Egypt Health Strategies to tackle NCDs
There has been an alarming rise in the incidence of non-communicable diseases (NCDs) in Egypt over the past few decades as more people are diagnosed year-on-year (Roberts et al., 2013:346). The rise of NCDs threatens to overwhelm the health system of Egypt, which is plagued with limited access to quality and affordable healthcare as well as weak health systems that cannot quickly respond to and ameliorate the escalating NCD crisis. NCDs have been the leading cause of mortality in developed nations, a statistic that is now being replicated in developing countries, mainly due to better control of communicable diseases, rising urbanization and changes in lifestyle (Engelgau et al. 2011). Therefore, it is imperative that intervention measures be instituted to tackle NCDs as a means of improving the health of the nation and reducing the health burden associated with the management and treatment of NCDs. Although there are many underlying causes of NCDs, lifestyle changes that have led to an increasingly sedentary existence are at the core of the rising epidemic (Peluso & Andrade 2005, 68). Tackling of NCDs necessitates the careful evaluation of the lifestyle of individuals to determine the factors that predispose an individual to a disease.
The disease and mortality statistics for Egypt have changed considerably over the past decades with mortalities due to communicable diseases declining sharply due to better access to health care and high coverage rates for immunization (WHO, a, 2010: 15). Conversely, the mortality due to NCDs has increased steadily over the years and currently accounts for approximately 85 percent of all recorded deaths in Egypt, with cardiovascular diseases, at 46 percent, being the leading cause of mortality (WHO, b, 2014). The changing disease profile calls for a change in health policies and strategy for allocating health resources to reflect the changing realities. One of the main triggers of NCDs is lifestyle, with research showing that the main risk factors that predispose individuals to these diseases include unhealthy heating habits, high blood pressure, high levels of serum cholesterol, sedentary lifestyle, tobacco smoking and obesity (Musaiger and Al-Hazzaa, 2012: 201).
The majority of the Egyptian population is young, and with NCDs increasingly affecting the younger population, the projections for the future are grim and the disease may reach epidemic levels, with serious consequences on the mortality rates (Mirkin, 2012). The incidence of NCDs is likely to be exacerbated by increasing levels of obesity amongst children and teenagers in Egypt, with research linking increased susceptibility to NDCs and obesity (Mirmiran et al., 2010: 1025; Sibai et al., 2010: 198 Musaiger, 2011). The smoking prevalence in Egypt is also relatively high at approximately 46 percent for males (WHO, b, 2014), and this is projected to rise, especially with the popularity of waterpipe tobacco (shisha) smoking (Fawzy, Kamal and Abdulla, 2011: 284). Smoking among the youth in Egypt is considered culturally acceptable and glamorous, influenced by subliminal smoking messaging in western mass media accessible to the youth, despite the patriarchal society in Egypt frowning on smoking (Islam and Johnson, 2007: 62). Smoking incidence in Egypt’s majority young population is likely to increase, posing a grave challenge to the management of NCDs, considering that smoking is one of the risk factors of some NCDs. Cognizant that cardiovascular diseases and cancers account for approximately 60 percent of all the deaths in Egypt, and that smoking is a major risk factor for both of the NCDs, there is an urgent need to formulate and implement a behavioural change strategy to reduce the level of smoking amongst the Egyptian population..
The aim of this paper is to:
- Develop a behavioural change model that can reduce the smoking incidence in Egypt by 30% by 2020
- Monitor the effectiveness of the model in engendering desirable behavioural changes
The objectives are:
- To decrease the smoking incidence within the Egyptian population through behavioural changes
- To compare Egypt’s progress with a similar country that has achieved behavioural change
- To monitor and evaluate the proposed strategy through short term and long term Key Performance Indicators.
