**2. Factors influencing the quality of NCDs prevention**

Different factors predict healthcare systems' capacity to prevent NCDs and its related risk factors. These predictors are determinants of NCDs prevention including the level of physical exercise, dietary choice, organised infrastructure, urbanisation and related policy, cultural norms, and accessibility of health information.

#### **2.1 Level of physical exercise**

Worldwide industrial expansion and an increased service sector have resulted in less work-related physical exercise, whilst at the same time, modern technology has also made it increasingly convenient to remain sedentary. Many people lead a life with little or no physical exercise, and their leisure time is often spent on sedentary activities such as live online chats, playing computer games, and watching television, with 60% of the world's population being estimated to lead a sedentary life [39, 40].

Research indicates that low-resourced countries are experiencing rapid nutritional transitions, lifestyle changes, and epidemiological transition

*Public Health in Developing Countries - Challenges and Opportunities*

cancer, diabetes, or chronic respiratory diseases.

attained by 2025 [9, 28]:

within the national context.

7.Stop the rise in diabetes and fat.

matured 15+ years.

private offices.

tions.

epidemic of NCDs. The WHO asserts that the world has reached a decisive point in the history of NCDs and has an unprecedented opportunity to alter its course. In an attempt to alter the damaging progression of NCDs, the WHO Member States agreed on a time-bound set on the following nine voluntary global targets to be

1.A 25% relative reduction in the overall mortality from cardiovascular diseases,

2.At least 10% relative reduction in the harmful use of alcohol, as appropriate,

5.A 30% relative decrease in the pervasiveness of current tobacco use in people

6.A 25% relative decrease in the pervasiveness of raised circulatory strain, or regulation of predominance of raised pulse, as indicated by national condi-

8.At least 50% of eligible people receive drug therapy and counselling (including

9.An 80% accessibility of the moderate fundamental innovations and essential drugs, including generics, required to treat major NCDs in both open and

Furthermore, the world health assembly set a target of a 25% reduction in overall mortality from four major NCDs, including cancer, diabetes, cardiovascular-, and chronic respiratory disease by 2025 [28]. The 25 × 25 strategy is today included in the World Health Organisations Global Action Plan 2013–2020. Amongst the nine voluntary national strategies, two are intended to reduce deaths due to the four illnesses mentioned earlier and to stop the increase in obesity and diabetes. The remaining national strategies focus specifically on incorporating decreased alcohol intake, promoting physical exercise, reducing nutritional salt and smoking, enhancing hypertension control, and improving the treatment of those at risk from the main NCDs. Countries need to make progress on all these targets to attain the overarching target of a 25% reduction of premature mortality from the four major NCDs by 2025 [29–32]. The action plan advocates a comprehensive vision, recognising the social, economic, and political determinants of diseases and the wide-ranging developmental healthcare scheme [29]. Conversely, it is uncertain, in low-resourced countries at a much lower economic level, how these declarations of commitment will be interpreted and implemented [33–35]. The prioritising of infectious communicable disease, a frail healthcare system, and poorly designed NCDs prevention policies prevent low-resourced countries not to implement these declarations of commit-

Moreover, to improve the prevention and control of NCDs, the United Nations High-Level Meeting presented four additional time-bound commitments in 2014

glycaemic control) to prevent heart attacks and strokes.

3.A 10% relative decrease in pervasiveness of deficient physical action.

4.A 30% relative decrease in mean populace admission of salt/sodium.

**12**

ment [1, 4].

following modernisation, westernisation, and increased reliance on technology. As a result, more time is available to pursue leisure activities, which leads to lifestyle diseases such as cardiovascular disease, diabetics, hypertension, overweight, and obesity [40, 41].

Naturally, the human body is designed for movement; however, planned strenuous physical exercise is not a part of the normal lifestyle. Furthermore, an individual cannot expect his/her body to function optimally and to remain healthy for extended periods if it is abused or is not used as intended [40]. In **Figure 2**, the diseases associated with a lack of physical exercise that contributes to a rise in NCDs are illustrated.

Research shows that physical inactivity is the most critical public health problem in the twenty-first century. For many years, scientists and health and fitness professionals have advocated regular physical exercise as the best defence against the development of many diseases, disorders, and illnesses [40]. Due to the recognised health benefits, it has, and the importance of maintaining a good quality of life, regular physical exercise received recognition in the first U.S. surgeon general's report on physical exercise and health. In this report, physical exercise was identified as a national health objective and recognised physical inactivity as a nationwide severe health problem; it provided clear-cut scientific evidence linking physical activity to numerous health benefits and presented demographic data describing physical exercise patterns and trends in the U.S. population. It also made physical exercise recommendations for improved health [42, 43].

