3 M4 MbmiWT Percentage who are overweight or obese BMI 2 25 kg m M3 M4 MbmiclassWT Percentage who are obese BMI 2 30 kg m M3 M4 MbmiclassWT Average waist circumference cm M2 MwaistWT Mean systolic blood pressure SBP mmHg M11a M12a M13a MbloodpressureWT Mean diastolic blood pressure DBP mmHg M11b M12b M13b MbloodpressureWT Percentage with raised BP SBP 2 140 and or DBP 2 90 mmHg Md Ee MraisedbpWT Percentage with raised BP SBP 2 160 and or DBP 2 100 mmHg M Eo MraisedbpWT St
27. coding column as identifier H4 H5 e Epi Info programme name Hraisedbptrad unweighted HraisedbptradWT weighted Part 6 Templates and Forms 6 3D 51 Section 3D Data Book Template WHO STEPS Surveillance Diabetes Description history of diabetes diagnosis and treatment results diagnosis and treatment Instrument questions e During the past 12 months have you ever been told by a doctor or other health worker that you have diabetes e Are you currently taking any of the following treatments advice for diabetes prescribed by a doctor or other health worker Diabetes diagnosed by doctor or Currently taking insulin prescribed Currently taking oral drugs prescribed health worker in last 12 months for diabetes by doctor or health for diabetes by doctor or health worker worker Both Both Both Age Group Men Women Sexes Men Women Sexes Men Women Sexes N N N N N N N N N 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier H7 H8a H8b e Fpi Info programme name Hdiabetes unweighted HdiabetesWT weighted Part 6 Templates and Forms 6 3D 52 Section 3D Data Book Template WHO STEPS Surveillance Diabetes Description history of diabetes lifestyle advice lifestyle advice Instrument question e Are
28. d Part 6 Templates and Forms Section 3D Data Book Template 6 3D 11 WHO STEPS Surveillance Highest level of Description highest level of education achieved by the survey participants education Instrument question e What is the highest level of education you have completed College Post university graduate primary completed degree n No formal Some Completed schooling primary Age Group schooling n n 25 34 years ge 35 44 years Ul 45 54 years S 55 64 years 25 64 years 25 34 years P 35 44 years 4 45 54 years o E 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier C6 e Epi Info programme name Ceduhigh unweighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D 12 WHO STEPS Surveillance Highest level of Description highest level of education achieved by the survey participants education cont Instrument question e What is the highest level of education you have completed No formal Some Completed Completed Completed College Post schoolin primary riar secondary hiah school university graduate Age Group g schooling p y school g completed degree n n n n n n n 25 34 years u 35 44 years 8 45 54 years S 55 64 years i 25 64 years Analysis Information e Questions used uses coding column as identifier C6 e Epi Info p
29. daily non daily 0 o 95 CI 95 CI 95 CI 95 CI 92 95 CI 95 CI 95 CI 9S 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier T1 T2 e Epi Info programme name Tsmokestatus unweighted TsmokestatusWT weighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D 19 WHO STEPS Surveillance Manufactured Description percentage of smokers who use manufactured cigarettes cigarette smokers Instrument question e On average how many of the following do you smoke each day Manufactured cigarette users Men Women Both Sexes Age Group N N N 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier T1 T2 T5a e Epi Info programme name Tsmokeman unweighted TsmokemanWT weighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D 20 WHO STEPS Surveillance Frequency of smoking Instrument question e Do you currently smoke any tobacco products such as cigarettes cigars or pipes e Do you currently smoke tobacco products daily Analysis Information Description percentage of current daily smokers among smokers Men N Women N Both Sexes N T Non daily ae Non d
30. e ate auc O A AO E mae acs agape ee 2 Sampling and Response Proportions inisesin e ni EE EEEE estedcdeastuasudepaauhcxounuantec iossaaddaniandcsaptladedaussaniiepeaistautsgaccinsss 3 Demographic Information RESUMS ccancaveeswpacsacsnseobsnaavesnnadsdesiagiete EEE EERE R EE ERE N EREE REENE E 8 TODACCO 0 Carn nee re eE T r E TEE A TO T A A tren ee err rete 19 Alcohol CaS IN MMT sees ns scp exe ur e eE EEE Ene conics eee EEEE REEE EEE Eae OE E E aeaee E EAA EEE aE EAE EAE OER ESE AEREE OT EN EAEE E EER Tiaia 28 Pri Ane Vegetable Consumption 2 usssuscsvcnssedacscensissacusnsiwmnntaibatenssaaducaaevesesnieduaiospncestaiunsanntoondswasstuestastuasdsciesdutstasaasacoindeetiesediongeslassinssassduenadietessdves 36 Physical ACU WILY ccsinisnsccaidenscn snap dccwnaba eE Oa EE E ncaa dnveav mots EE EE EA EE AE EE E ERA A E AES 40 Blood Pressure and Diabetes g Ic 01 seme ne ante nen te nent Pa Ene nr rent ee net ts stese stts Sestese SEES SEESE eee eee SESSE SSeS eee ener ee 49 Physical Meds r mentS sssini r aeia EEA EAA cca pts aa E EEE ede EEE E AE cea 55 Biochemical Meas remi ntS as issasusacisacveseiicnvedn sacesorsapoantesedsaeunadesensesinncondenayiicndn see hewsssas air ouvyieatipbadasseun ba EAEE EE TAREE EA EEEa EEA EE EERE Ra Sa Eeeh 64 RAIS E EES E A E E AE EAE E N 68 e All the questions include C1 C2 or C3 in the Questions used uses coding column as identifier section of the analysis block e Unweighted tables will not have confidence interva