Smoking in Egypt
Egypt is facing an increasing NCD disease burden that threatens to overwhelm the public health system and increase mortality despite the giant steps the country has taken to significantly reduce mortality due to communicable diseases (Nikolic, Stanciole and Zaydman, 2011: 3). The rise in NCDs is correlated to the increased incidence in smoking not only in the adult population but also among the young (Ellabany and Abel-Nasser, 27). Although smoking is predominantly done by approximately 46% of males, there are a few women, less than 1% of the population, who are also engaging in the habit and, therefore, should also be considered in any intervention measures, considering that the increase in female smoking prevalence has been rising faster than that of men (Hanafy et al., 2010: 1).
Although there has been a general decrease in smoking incidence in most of the developed countries, in Egypt, the opposite seems to be happening with smoking prevalence among men and women increasing in the recent past. There are a number of factors that have led to the increase in the smoking prevalence. First, there has been a gradual weakening of the social norms against female smoking, leading to a rapid increase in the smoking prevalence amongst women, especially young women, implying that the future cohort of smokers is likely to have a considerable percentage of women, compared to the present (Hanafy et al., 2010: 1). Secondly, tobacco products in Egypt are relatively cheap, encouraging many people to try smoking because they can afford to sustain the habit. Another factor that has contributed to increasing prevalence is the favorable image that smoking has in the mind of the youth, as a habit that is glamorous, a perception influenced by the subliminal smoking messages from popular western culture (Sargent and Hanewinkel, 2008: 416). Lastly, the change in shisha smoking, from a rural poor pastime to a popular urban pastime with dedicated cafes, has led to an increase in the number of smokers because there is a new breed of smokers that exclusively smoke shisha, adding to the already large group of cigarette smokers (Abdelwahid and Diab, 2012: 3).
Current national strategies
Egypt does not have a coherent and well thought-out strategy for combating the increasing prevalence of smoking amongst its young population. In addition, the statistics on smoking remain sketchy as the government is yet to undertake a comprehensive survey on smokers. Generation of reliable statistics, especially on female smokers is hampered by the social norms that consider female smoking as misbehavior, prompting women to underreport and misreport their smoking habits. However, the government has begun a campaign of using cigarette packs to pass across anti-smoking messages by indicating the likely negative consequences that are associated with smoking (Salam, 2010). In addition, the Egyptian government does not have an effective monitoring mechanism to determine whether its anti-tobacco campaign is efficacious.
Although there has been a gradual weakening of the Egyptian social norms that were based on Islam, the Egyptian community still remains mainly patriarchal with women only recently moving into the mainstream. Consequently, data on smoking, especially for women is sketchy and unreliable, while that for men is dated and tends to be approximated. Smoking within the Egyptian society is socially acceptable for males, and special cafes have sprouted in urban centers, where males get together and smoke shisha. The rapid modernization of the society is also leading to changes in perception about women smoking, and hence more women are taking up smoking, implying that in the not so distant future, the number of women that are smoking is likely to be closer to that of men unlikely currently, where the number of women smokers is negligible. Increasing awareness of the dangers of smoking to the community may help to arrest the escalating smoking prevalence within the population.
Health Promotion and Social Marketing benchmarks
The strategy needed is one that will reduce the tobacco smoking prevalence in the Egyptian population and consequently the health burden on the health care system caused by NDCs triggered by smoking. This requires a behavior change in the population because it is only through behavioral change that individuals can quit smoking. Behavioral change can be achieved though a paradigmatic shift in the thinking of people vis-à-vis the appropriateness of the smoking habit. When smoking is seen as an undesirable habit, people are likely to stop smoking and hence the strategy should be geared towards ensuring that people develop a negative attitude towards smoking.
An integrated strategy that incorporates several theoretical behavioral change models will be used. The health belief model developed by Rosenstock (1966) is one of the theoretical models that will be used to develop the health promotion strategy. The theory is based on the assumption that people will adopt a recommended action if they perceive that the benefits of quitting smoking are greater than the barriers to quitting.
