NO replacement or substitution is allowed for schools that do not agree to participate

235 Data฀collection฀and฀processing Data collection Before initiating the collection of data, countries must participate in a workshop to train their research coordinators RCs in the GYTS standard methodology and procedures. his assures continuity across the regions, consistency in sample design and selection procedures, and questionnaire development ensuring the core remains intact, and uniformity in field procedures for data collection. Once the training workshop is over, RCs return to their respective countries and conduct the survey among students in selected schools. Each student completes a questionnaire with responses coded as filled in bubbles on answer sheets. After com- pleting the data collection of GYTS, the RCs send the survey forms answer and header sheets and school and classroom level forms to CDC for data processing. Data processing Answer sheets received by CDC are scanned using optical scanning hardware. Scanned data files proceed through a data cleaning process that includes matching record length to scanned format, reviewing non-responses out of range and missing and logic editing. Each data record is weight-adjusted for school, class and student non-participation. Finally, all records are adjusted for grade and gender stratification. here is continuing interaction between CDC staff and the RC and regional office while cleaning and editing the data file. Data analysis Once the data has been collected and processed, WHO and CDC, in collaboration with associate partners, conduct data analysis workshops to provide hands-on train- ing to the country RCs for an in-depth analysis of their data sets. Analysis workshops include training in the use of EpiInfo free software that encompasses procedures for analysing complex survey data and country report writing. Data reporting Once the data file is finalized, CDC produces 100+ Weighted Frequency Tables and 100+ Preferred Tables. CDC prepares a draft one-page fact sheet highlighting the main GYTS findings. he final data file, tables and the fact sheet are sent to the cor- responding regional office via e-mail and hard copy. 1. Tabulated data: he raw data are used in calculations for tabulated data. As part of the data processing for GYTS, CDC prepares two types of tables, Weighted Fre- quency and Preferred Tables: •฀ he Weighted Frequency Tables are produced as separate tables for each question in the country questionnaires. Tabulations are given for total, by gender and by grade. •฀ A set of Preferred Tables is produced by CDC, which translates each core question, based on historical classification and including cross comparisons, into variables that are utilized as indicators to monitor tobacco activity within the country. 236 2. Country fact sheet: he country fact sheet contains highlights from the country’s data. he purpose of the fact sheet is to provide the country with data in a one-page format that can be used for quick response to inquiries about the GYTS andor for initial data release. Data from all students who participate in a country’s GYTS are included in the fact sheet. 3. Country report: he purpose of the country report is to promote the development of a country’s tobacco control programme, which draws its evidence base from GYTS. his report should prove most useful as it relates to policy and programme develop- ment in the country. Current฀status฀and฀preliminary฀findings he GYTS was developed to provide systematic global surveillance of youth tobacco use. he GYTS provides data that can be used by countries to: 1 evaluate their coun- try-specific tobacco control programme; 2 monitor trends in global youth tobacco use; and 3 compare tobacco use among countries and regions. As of January 2004, a total of 120 countries representing all six WHO regions have participated in the GYTS. In addition, repeat GYTS have been completed in 14 countries, 10 are in the field, and 11 are preparing for the field. For the first time, the GYTS has documented in a systematic way a global problem in youth tobacco use. he problem is of equal concern in developed and develop- ing countries. Of the 120 countriesregions that have completed GYTS, not a single site had a prevalence rate of current “any tobacco use”, “current smoking”, or “oth- er tobacco use” equal to zero. In addition, almost one in four students who ever smoked cigarettes smoked their first cigarette before the age of 10. 