31. e blood We will collect information from insert sample size participants throughout the area in which the survey is being conducted Information will be gathered through X number of steps of data collection e Step 1 Interview questions e Step 2 Measurements of height weight waist amp blood pressure e Step 3 Blood tests for sugar and fats The table below shows each of the steps involved You will be given time to consider your participation We will describe the STEPS surveillance to you You may ask any questions you may have We will ask you to sign a consent form Continued on next page Part 6 Templates and Forms 6 2 3 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Participant Information Form Step 1 2 amp 3 Continued What s involved continued You will be asked to participate in Step 1 This will involve a Ministry of Health employee asking you some questions about your e Age e Education e Employment and income e Tobacco and alcohol use e Fruit and vegetable intake e Physical activity e History of diabetes and or raised blood pressure You will then be asked to participate in Step 2 This will involve a Ministry of Health employee taking some simple measurements of your e Height e Weight e Waist circumference e Blood pressure You may also be asked to participate in Step 3 This will involve taking a small amount of blood from a vein in your
32. ears of smoking among current daily smokers duration of smoking Instrument question e How old were you when you first started smoking daily Age started smoking mean age Years of smoking mean duration Men Women Both Sexes Men Women Both Sexes Age Group N N N N N N mean mean mean mean mean mean 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier T1 T2 T3 T4 e Epi Info programme name Tsmokeagetime unweighted TsmokeagetimeWT weighted Part 6 Templates and Forms 6 3D 23 Section 3D Data Book Template WHO STEPS Surveillance Percentage of ex daily smokers in the population Instrument question e In the past did you ever smoke daily e How old were you when you stopped smoking daily Description percentage of ex daily smokers and the mean duration in years since they quit smoking daily Ex daily smokers Time since ease a duration in Men Women Both Sexes Men Women Both Sexes Age Group N N N N N N mean mean mean 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier T6 T7 T8 e Epi Info programme name Tsmokeexdaily unweighted TsmokeaexdailyWT weighted Par
33. ection 3D Data Book Template WHO STEPS Surveillance Heart rates Description mean heart rate result and percentage with increased heart rates Instrument question e Heart Rate measurement Beats per minute Beats per minute over 100 Men Women ae Men Women bane Age Group N N N N N N mean mean mean 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier M16a M16b M16c e Epi Info programme name Mheartrate unweighted MheartrateWT weighted Part 6 Templates and Forms 6 3D 63 Section 3D Data Book Template WHO STEPS Surveillance Biochemical Measurements Fasting blood Description mean fasting blood glucose results and participants with raised fasting blood glucose glucose Instrument questions e During the last 12 hours have you had anything to eat or drink other than water e Blood glucose measurement Note Non fasting recipients excluded Fasting blood glucose mmol L Fasting blood glucose 2 7 mmol L Both Both Men Women Men Women Sexes Sexes Age Group N N N N N N mean mean mean 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier B1 B5 Epi Info programme name Bglucose unweigh
34. ed on categories provided in the table vegetable consumption Instrument questions Risky eating e In a typical week on how many days do your eat fruit e How many servings of fruit do you eat each on one of those days e In a typical week on how many days do your eat vegetables e How many servings of vegetables do you eat each on one of those days Fruit or vegetables eaten on fewer Under 2 servings of fruit or Under 14 servings of fruit or vegetables than 4 days week vegetables day when eaten week Both Both Both Age Group Men Women Sexes Men Women Sexes Men Women Sexes N N N N N N N N N 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier D1 D2 D3 D4 e Epi Info programme name Driskyeating unweighted DriskyeatingWT weighted Part 6 Templates and Forms 6 3D 38 Section 3D Data Book Template WHO STEPS Surveillance Type of oils Description type of oil or fat most often used for meal preparation in households presented only for both sexes because results are used most for the household not individuals frequently Instrument question e What type of oil or fat is most often used for meal preparation in your household Vegetable oil Lard Butter Margarine None used other 95 Cl 95 Cl 95 Cl 95
35. ep 3 Biochemical Measurements Mean fasting blood glucose mmol L B1 B5 BglucoseWT Percentage with raised fasting blood glucose 2 7 0 mmol L B1 B5 BglucoseWT Mean total blood cholesterol mmol L B7 BtotallipidsWT Percentage with raised total cholesterol 2 5 2 mmol L B7 BtotallipidsWT Percentage with raised total cholesterol 2 6 5 mmol L B7 BtotallipidsWT Summary of combined risk factors Codes used for summary of combined risk factors e current daily smokers T2 D2 D4 M3 M4 M11a e less than 5 servings of fruits amp vegetables per day b M12a b M13a b P1 e Low level of activity lt 600 MET minutes P15 e overweight or obese BMI 2 25 kg m e raised BP SBP 2 140 and or DBP 2 90 mmHg Percentage with low risk i e none of the risk factors included above See above raisedriskWT Percentage with raised risk i e at least three of the risk factors included above distributed in the age groups below Percentage with raised risk aged 25 to 44 years old See above raisedriskWT Percentage with raised risk aged 45 to 64 years old See above raisedriskWT For additional information please contact STEPS country focal point name email addresses WHO STEPS chronic disease risk factor surveillance www who int chp steps lt Site Country gt STEPS Survey lt year gt Fact Sheet The STEPS survey of chronic disease risk factors in country site name was carried out from insert month