#### **2.2 Dietary choice**

Consumption of high levels of trans fats, saturated fats, processed and refined foods, sugar, salt, and sugary drinks is associated with an increased risk of CVD and diabetes, whilst adequate consumption of fruit and vegetables is associated with a reduced risk of coronary heart disease and stroke. Unhealthy diets tend to follow a socio-economic gradient. Higher quality diets are associated with persons of greater affluence, whilst energy-dense nutrient-poor diets are associated with persons of more limited economic

**15**

**Figure 3.**

*for consumption.*

*The Global Burden and Perspectives on Non-Communicable Diseases (NCDs)…*

greater share of the disease burden amongst men than women [46, 47].

means [44, 45]. Education and gender also impact diet, with unhealthy eating habits associated with lower levels of education. Moreover, low fruit intake represented a 50%

In low-resourced countries, the wrong perceptions about body image contribute to consume unhealthy dietary sources such as high level of trans fats, saturated fats, raw beef, goat meats, and fast foods [47]. In some Asian and the majority of African countries, having a big, fat stomach is considered as being charismatic, powerful, healthy, and perceived as a sign of wealthy [1, 48]. Following this perception, a more significant number (52%) of the public consumes high-fatty food substances which spontaneously results in acquiring NCDs [1, 49, 50]. **Figures 3a–c** depicts examples of red meats, such as raw beef meat called "Kurt Siga", red raw ground beef with spices and yoghurt called "Kitfo", and partially roasted meat respectively of which high levels of consumption and frequent consumption increased risk of NCDs due to high fat levels [1, 50]. This dietary practice is very customary amongst the diverse Ethiopian communities. Such unhealthy dietary practices are practised mainly amongst wealthy community groups and

*(a) Raw fatty beef meat. (b) Raw grinded beef meat with spices and yoghurt. (c) Partially roasted beef meat* 

*DOI: http://dx.doi.org/10.5772/intechopen.89516*

**Figure 2.** *NCDs associated with lack of physical exercise.*

#### *The Global Burden and Perspectives on Non-Communicable Diseases (NCDs)… DOI: http://dx.doi.org/10.5772/intechopen.89516*

means [44, 45]. Education and gender also impact diet, with unhealthy eating habits associated with lower levels of education. Moreover, low fruit intake represented a 50% greater share of the disease burden amongst men than women [46, 47].

In low-resourced countries, the wrong perceptions about body image contribute to consume unhealthy dietary sources such as high level of trans fats, saturated fats, raw beef, goat meats, and fast foods [47]. In some Asian and the majority of African countries, having a big, fat stomach is considered as being charismatic, powerful, healthy, and perceived as a sign of wealthy [1, 48]. Following this perception, a more significant number (52%) of the public consumes high-fatty food substances which spontaneously results in acquiring NCDs [1, 49, 50]. **Figures 3a–c** depicts examples of red meats, such as raw beef meat called "Kurt Siga", red raw ground beef with spices and yoghurt called "Kitfo", and partially roasted meat respectively of which high levels of consumption and frequent consumption increased risk of NCDs due to high fat levels [1, 50]. This dietary practice is very customary amongst the diverse Ethiopian communities. Such unhealthy dietary practices are practised mainly amongst wealthy community groups and

#### **Figure 3.**

*(a) Raw fatty beef meat. (b) Raw grinded beef meat with spices and yoghurt. (c) Partially roasted beef meat for consumption.*

*Public Health in Developing Countries - Challenges and Opportunities*

exercise recommendations for improved health [42, 43].

overweight, and obesity [40, 41].

are illustrated.