1 hus, future health consequences of tobacco use and dependency on tobacco appear to be a sig- nificant problem facing countries throughout the world. hese findings suggest that immediate attention needs to be given to developing both global and country-specif- ic tobacco control programmes to reduce tobacco use among young people. Tobacco฀use฀surveillance฀among฀adults฀–฀the฀WHO฀STEPwise฀approach he STEPwise approach to surveillance STEPS is the surveillance tool for adults recommended by WHO, covering all risk factors contributing to non-communicable diseases NCDs, including tobacco use. he objective is to unify all WHO approach- es to defining core variables for population-based surveys, surveillance and monitor- ing instruments to achieve data comparability over time and between countries. STEPS is based on the concept that surveillance systems require standardized data collection as well as sufficient flexibility to be appropriate in a variety of country situa- tions and settings. he STEPwise approach incorporates mechanisms for developing an increasingly comprehensive and complex surveillance system, depending on local needs and resources. he degree of complexity refers to whether questionnaires alone are used, physical measures are collected, or blood collectionsanalysis are undertaken. 237 The฀STEPS฀process STEPS is a sequential process, starting with gathering information on key risk factors by the use of questionnaires Step 1, then moving to simple physical measurements Step 2, and only then recommending the collection of blood samples for biochemical assessment Step 3, Figure 1. Within each step, core, expanded and optional informa- tion can be collected. At a minimum, core information provides the basic, comparable variables to describe prevalence and trends in the most common risk factors. Expanded modules provide more detailed–though still standardized–information on the major risk factors. Optional modules can be added to provide data on risk fac- tors not included in the standard STEPS approach, to obtain country or culturally specific information. he risk factors of choice used in the STEPwise approach to NCD risk factors are those that respond to the following criteria; •฀ hey make the greatest contribution to mortality and morbidity from chronic dis- ease •฀ hey can be changed through primary intervention. •฀ hey are easily measured in populations. Tobacco use is one of the eight risk factors that fit these criteria. Others are alcohol consumption, low fruitvegetable intake, physical inactivity, obesity, blood pressure, cholesterol and diabetes. he STEPS instrument including Step 1, Step 2 and Step 3 can be viewed in Annex 1. he tobacco questions have been extracted from the STEPS instrument and the rationale for each question is explained below. Question-by-question specifications Table฀1.฀฀ Number฀of฀countries฀participating฀in฀the฀GYTS฀by฀WHO฀region WHO฀regions Number฀of฀countries Completed In฀field Preparing฀for฀field Training฀planned Regional฀Office฀ for฀Africa 27 ฀2 3 14 Regional฀Office฀for฀ the฀Americas 36 ฀1 1 ฀0 Regional฀Office฀ for฀the฀Eastern฀ Mediterranean 17 ฀4 1 ฀0 Regional฀Office฀ for฀Europe 19 ฀7 3 ฀0 Regional฀Office฀for฀ South-East฀Asia ฀6 ฀2 ฀2 Regional฀Office฀for฀ the฀Western฀Pacific 15 ฀2 1 10 Total 120 18 9 26 238 relevant to the tobacco questions can be viewed in Annex 2; these explain what is intended by each question. Rationale฀for฀tobacco฀questions Tobacco use in communities can be measured through population surveys andor by examining government data on apparent consumption of tobacco products calculat- ed from cigarette production and importexport data. All definitions used in STEPS, regarding smoking status are recommended by the WHO publication Guidelines for controlling and monitoring the tobacco epidemic 2. According to these guidelines any population can be divided into two categories, smokers and non-smokers. A smoker is someone who at the time of the survey smokes any tobacco product either daily or occasionally. Smokers may be further subdivided into two categories: •฀ ฀A daily smoker is someone who smokes any tobacco product at least once a day •฀ An occasional smoker non-daily smoker is someone who smokes, but not every day A non-smoker is someone who, at the time of the survey, does not smoke at all. Non- smokers can be divided into three categories: •฀ Ex-smokers are people who were formerly daily smokers but currently do not smoke at all Figure฀1.฀฀ WHO฀STEPS฀–฀NCD฀risk฀factors:฀concept B U I L D I N G B L O C K S F O R T O B A C C O C O N T R O L : A H A N D B O O K 239 •฀ Never smokers are those who either have never smoked at all or have never been dai- ly smokers and have smoked less than 100 cigarettes in their lifetime •฀ Ex-occasional smokers are those who were formerly occasional but never daily smokers and who smoked 100 or more cigarettes or the equivalent amount of to- bacco in their lifetime. STEPS฀Questionnaire.฀Tobacco฀section Core questions: WHO suggests some core questions to establish the smoking status of each adult individual in the sample to determine the prevalence of tobacco use in the adult population. 