36. er median inter median inter median inter median inter quartile range quartile range quartile range quartile range quartile range quartile range 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier P1 P2 P3 P4 P5 P6 e Epi Info programme name Pwork unweighted PworkWT weighted Part 6 Templates and Forms 6 3D 47 Section 3D Data Book Template WHO STEPS Surveillance Recreational Description median time of recreational moderate and vigorous intensity physical activity per day physical activity Instrument question e recreational activities Men N Women N Both N Moderate Vigorous Moderate Vigorous Moderate Vigorous Age Group median inter median inter median inter median inter median inter median inter quartile range quartile range quartile range quartile range quartile range quartile range 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier P10 P11 P12 P13 P14 P15 e Epi Info programme name Precreation unweighted PrecreationWT weighted Part 6 Templates and Forms 6 3D 48 Section 3D Data Book Template WHO STEPS Surveillance Blood Pressure and Diabetes History
37. h raised BP SBP 2 140 and or DBP 2 90 mmHg Percentage with raised BP SBP 2 160 and or DBP 2 100 mmHg Step 3 Biochemical Measurements Mean fasting blood glucose mmol L Percentage with raised blood glucose 2 7 0 mmol L Mean total blood cholesterol mmol L Percentage with raised total cholesterol 2 5 2 mmol L Percentage with raised total cholesterol 2 6 5 mmol L Summary of combined risk factors current daily smokers less than 5 servings of fruits amp vegetables per day Low level of activity lt 600 MET minutes overweight or obese BMI 2 25 kg m raised BP SBP 2 140 and or DBP 90 mmHg Percentage with low risk i e none of the risk factors included above Percentage with raised risk i e at least three of the risk factors included above distributed in the age groups below Percentage with raised risk aged 25 to 44 years old Percentage with raised risk aged 45 to 64 years old For additional information please contact STEPS country focal point name email addresses WHO STEPS chronic disease risk factor surveillance fact sheet www who int chp steps WHO STEPS Chronic Disease Risk Factor Surveillance DATA BOOK FOR lt INSERT COUNTRY SITE NAME gt Part 6 Templates and Forms 6 3D 1 Section 3D Data Book Template WHO STEPS Surveillance Table of Contents Note Table ol Contents assassins A cos cs bons s
38. id you have each day Analysis Information Age Group Drinks during last 7 days Men Women Both Sexes N N N mean mean mean 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years e Questions used uses coding column as identifier Al A4 A5 e Epi Info programme name Anumdrinklastwk unweighted AnumdrinklastwkWT weighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D 29 WHO STEPS Surveillance Description number of standard drinks consumed per day drinks per day Instrument question e When you drink alcohol on average how many drinks do you have during one day Men N Women N Drinks per day Drinks per day Age Group 1 2 3 4 5 4 5 6 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier Al A3 e Epi Info programme name Anumdrinkperday unweighted AnumdrinkperdayWT weighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D 30 WHO STEPS Surveillance Frequency of Description frequency of alcohol consumption in the last year alcohol consumption Instrument question e In the past 12 months how frequently have you had at least one drink Men N Women N Dail 5 6 days 1 4 days 1 3days lt once
39. k Template WHO STEPS Surveillance Triglycerides Description mean triglyceride results Instrument question e Triglyceride measurement Triglycerides mmol L Triglycerides above 2 26 mmol L 200mqg dl Both Both Age Group MED Women Sexes Men women Sexes N N N N N N mean mean mean 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier B8 e Epi Info programme name Btriglyceride unweighted BtriglycerideWT weighted Part 6 Templates and Forms 6 3D 67 Section 3D Data Book Template WHO STEPS Surveillance Raised Risk Description summary of combined risk factors current daily smokers less than 5 servings of fruits amp vegetables per day low level of activity lt 600 MET minutes overweight or obese BMI gt 25 kg m raised BP SBP gt 140 and or DBP gt 90 mmHg Instrument question combined from Step 1 Analysis Information e Questions used uses coding column as identifier T2 D1 D2 D3 D4 M3 M4 M1 la b M12a b M13a b P1 P15 e Epi Info programme name raisedrisk unweighted raisedrisk WT weighted Low risk none of the risk factors Raised risk at least 3 of the risk factors Both Both Age Group Men Women Sexes Men Women Sexes N N N N N N 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 25
40. l 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier H9 H10 e Epi Info programme name Hdiabetestrad unweighted HdiabetestradWT weighted Part 6 Templates and Forms Section 3D Data Book Template WHO STEPS Surveillance Physical Measurements Height weight Description mean results for height weight and body mass index excluding pregnant women and BMI Instrument questions e Height e Weight Height cm Weight kg BMI kg m Both Both Both PE Men Women Save Men Women Saya Men Women Sexes g N N N N N N N N N mean mean mean mean mean mean mean mean mean 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier M3 M4 e Epi Info programme name Mbmi unweighted MbmiWT weighted 6 3D 55 Part 6 Templates and Forms Section 3D Data Book Template WHO STEPS Surveillance BMI categories Description BMI classifications excluding pregnant women Instrument questions e Height e Weight Men Women Under Normal Over Obese Under Normal Over Obese Age Gr u weight weight weight weight weight weight g P lt 18 5 18 5 24 9 25 0 29 9 _30 0 lt 18 5 18 5 24 9 25 0 29 9 _30