**2.2 Dietary choice**

following modernisation, westernisation, and increased reliance on technology. As a result, more time is available to pursue leisure activities, which leads to lifestyle diseases such as cardiovascular disease, diabetics, hypertension,

Naturally, the human body is designed for movement; however, planned strenuous physical exercise is not a part of the normal lifestyle. Furthermore, an individual cannot expect his/her body to function optimally and to remain healthy for extended periods if it is abused or is not used as intended [40]. In **Figure 2**, the diseases associated with a lack of physical exercise that contributes to a rise in NCDs

Research shows that physical inactivity is the most critical public health problem in the twenty-first century. For many years, scientists and health and fitness professionals have advocated regular physical exercise as the best defence against the development of many diseases, disorders, and illnesses [40]. Due to the recognised health benefits, it has, and the importance of maintaining a good quality of life, regular physical exercise received recognition in the first U.S. surgeon general's report on physical exercise and health. In this report, physical exercise was identified as a national health objective and recognised physical inactivity as a nationwide severe health problem; it provided clear-cut scientific evidence linking physical activity to numerous health benefits and presented demographic data describing physical exercise patterns and trends in the U.S. population. It also made physical

Consumption of high levels of trans fats, saturated fats, processed and refined foods, sugar, salt, and sugary drinks is associated with an increased risk of CVD and diabetes, whilst adequate consumption of fruit and vegetables is associated with a reduced risk of coronary heart disease and stroke. Unhealthy diets tend to follow a socio-economic gradient. Higher quality diets are associated with persons of greater affluence, whilst energy-dense nutrient-poor diets are associated with persons of more limited economic

**14**

**Figure 2.**

*NCDs associated with lack of physical exercise.*

high government officials [50]. Practising these dietary choices frequently result in overweight, obesity, high blood pressure, kidney disease, and premature ageing [51, 52]. Additionally, food cooking oil known as "Hayat" and "Palm oil" which is in use amongst the majority of the Ethiopian is full of high cholesterol, and this can easily harm the health of the users [1].

Another unhealthy dietary practice frequently practised amongst low-resourced populations, particularly in East Africa such as Ethiopia, Eritrean, Djibouti, Somalia, Kenya, Tanzania, and Sudan and Arab countries such as Saudi Arabia, United Arab Emirates, Yemen, Bahrain, Kuwait, and Oman, is "Khat chewing". Khat is a leafy plant with natural amphetamine content and chewed by 20 million people each day in Arabian peninsula and East African region mainly in Ethiopia (**Figure 4**) [53]. Khat chewing has incredible stimulation effects on chewers nervous system and predominantly addictive. The practice of Khat chewing is frequent amongst university students, shop keepers, drivers, and majority of the Muslim community, teachers, and some government officials [54]. Evidence shows that Khat chewing is associated with escalated degrees of cardiovascular complications, stroke, myocardial infections, cardiomyopathy, gastritis, poor oral hygiene, neurosis, poor academic performance, periodontal disease, and decreased quality of life [55, 56].

**Figure 4.** *Chewable leaves of Chat plant.*

Khat dependence is associated with wasting of longer working hours and family time. Evidence in Yemen and Saudi Arabia shows that lousy mood, psychosomatic dependence, sleeplessness, and physical indicators were observed amongst Khat chewers, and they spend an aggregate of 6 hours a day and 5.7 days a week for Khat use [57, 58]. Similarly, Khat chewing is associated with diminished antioxidants of saliva Khat chewers [59]. Moreover, Khat chewing is associated with the development of type 2 diabetes. Evidence in Saudi Arabia indicates that Khat chewing increases the likelihoods of developing type 2 diabetic disease four times than nonchewers [60]. Evidence in East African countries such as Ethiopia, Kenya, Eretria, Somalia, Sudan, Rwanda, and Uganda indicates that Khat chewing is associated with the development of high blood pressure, type 2 diabetes, heart failure, mental health problems, group segregation, family cessation, and abandonment of public accountabilities [61, 62].

#### **2.3 Organised infrastructure**

Within the healthcare framework, the availability of interrelated material and infrastructure are other determinants of healthcare. For NCDs, neighbourhood environments broadly define the conditions in which people live and have a

**17**

*The Global Burden and Perspectives on Non-Communicable Diseases (NCDs)…*

compared with children not facing such conditions [2, 39, 64].

**2.4 Urbanisation and urban development policy**

ing in rural areas [63, 64].

**2.5 Cultural norms**

ties associated with city living [65–67].

change when the associated health risks are explained [69].