Once individuals understand the dangers that they expose themselves to through smoking as well as the severity of the consequences of smoking, they can consider quitting smoking. This theory shall be used alongside the transtheoretical model proposed by Prochaska and Velicer (1997) after studying the difficulties that smokers who decided to quit passed through. This theory is especially pertinent in promoting health amongst smokers due to the relatively high rates of relapse for smokers who quit. The theory posits that to prevent relapse, health promoters should give smokers the requisite skills training to help them handle the challenges associated with quitting. The smokers should also undergo cognitive reframing and lifestyle rebalancing to ensure that they can view the new non-smoking life as more desirable than the smoking life and hence will strive to ensure that they remain non-smokers.
Evidence: Influence of Mass media
The mass media has a tremendous influence on the value system that the youth have, with the youth generally copying what they consider ‘cool’ habits from what they see in the media (Islam and Johnson, 2007: 62). The media can, therefore, have a corrupting influence on the gullible youth especially when smoking is depicted as a desirable and glamorous habit. However, the media, when controlled can also be used in the health promotion campaign by disseminating information on the adverse effects of smoking. The cigarette packaging can also be used to transmit the adverse effects of smoking by having pictures showing the consequences of smoking, for example lung cancer. For this strategy to be effective, the media should censure any images that promote smoking and ensure that there are no ads for tobacco products. These are measures that Malaysia has used in its anti-smoking campaigns with some success. A concerted anti-smoking campaign in the media as well as a ban on smoking ads can help to reduce the smoking incidence by 10%. This is because the positive image of smoking will be eroded an smoking will be seen largely as a bad choice reducing the pressure on youth to smoke.
Egypt has relatively cheap cigarettes, which encourages many people to begin and continue smoking because they can afford the habit. Increasing the taxes of cigarettes significantly automatically leads to an increase in prices, which will cause a considerable number of people to consider quitting the habit due to the increased expenses. Evidence from developing countries on the efficacy of this strategy is sketchy because of the availability of home-made tobacco, which is cheaper. However, for Egypt, this tactic can be effective because all of the country’s tobacco is imported hence easy to tax. When the price of cigarettes rises by 10%, demand reduces by 4% (Bader, Boisclair and Ferrence, 2011: 4122), and if Egypt can raise the price of cigarettes by 30% through taxation, the demand is likely to reduce by over 10%
Involves the banning of smoking in public places, prohibition of sale to underage’s, prohibition on advertising and ceilings on tar and nicotine content. Legislation makes it difficult and cumbersome to smoke and can cause some people to quit, with evidence from Malaysia showing that implementing anti-smoking legislative measures is necessary in reducing the smoking prevalence among the population (Preventing Cancer, 2007). Clean air legislation can help to reduce smoking incidence by approximately 5%.
Short term outcomes indicators
- Monitor the quarterly import data for tobacco leaf to determine the trend in the imported volume, with volumes anticipated to reduce by 1% after one year
- Review the net change in the number of shisha cafes by collecting data on the current number of cafes and subsequent changes in the number of cafes opened or closed over one quarter
- Review compliance with advertising and packaging requirements by looking at images on cigarette packs and the frequency of smoking images in the mass media.
Long-term outcomes indicators
- Review behavioral change using annual attitudinal surveys to determine prevailing attitudes towards smoking
- Monitor the prevalence of NCDs, especially those that smoking is a risk factor through analysis of health sector data.
Abdelwahid, E., Ali, H. & Diab, A, 2012. Patterns of smoking among undergraduates of Suez Canal University, Egypt. 1:577 doi:10.4172/ scientificreports.577
Bader, P., Boisclair, D. & Ferrence, R. 2011. Effects of tobacco taxation and pricing on smoking behavior in high risk populations: a knowledge synthesis. International Journal of Environmental Research and Public Health, 8, (11) pp. 4118-4139.