41. ls associated with them e You need to run the Epi Info programmes MissingAgeSexConsent and AgeSex10 prior to running any of the programmes in the data book You only need to run these programmes one time Part 6 Templates and Forms 6 3D 2 Section 3D Data Book Template WHO STEPS Surveillance Sampling and Response Proportions Step 1 Description summary results for the response proportions for step 1 response proportions Men Women Both Sexes Age Group Eligible Participated Eligible Participated Eligible Participated N n N n N n 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier interview tracking form e Epi Info programme name Responsestep1 unweighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D 3 WHO STEPS Surveillance Step 2 Description summary results for the response proportions for step 2 response proportions Men Women Both Sexes Age Group Eligible Participated Eligible Participated Eligible Participated N n N n N n 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier interview tracking form e Epi Info programme name Responsestep2 unweighted Part 6 Templates and F
42. n e Questions used uses coding column as identifier D1 D2 D3 D4 e Epi Info programme name Dservings unweighted DservingsWT weighted Part 6 Templates and Forms 6 3D 36 Section 3D Data Book Template WHO STEPS Surveillance Five or more combined fruit and vegetables per day Instrument questions Description percentage consuming five or more fruit and or vegetables per day e In a typical week on how many days do your eat fruit e How many servings of fruit do you eat each on one of those days e In a typical week on how many days do your eat vegetables e How many servings of vegetables do you eat each on one of those days No daily consumption of fruit or Less than five servings of fruit Five or more fruit and or vegetables per vegetable and or vegetable per day day Both Both Both Age Group Men Women Sexes Men Women Sexes Men Women Sexes N N N N N N N N N mean mean mean mean mean mean mean mean mean 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier D1 D2 D3 D4 e Epi Info programme name Dfiveormore unweighted DftveormoreWT weighted Part 6 Templates and Forms 6 3D 37 Section 3D Data Book Template WHO STEPS Surveillance Fruit and Description percentage of population classified as risky bas
43. nd Forms Section 3D Data Book Template 6 3D 58 WHO STEPS Surveillance Waist to hip Description waist hip ratio excluding pregnant women ratio Instrument question e Waist circumference measurement e Hip circumference measurement Men N Women N Waist hip Waist hip Waist hip Waisthip Age Group ratio rano ratio rato gt 1 00 gt 0 85 mean mean 95 Cl 95 CI 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier M7 M15 e Epi Info programme name Mhipwaistratio unweighted MhipwaistratioWT weighted Part 6 Templates and Forms 6 3D 59 Section 3D Data Book Template WHO STEPS Surveillance Blood pressure Instrument question e Reading 1 3 systolic and diastolic blood pressure Description mean blood pressure results average of three readings Systolic Diastolic mmHg mmHg Both Both Age Group Men women Sexes Men women Sexes N N N N N N mean mean mean mean mean mean 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier M11la M11b M12a M12b M13a M13b e Epi Info programme name Mbloodpressure unweighted MbloodpressureWT weighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D
44. nks during a single occasion drinks ona single occasion Instrument question e In the past 12 months on how many days did you have four or more standard drinks in a single day Analysis Information e Questions used uses coding column as identifier Al A8 e Epi Info programme name Abingewomen unweighted AbingewomenWT weighted Part 6 Templates and Forms Section 3D Data Book Template Women N Age Group mean 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years 6 3D 35 WHO STEPS Surveillance Fruit and Vegetable Consumption Fruit and vegetable consumption Instrument questions e In a typical week on how many days do your eat fruit e How many servings of fruit do you eat each on one of those days e In a typical week on how many days do your eat vegetables e How many servings of vegetables do you eat each on one of those days Description mean number of fruit vegetable and combined fruit and vegetable servings per day Daily number of servings of Daily number of servings of Daily number of servings of fruit and fruit vegetables vegetables Both Both Both Age Group Men Women Sexes Men Women Saves Men Women Savas N N N N N N N N mean mean mean mean mean mean mean mean mean 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Informatio
45. nnect your name and your answers without identifying you You may be contacted by the Survey Team again only if it is necessary to complete the information on the survey Your participation is voluntary and you can withdraw from the survey after having agreed to participate You are free to refuse to answer any question that is asked in the questionnaire If you have any questions about this survey you may ask me or contact name of institution and contact details or Principal Investigator at site You will have a small amount of blood taken from a vein in your arm to be tested for sugar and fat This may cause some mild pain You will be informed about the kind of tests which will be done on your blood sample Signing this consent indicates that you understand what will be expected of you and are willing to participate in this survey Read by Participant Interviewer o do o Agreed Refused O O i I hereby provide INFORMED CONSENT to take part in Step 3 of the Chronic Disease Risk Factor Study Name Sign Witness Sign Part 6 Templates and Forms 6 2 7 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Kish Household Coversheet Directions to Order the adults 1 6 by fill out Adult e males in order of decreasing age oldest to youngest o N e females in order of decreasing age oldest to youngest Example Sex Age Adultn m s Jh E a 3 m 3 k List all