**2.6 Accessibility of health information**

significant influence on the risk of NCDs [40, 63]. A randomised control study in which mothers and families were given the opportunity to move from a neighbourhood with a high level of poverty to one with a lower level found that moving to a better-off neighbourhood was associated with a reduction in NCDs. Multiple mechanisms have been proposed whereby the neighbourhood environment affects the risk of NCDs, including interrelated material mechanisms [64]. These material mechanisms include the nature of the built environment, such as proximity to food outlets selling processed foods, as well as psychosocial mechanisms, such as conforming to social norms of behaviour. Also, children living in unfavourable social conditions, unsafe surroundings, poor housing, and no access to sidewalks, parks, and recreation centres were 20–60% more likely to be overweight or obese

Urbanisation is associated with an increased prevalence of NCD risk behaviours, which are increasing at a rapid rate. More than half of the global population lived in cities in 2010, a proportion expected to reach 60% in 2030 and 70% in 2050. In countries where rural-to-urban migration is commonplace, urban life may be less conducive to physical exercise than life in rural areas. As countries develop, the sprawling nature of urban expansion and increased disposable income encourages mechanised transport and discourages walking and cycling. The nature of work available in urban areas may require less energy expenditure than subsistence farm-

A study of physical activity concerning hypertension, obesity, and diabetes found that it was lower amongst rural than urban dwellers. The prevalence of obesity, diabetes, and hypertension was higher amongst the urban population, and physical inactivity amongst urban groups was associated with a higher BMI, blood pressure, and fasting blood glucose levels. NCD prevention and control may require that cities adopt models of urbanisation that address the health impacts and inequi-

Evidence indicated that beliefs and norms amongst some social groups might include preferences for foods high in animal fat, which is socially acceptable or perceived as a sign of good health but result in overweight, obesity, hypertension, and health problems. Ethnographic studies found that amongst blacks in South Africa, Arabs in Niger, groups in rural Jamaica, Puerto Ricans in Philadelphia, and members of a Fijian village, a big body size and fatness reflect wealth and prosperity, beauty, marriageability, attractiveness, fertility, and "closeness to God", as is the case of Habesha in Ethiopia [1, 48, 68]. In contrast, much of the industrial West associate fatness with ugliness, undesirability, and lack of self-control, whilst associating slimness with health, beauty, intelligence, wealth, self-discipline, and "goodness". There is some evidence that the Western slim-body ideal is becoming globalised, with thinness now being desired in many places where fatness was previously preferred. Moreover, the beliefs amongst those who idealise fatness may

Health information is a tool that provides data to the healthcare system, which can be used to enhance, promote, improve, and create awareness about the health of

*DOI: http://dx.doi.org/10.5772/intechopen.89516*

*The Global Burden and Perspectives on Non-Communicable Diseases (NCDs)… DOI: http://dx.doi.org/10.5772/intechopen.89516*

significant influence on the risk of NCDs [40, 63]. A randomised control study in which mothers and families were given the opportunity to move from a neighbourhood with a high level of poverty to one with a lower level found that moving to a better-off neighbourhood was associated with a reduction in NCDs. Multiple mechanisms have been proposed whereby the neighbourhood environment affects the risk of NCDs, including interrelated material mechanisms [64]. These material mechanisms include the nature of the built environment, such as proximity to food outlets selling processed foods, as well as psychosocial mechanisms, such as conforming to social norms of behaviour. Also, children living in unfavourable social conditions, unsafe surroundings, poor housing, and no access to sidewalks, parks, and recreation centres were 20–60% more likely to be overweight or obese compared with children not facing such conditions [2, 39, 64].

#### **2.4 Urbanisation and urban development policy**

Urbanisation is associated with an increased prevalence of NCD risk behaviours, which are increasing at a rapid rate. More than half of the global population lived in cities in 2010, a proportion expected to reach 60% in 2030 and 70% in 2050. In countries where rural-to-urban migration is commonplace, urban life may be less conducive to physical exercise than life in rural areas. As countries develop, the sprawling nature of urban expansion and increased disposable income encourages mechanised transport and discourages walking and cycling. The nature of work available in urban areas may require less energy expenditure than subsistence farming in rural areas [63, 64].

A study of physical activity concerning hypertension, obesity, and diabetes found that it was lower amongst rural than urban dwellers. The prevalence of obesity, diabetes, and hypertension was higher amongst the urban population, and physical inactivity amongst urban groups was associated with a higher BMI, blood pressure, and fasting blood glucose levels. NCD prevention and control may require that cities adopt models of urbanisation that address the health impacts and inequities associated with city living [65–67].