Ellabany E. & Abel-Nasser, M., n.d. Community based survey study On Non-communicable diseases and their Risk Factors, Egypt, 2005- 2006. Ministry of Health & population, Egypt Preventive Sector [Online]. Available at < http://www.who.int/chp/steps/STEPS_Report_Egypt_2005-06.pdf > [Accessed 10 April 2015]
Engelgau, M., S. El-Saharty, P. Kudesia, et al., 2011. Capitalizing on the Demographic Transition: Tackling Noncommunicable Diseases in South Asia. Washington, DC: World Bank.
Fawzy, A. Kamal, N. and Abdulla, A., 2011. Reproductive toxicity of tobacco shisha smoking on semen parameters and hormones levels among adult Egyptian Men. Research Journal of Environmental Toxicology, 5, pp. 282-292.
Hanafy, K., Saleh, A., Elmallah, M., Omar, H., Bakr, D. & Chaloupka, J., 2010. The economics of tobacco and tobacco taxation in Egypt. Paris: International Union against Tuberculosis and Lung Disease.
Islam, S. & Johnson, C., 2007). Western media’s influence on Egyptian adolescents’ smoking behavior: The mediating role of positive beliefs about smoking. Nicotine & Tobacco Research, 9(1) pp. 57-64.
Mirkin B., 2010. Arab human development report. United Nations Developing Programme; 2010. Population levels, trends and policies in the Arab region: Challenges and opportunities. Available at: <http://www.arab-hdr.org/publications/other/ahdrps/paper01-en.pdf.> [Accessed 10 April 2015]
Mirmiran, P., Sherafat-Kazemzadeh, R., Jalali-Farahani, S. & Azizi, F., 2010. Childhood obesity in the Middle East: a review. East Mediterranean Health Journal, 16, pp. 1009–1117.
Musaiger A., 2011. Overweight and obesity in the eastern Mediterranean: prevalence and possible causes. Journal of Obesity 2011:407237
Musaiger, A. and Al-Hazzaa, H., 2012. Prevalence and risk factors associated with nutrition-related noncommunicable diseases in the Eastern Mediterranean region. International Journal of General Medicine 5, pp. 199-217.
Nikolic, I., Stanciole, A. & Zaydman, M., 2011. Chronic emergency: Why NCDs matter. Washington: The World Bank.
Peluso M. and Andrade H., 2005. Physical activity and mental health: the association between exercise and mood. Clinics 60, pp. 61–70.
Preventing Cancers (and Other Diseases) by Reducing Tobacco Use. National Academy of Sciences [Online] Available at: <http://www.ncbi.nlm.nih.gov/books/NBK54023/> [Accessed 10 April 2015].
Prochaska, J. & Velicer, F., 1997. The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), pp. 38-48.
Roberts, B., Patel, P., Dahab, M. and McKee, M., 2013. The Arab Spring: Confronting the challenge of non-communicable disease. Journal of Public Health Policy 34,(2) pp. 345-352.
Rosenstock, I., 1966. Why people use health services. Milbank Memorial Fund Quarterly, 44(3), pp. 34-127.
Salam, M., 2010. Egypt’s war on smoking. Ikhwanweb [Online] last updated 29 Aprl 2010. Available at <http://www.ikhwanweb.com/article.php?id=24536> [Accessed 10 April 2015].
Sargent, D. & Hanewinkel, R., 2008. Viewing movie smoking undermines antismoking parental practices. Przegl Lek, 65, pp. 415–19.
Sibai, A., Nasreddine, L., Mokdad, A., Adra, N., Tabet, M. &Hwalla N., 2010. Nutrition transition and cardiovascular disease risk factors in Middle East and North Africa Countries: reviewing the evidence. Ann Nutr Metab. 57, pp.193–203.
WHO (a), 2010. Country Cooperation Strategy for WHO and Egypt 2010–2014. Cairo: WHO Regional Office.
WHO (b), 2014. Egypt: Noncommunicable Dis