46. of the user manual Part 4 Section 3 Questions required to a eee calculate result based on Epi Info Programme Results for adults aged 25 64 years incl 95 Cl adjust if necessary coding column always Name need C1 C2 or C3 Step 1 Tobacco Use Percentage who currently smoke tobacco daily T2 TsmokestatusWT For those who smoke tobacco daily Average age started smoking years T2 T3 TsmokeagetimeWT Average years of smoking T2 T4a c TsmokeagetimeWT Percentage smoking manufactured cigarettes T2 T5a TsmokemanWT For smokers of manufactured cigarettes Mean number of manufactured cigarettes smoked per day T5a TsmoketypeWT Step 1 Alcohol Consumption Percentage of abstainers who did not drink alcohol in the last year A1 AconsumptionWT Percentage of current drinkers who drank alcohol in the past 30 days A4 AconsumptionWT For those who drank alcohol in the last 30 days Percentage of women who had 4 or more drinks on any day in the A4 A5a g AheavydrinkingWT last week a of men who had 5 or more drinks on any day in the last A4 A5a g AheavydrinkingWT Percentage who drank alcohol on 4 or more days in the last week A4 Ada g AheavydrinkingWT Step 1 Fruit and Vegetable Consumption in a typical week Mean number of servings of fruit consumed per day D1 D2 DservingsWT Mean number of servings of vegetables consumed per day D3 D4 DservingsWT Sin who ate less than 5 of com
47. on e During each of the past 7 days how many standard drinks of any alcoholic drink did you have each day Men N Women N Both Sexes N Drank on 5 drinks 20 drinks Drank on 4 drinks 15 drinks Drank on Age Group 4 days on any day in 7 days 4 days on any day in 7 days 4 days 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier Al A4 A5 e Epi Info programme name Aheavydrinking unweighted AheavydrinkingWT weighted 6 3D 33 Part 6 Templates and Forms Section 3D Data Book Template WHO STEPS Surveillance Five or more Description mean number of occasions where consumer drank five or more drinks during a single occasion drinks ona single occasion Instrument question e In the past 12 months on how many days did you have five or more standard drinks in a single day Analysis Information e Questions used uses coding column as identifier Al A7 e Epi Info programme name Abingemen unweighted AbingemenWT weighted Part 6 Templates and Forms Section 3D Data Book Template Men Age Grou bim 9 p mean 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years 6 3D 34 WHO STEPS Surveillance Four or more Description mean number of occasions where consumer drank four or more dri
48. or conducting chronic disease risk factor surveillance See Part 1 Section 1 Rationale for Surveillance Part 6 Templates and Forms 6 1 2 Section 1 Planning and Set Up Templates WHO STEPS Surveillance Goals and Objectives Introduction Goals Objectives Scope Introduction Overview of scope Sample size Identify the planned goals or use for the information gathered For example as a contribution to ongoing data collection to e Describe the current levels of risk factors for chronic diseases in this population e Track the direction and magnitude of trends in risk factors e Plan or evaluate a health promotion or preventive campaign e Collect data from which to predict likely future demands for health services Specify objectives that support gathering essential information only Specify the scope of surveillance to be conducted over time ie Step 1 Step 2 or Step 3 plus coverage of core expanded and optional items Identify the sample size and sample frame that will be used Geographical Identify geographical coverage coverage Timeframe Describe the broad timeframes Sustainability Specify if STEPS sustainability can be assured and plans for future surveys and future surveys Part 6 Templates and Forms 6 1 3 Section 1 Planning and Set Up Templates WHO STEPS Surveillance Resources Introduction Personnel Specify required resources in terms of all personnel required for the required s
49. orms 6 3D 4 Section 3D Data Book Template WHO STEPS Surveillance Step 3 Description summary results for the response proportions for step 3 response proportions Men Women Both Sexes Age Group Eligible Participated Eligible Participated Eligible Participated N n N n N n 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier interview tracking form if applicable e Epi Info programme name Responsestep3 unweighted Part 6 Templates and Forms 6 3D 5 Section 3D Data Book Template WHO STEPS Surveillance District Description summary results for the response proportions by district response proportions Men N Women N District District District District District District District District District District Age Group 1 2 3 4 5 1 2 3 4 5 n n n n n n n n n n 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier I1 e Epi Info programme name District unweighted 6 3D 6 Part 6 Templates and Forms Section 3D Data Book Template WHO STEPS Surveillance District response proportions continued Analysis Information Description summary results for the response proportions by district Both Sexes N Z2
50. personal identifiers to WHO Geneva STEPS team Inform all interested parties where the information is stored Note Make sure that participant identification information is never stored in the same location electronically and in paper form with the rest of the dataset Label all the boxes clearly with e Name and date of the project e Box contents Part 6 Templates and Forms 6 4 1 Section 4 Archiving WHO STEPS Surveillance