#### **2.5 Cultural norms**

*Public Health in Developing Countries - Challenges and Opportunities*

mance, periodontal disease, and decreased quality of life [55, 56].

can easily harm the health of the users [1].

high government officials [50]. Practising these dietary choices frequently result in overweight, obesity, high blood pressure, kidney disease, and premature ageing [51, 52]. Additionally, food cooking oil known as "Hayat" and "Palm oil" which is in use amongst the majority of the Ethiopian is full of high cholesterol, and this

Another unhealthy dietary practice frequently practised amongst low-resourced populations, particularly in East Africa such as Ethiopia, Eritrean, Djibouti, Somalia, Kenya, Tanzania, and Sudan and Arab countries such as Saudi Arabia, United Arab Emirates, Yemen, Bahrain, Kuwait, and Oman, is "Khat chewing". Khat is a leafy plant with natural amphetamine content and chewed by 20 million people each day in Arabian peninsula and East African region mainly in Ethiopia (**Figure 4**) [53]. Khat chewing has incredible stimulation effects on chewers nervous system and predominantly addictive. The practice of Khat chewing is frequent amongst university students, shop keepers, drivers, and majority of the Muslim community, teachers, and some government officials [54]. Evidence shows that Khat chewing is associated with escalated degrees of cardiovascular complications, stroke, myocardial infections, cardiomyopathy, gastritis, poor oral hygiene, neurosis, poor academic perfor-

Khat dependence is associated with wasting of longer working hours and family time. Evidence in Yemen and Saudi Arabia shows that lousy mood, psychosomatic dependence, sleeplessness, and physical indicators were observed amongst Khat chewers, and they spend an aggregate of 6 hours a day and 5.7 days a week for Khat use [57, 58]. Similarly, Khat chewing is associated with diminished antioxidants of saliva Khat chewers [59]. Moreover, Khat chewing is associated with the development of type 2 diabetes. Evidence in Saudi Arabia indicates that Khat chewing increases the likelihoods of developing type 2 diabetic disease four times than nonchewers [60]. Evidence in East African countries such as Ethiopia, Kenya, Eretria, Somalia, Sudan, Rwanda, and Uganda indicates that Khat chewing is associated with the development of high blood pressure, type 2 diabetes, heart failure, mental health problems, group segregation, family cessation, and abandonment of public

Within the healthcare framework, the availability of interrelated material and infrastructure are other determinants of healthcare. For NCDs, neighbourhood environments broadly define the conditions in which people live and have a

**16**

**Figure 4.**

accountabilities [61, 62].

*Chewable leaves of Chat plant.*

**2.3 Organised infrastructure**

Evidence indicated that beliefs and norms amongst some social groups might include preferences for foods high in animal fat, which is socially acceptable or perceived as a sign of good health but result in overweight, obesity, hypertension, and health problems. Ethnographic studies found that amongst blacks in South Africa, Arabs in Niger, groups in rural Jamaica, Puerto Ricans in Philadelphia, and members of a Fijian village, a big body size and fatness reflect wealth and prosperity, beauty, marriageability, attractiveness, fertility, and "closeness to God", as is the case of Habesha in Ethiopia [1, 48, 68]. In contrast, much of the industrial West associate fatness with ugliness, undesirability, and lack of self-control, whilst associating slimness with health, beauty, intelligence, wealth, self-discipline, and "goodness". There is some evidence that the Western slim-body ideal is becoming globalised, with thinness now being desired in many places where fatness was previously preferred. Moreover, the beliefs amongst those who idealise fatness may change when the associated health risks are explained [69].

#### **2.6 Accessibility of health information**

Health information is a tool that provides data to the healthcare system, which can be used to enhance, promote, improve, and create awareness about the health of a community. It is evidenced that health information systems are an essential tool for collecting data about the health conditions and indicators of a country to help with decision-making. It is documented that reliable health data that is collected, analysed, and interpreted can assist policymakers, health organisations, the healthcare system, and healthcare providers in formulating appropriate disease preventive strategies. It has also been demonstrated that health data can be made available to the public through various health information channels, such as healthcare providers, counselling, teaching, and advice; mass media, such as radio television, internet, social media; and telecommunication, such as mobile short message service (SMS) [4, 70].

Despite the wide-ranging health benefits of health information, the attention given to addressing NCDs-related risk factors, morbidity, mortality, the health burden, and preventive mechanisms using the various sources of health information is inadequate in low-resourced countries. Similarly, the attention devoted to the accessibility of health information coverage is deficient in the healthcare system of developing countries [4].