1a. Do you currently smoke any tobacco products, such as cigarettes, cigars or pipes? 1b. If yes, do you currently smoke tobacco products daily? hese two questions permit the estimation of the main categories of current smoking status, which is the most important estimation in large health surveys. If there is an opportunity for more questions, it is highly recommended to use questions about pre- vious history of tobacco use see below-expanded questions. 2a. How old were you when you first started smoking daily? 2b. Do you remember how long ago it was? he WHO guidelines actually recommend asking about number of years that a per- son smoked daily. his way it is possible not to count the time period when the person was not smoking. However, by asking the question in two different ways, con- trolling for recall error is possible. Age at onset is especially important in assessing the smoking status in adolescents, since adults are more likely to quit, but young people are in the process of smoking initiation. 3. On average, how many of the following do you smoke each day? Manufactured cigarettes, hand-rolled cigarettes, pipes full of tobacco, cigars, cheroots, cigarillos his is an additional question about daily consumption and is also used for assess- ing the prevalence of tobacco use. he list of items should be modified to suit local tobacco use patterns. Expanded questions: Whenever possible, the survey should contain expanded ques- tions for determining the history of smoking status and use of smokeless tobacco. 4. In the past, did you ever smoke daily? 5a. If yes, how old were you when you stopped smoking daily? 5b. How long ago did you stop smoking daily? If there is an opportunity for more questions, the questions on past consumption of tobacco are crucial. By combining the questions of current and previous use of tobacco, it is possible to determine the prevalence of all major categories of smok- ing status 2. 240

6. Do you currently use any smokeless tobacco such as snuff, chewing tobacco,

betel? 6b. If yes, do you currently use smokeless tobacco products daily? 7. On average, how many times a day do you use… RECORD FOR EACH TYPE Because tobacco is used in a variety of forms, it is essential to assess the use of smoke- less tobacco particularly in settings where smokeless tobacco is preferred to smoked tobacco. In some countries of the African and Eastern Mediterranean Regions, the use of tobacco products such as chewing tobacco, water pipes, narguileh or sheesha often surpass cigarette smoking. STEPS฀implementation฀at฀country฀level he ultimate goal of the STEPS approach is to increase a country’s capacity to devel- op a sustainable infrastructure for NCD surveillance 3. To achieve this, strategic alliances are necessary at the global, regional and country level Figure 2. WHO headquarters provides global coordination for implementing STEPS across the WHO regions. WHO headquarters, in collaboration with the WHO regional offices, pro- vides STEPS training to STEPS focal points by region and country. he WHO STEPS training utilizes a “train the trainer” approach, ensuring that knowledge transfer and capacity is improved and maintained at country level. Train- ing covers all aspects of the planning, implementation, data collection, analysis and dissemination of the results of a STEPS survey within the context of an integrated surveillance system. WHO regional offices implement the programmes within coun- tries and organize the training workshops. Current฀status Currently, STEPS is being carried out in four WHO regions, namely the WHO Afri- can Region, the WHO Eastern Mediterranean Region, the WHO South-East Asia Region and the WHO Western Pacific Region, and covers over 35 countries. Over 50 countries have been trained in regional training workshops as well as national work- shops. Practical฀considerations •฀ Each WHO Member State implementing STEPS is advised to convene a group or a committee, which works as the equivalent of national inter-agency coordinating committee Figure 2. his committee should oversee the practical and logistic is- sues relating to the overall country level implementation of STEPS, as well as pro- viding assistance in translating data into policy and programmes. •฀ he data collected must be relevant for the development of public health interven- tions. •฀ he collection and analysis of good quality data are not enough to inform policy in an environment in which the health agenda is subject to competing priorities. herefore, it is necessary to further provide policy-makers with accurate, useful and easily interpreted results. he STEPS approach was designed with this fact in mind