51. persons age 25 64 in household Sex Age Adult n Selected Respondent Household Number Cluster Number Participant ID If n of If n of If n of If n of adults is adults is adults is adults is Selection Table F Select If n of Select If n of Select If n of Select adult adults is adult adults is adult adults is adult n a 2 1 2 6 or more Part 6 Templates and Forms 6 2 8 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Kish Household List Directions Match the household number assigned to the household with the Kish table below and identify which table from the Kish Summary of Eight Tables should be used Household Kish Table Household Kish Table 47 48 etc Part 6 Templates and Forms 6 2 9 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Kish Summary of Eight Tables Directions Identify which table to use for each household with the Kish household list Fill out the Kish coversheet and using the number of eligible respondents in the household and the Table number already identified select the participant Example e Ifthe Table number was C and there were 4 adults in the household the adult numbered 2 should be interviewed e If the Table number was E1 and there were 5 adults in the household the adult numbered 3 should be interviewed If the number of adults in household is Table 6 or Select ad
52. pplication I understand that if the protocol for this research changes in any way I must inform the Research Ethics Review Committee Name Signature Date I have read the application and believe it to be scientifically and ethically sound I approve the research design I give my consent for the application to be forwarded to the Ethics Committee Name Signature Date Note Where the head of department is also one of the investigators the head of department declaration must be signed by the appropriate Dean or relevant senior officer Part 6 Templates and Forms 6 1 10 Section 1 Planning and Set Up Templates WHO STEPS Surveillance Section 2 Interview Blood Collection and Data Entry Forms Overview Introduction This section includes some document templates that can be used during the interview measurement and data entry stages In this section This section contains the following forms for use during the survey Kish Household Coversheet Clinic Registration Form Step 3 6 2 14 Data Entry Tracking Form 6 2 17 Data Entry Folder Coversheet 6 2 18 Part 6 Templates and Forms 6 2 1 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Notification of WHO STEPS Surveillance Visit World Health Organization Today Ministry of Health employees visited your household to conduct a survey of people between the ages of 25 to 64 on health issues We will try and return on the date
53. r C9b or C9c e Epi Info programme name Cmeanincome unweighted Part 6 Templates and Forms 6 3D 17 Section 3D Data Book Template WHO STEPS Surveillance Estimated Description summary of participant household earnings by quintile presented only for both sexes because results are for the household household not individuals earnings Instrument question e If you don t know the amount can you give an estimate of the annual household income if I read some options to you Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Age Group Under Taia PE AE TORREN Kimei OE KARES Over n n n n n 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier C10 e Epi Info programme name Cquintile unweighted Part 6 Templates and Forms 6 3D 18 Section 3D Data Book Template WHO STEPS Surveillance Tobacco Use Smoking Status Description smoking status among total population Instrument questions e Do you currently smoke any tobacco products such as cigarettes cigars or pipes e Do you currently smoke tobacco products daily Men N Women N Both Sexes N Current smoker Current smoker Current smoker Does Does Does Dail d not Dail d not Dail d not Age Group Daily Non daiy 2Y8 C smoke Daily Non daily smoke Daily Non daily Y 2 smoke non daily non
54. rogramme name Ceduhigh unweighted Part 6 Templates and Forms 6 3D 13 Section 3D Data Book Template WHO STEPS Surveillance Employment status Description proportion of participants in paid employment and those who are unpaid Unpaid includes persons who are non paid students homemakers retired and unemployed Instrument question e Which of the following best describes your main work status over the last 12 months Men N Women N Both Sexes N Age Group Govt Non govt Self Unpaid Gov t Non gov t Self Unpaid Govt Non gov t Self Unpaid employee employee employed employee employee employed employee employee employed n n n n n n n n n n n n 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier C7 e Epi Info programme name Cworkpaid unweighted Part 6 Templates and Forms 6 3D 14 Section 3D Data Book Template WHO STEPS Surveillance Unpaid work Description proportion of participants in unpaid work and unemployed Instrument question e Which of the following best describes your main work status over the last 12 months Men N Women N Unemployed Unemployed Non Home Non ERS paid Student maker Retired Able to Not able paid Student Sas Retired Able to Not able work to work maser work to work n n n n n n n n n n n n
55. s The specific questions for each groups is presented below Activity at work Does your work involve vigorous intensity activity that causes large increases in breathing or heart rate like examples for at least 10 minutes continuously In a typical week on how many days do you do vigorous intensity activities as part of your work How much time do you spend doing vigorous intensity activities at work on a typical day Does your work involve moderate intensity activity that causes small increases in breathing or heart rate such as brisk walking for at least 10 minutes continuously In a typical week on how many days do you do moderate intensity activities as part of your work How much time do you spend doing moderate intensity activities at work on a typical day Travel to and from places Do you walk or use a bicycle for at least 10 minutes continuously to get to and from places In a typical week on how many days do you walk or bicycle for at least 20 minutes continuously to get to and from places Continued on next page Part 6 Templates and Forms 6 3D 40 Section 3D Data Book Template WHO STEPS Surveillance Physical Activity Continued Introduction How much time do you spend walking or bicycling for travel on a typical day continued Recreational activities Do you do any involve vigorous intensity sports fitness or recreational activities that cause large increases in breathing or heart r
56. s received ethical approval from the Research Ethics Review approval Committee of insert name of institution and of location Part 6 Templates and Forms 6 2 5 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Consent Form 1 Step 1 amp 2 Dear Participant Random selection Confidentiality Voluntary participation Consent to participate Signatures You have been randomly selected to be part of this survey and this is why we would like to interview you This survey is conducted by the World Health Organization in collaboration with the Ministry of Health and the WHO Regional Office and will be carried out by professional interviewers from name of institution This survey is currently taking place in several countries around the world The information you provide is totally confidential and will not be disclosed to anyone It will only be used for research purposes Your name address and other personal information will be removed from the instrument and only a code will be used to connect your name and your answers without identifying you You may be contacted by the survey team again only if it is necessary to complete the information on the survey Your participation is voluntary and you can withdraw from the survey after having agreed to participate You are free to refuse to answer any question that is asked in the questionnaire If you have any questions about this survey you may ask
57. t 6 Templates and Forms 6 3D 24 Section 3D Data Book Template WHO STEPS Surveillance Current Users Description percentage of current users of smokeless tobacco and the proportion of them using it daily of smokeless tobacco Instrument question e Do you currently use any smokeless tobacco such as snuff chewing tobacco betel e Do you currently use smokeless tobacco products daily Current Smokeless tobacco use Proportion or users curronuy Ex daily smokeless tobacco users using smokeless tobacco daily Both Both Both Age Group Men Women Savas Men Women Sexes Men Women Sexes N N N N N N N N N 95 CI 95 Cl 95 CI 95 CI 95 Cl 95 CI 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier T9 T10 T12 e Epi Info programme name Tsmokelessexdaily unweighted Tsmokelessexdaily WT weighted Part 6 Templates and Forms 6 3D 25 Section 3D Data Book Template WHO STEPS Surveillance Frequency of smokeless tobacco use Instrument question among users by e On average how many times a day do you use Description mean frequency of smokeless tobacco use by smokeless tobacco users by type type Men N Women N Both Sexes N Snuff by Snuff by Chewing Betel Other Snuff by Snuff by Chewing Betel Other Snuff by Sn
58. ted BglucoseWT weighted Part 6 Templates and Forms 6 3D 64 Section 3D Data Book Template WHO STEPS Surveillance Total Description mean total cholesterol results cholesterol Instrument question e Total cholesterol measurement Total cholesterol mmol L Total cholesterol 2 5 2 mmol L Total cholesterol 6 5 mmol L Both Both Both Reeeus Men Women Sexes Men Women Sexes Men Women Sexes N N N N N N N N N mean mean mean mean mean mean mean mean mean 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier B7 e Epi Info programme name Btotallipids unweighted BtotallipidsWT weighted Part 6 Templates and Forms 6 3D 65 Section 3D Data Book Template WHO STEPS Surveillance High density Description mean HDL results lipoprotein HDL Instrument question e HDL cholesterol measurement HDL mmol L HDL below 0 9 mmol L Men Women aa Men Women ora Age Group N N N N N N mean mean mean 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier B9 e Epi Info programme name Bhdllipids unweighted BhdllipidsWT weighted Part 6 Templates and Forms 6 3D 66 Section 3D Data Boo
59. ted by doctor or Advised or treated by doctor or Advised or treated by doctor or health health worker to lose weight health worker to stop smoking worker to start or do more exercise Both Both Both Age Group Men Women Sexes Men Women Sexes Men Women Sexes N N N N N N N N N 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 95 CI 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier H3 c e e Epi Info programme name Hraisedbplifestyle unweighted HraisedbplifestyleWT weighted Part 6 Templates and Forms 6 3D 50 Section 3D Data Book Template WHO STEPS Surveillance Blood pressure Description percentage of population with raised blood pressure who are seeking advice with traditional healers advice by a traditional Instrument questions peal e During the past 12 months have you seen a traditional healer for raised blood pressure e Are you currently taking any herbal or traditional remedy for your high blood pressure Seen a traditional healer in the last Currently taking herbal or traditional 12 months remedy for high blood pressure Both Both Age Group Men ene Sexes men women Sexes N N N N N N 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses
60. ty activity Sr activity activity ae activity activity activity activity 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier Work P1 P2 P3 P4 P5 P6 Transport P7 P8 P9 Recreation P10 P11 P12 P13 P14 P15 e Epi Info programme name Ptotallevels unweighted PtotallevelsWT weighted Part 6 Templates and Forms 6 3D 42 Section 3D Data Book Template WHO STEPS Surveillance Total physical Description median time of total physical activity per day activity Instrument questions activity at work e travel to and from places e recreational activities Men Women Both N N N Age Group Median inter Median inter Median inter quartile range quartile range quartile range 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier Work P1 P2 P3 P4 P5 P6 Transport P7 P8 P9 Recreation P10 P11 P12 P13 P14 P15 e Epi Info programme name Ptotal unweighted PtotalWT weighted Part 6 Templates and Forms 6 3D 43 Section 3D Data Book Template WHO STEPS Surveillance Setting specific Description median time spent per day in minutes in work transport and recreation related physical activity
61. u for agreeing to participate in the STEPS Surveillance CLINIC APPOINTMENT Centre PLEASE BRING THIS FORM WITH YOU WHEN YOU COME FOR AN APPOINTMENT Part 6 Templates and Forms 6 2 12 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Fasting Instructions Step 3 Introduction To get accurate results from the blood test it is very important that you have fasted Fasting Please ensure that you DO NOT have anything to eat or drink including instructions chewing gum except plain water after 10 00 PM on the night BEFORE the clinic appointment or on the morning of the clinic appointment Note for If you have diabetes controlled with tablets and or insulin please AVOID diabetics taking these on the morning of your appointment but bring them with you to take after testing is completed Please take any other morning medications as usual Part 6 Templates and Forms 6 2 13 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Clinic Registration Form Step 3 Centre Village Cluster Number Technician ID Participant Name Consent form Fasting status Arrival ID place a y time Part 6 Templates and Forms 6 2 14 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Blood Collection Form
62. uff by Chewing Betel quid Other Age Group mouth nose tobacco quid mouth nose tobacco quid mouth nose tobacco mean mean mean mean mean mean mean mean mean mean mean mean mean mean mean 0 0 0 0 95 Cl 95 Cl 95 Cl aK ai 95 Cl 95 Cl 95 Cl 95 Cl on 95 Cl 95 Cl 95 Cl 95 Cl on 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier T11 a other e Epi Info programme name Tsmokelesstype unweighted TsmokelesstypeWT weighted Part 6 Templates and Forms Section 3D Data Book Template 6 3D 26 WHO STEPS Surveillance Current Description percentage of tobacco users daily and non daily includes smoking and smokeless among the total population tobacco users Instrument questions e Do you currently smoke tobacco products daily e Do you currently use smokeless tobacco products daily Current daily tobacco user Current tobacco user Men Women Both Sexes Men Women Both Sexes Age Group N N N N N N mean mean mean 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 95 Cl 25 34 years 35 44 years 45 54 years 55 64 years 25 64 years Analysis Information e Questions used uses coding column as identifier T1 T2 T9 T10 e Epi Info programme name Tdailyuser unweighted TdailyuserWT weighted Part 6 Templates and Forms 6 3D 27 Section 3D Data Book Template WHO
63. ult numbered Note This table is embedded in the Kish coversheet and does not need to be carried around by the interviewer Part 6 Templates and Forms 6 2 10 Section 2 Interview Blood Collection and Data Entry Forms WHO STEPS Surveillance Interview Tracking Form Centre Village Cluster Number Technician ID A At 2s Male Female Step 1 Step 2 Step 3 an S 2 Home S oo E Eo oe 2 2 2 o 2 oj 2 2 gE Individual Comment 5S5 S 3 A 2 eis Eis Se 5 eltitiziti ti airia 2 2 2 Z sm llalla Slol t oS wla BS Sl al S Sl al Ss Zs a 1 Se lwelwmloelwelelololwoal BS e2 F S 2 2 2 2 2 T a Fle Nl nalt nl N ent na Ble Ole R O ea ele lt Notes Individuals who are not usual residents are not eligible Please see definition in the Glossary Part 7 Step 1 Yes Step 2 Decline should only occur for people who are absolutely unable to attend Step 2 explain in Comment for each such person Fill in form by using y n for At home corresponds with yes no and using an x for the correct responses in Male Female Step 1 Step 2 Step 3 Part 6 Templates and Forms Section 2 Interview Blood Collection and Data Entry Forms 6 2 11 WHO STEPS Surveillance Clinic Appointment Card Step 3 APPOINTMENT TIME Thank yo
64. urveillance Equipment Specify required resources in terms of all equipment required for the surveillance Facilities Specify required resources in terms of all facilities required for the surveillance Resources Describe resources that have already been committed or which are expected already including support from WHO committed Resources Specify resources required from other organisations involved required from other organisations Action Plan Introduction Plan Provide a chart of the main tasks with estimated start dates and timeframes for completion of each phase Communication Strategy and Publicity Introduction Publicity plan Specify methods for informing and involving community leaders and community groups in the STEPS surveillance project Part 6 Templates and Forms 6 1 4 Section 1 Planning and Set Up Templates WHO STEPS Surveillance Reporting and Disseminating Results Introduction Reporting Describe to whom and how the results will be reported and disseminated Budget Introduction Budget Provide a detailed budget that includes e total funds required for each year planned to implement all STEPS activities as identified in the scope e source of funds and e funding gap Part 6 Templates and Forms 6 1 5 Section 1 Planning and Set Up Templates WHO STEPS Surveillance Ethical Approval Form Part 1 General Information Introduction Survey tile The title of the proposed survey is STEPS Chronic

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