Southeast Asia faces an epidemic of chronic non-communicable diseases, now responsible for 60% of deaths in the region. The problem stems from environmental factors that promote tobacco use, unhealthy diet, and inadequate physical activity. Disadvantaged populations are the hardest hit, with death rates inversely proportional to a country's gross national income. Families shoulder the financial burden, but entire economies suffer as well. Although attempts to control non-communicable diseases are increasing, more needs to be done. Health-care systems need to be redesigned to deliver chronic care that is founded on existing primary health-care facilities, but supported by good referral systems. Surveillance of key modifiable risk factors is needed to monitor the magnitude of the problem and to study the effects of interventions. All branches of government and all sectors of society have to get involved in establishing environments that are conducive to healthy living. The Association of Southeast Asian Nations is in a unique position to make a united stand against chronic non-communicable diseases in the region. Inaction will affect millions of lives—often, the lives of those who have the least.
Introduction
The sea splits southeast Asia into a vast collection of island fragments large and small, to an extent unlike other regions around the world. This splintered geography is the foundation of wide variation in history and heritage and is the root of a rich social and cultural heterogeneity—not only between countries, but within countries as well. In recent years, however, globalisation and technological advances have combined to create a potent force for convergence, bringing nations closer together in terms of accessibility, communication, commerce, ideas, and even culture. Today, the region has become an interesting mixture of historical diversity and contemporary convergence.
One manifestation of this convergence is the rapid epidemiological and demographic transition in the region,1 which is characterised by a reduction in deaths from communicable diseases, an increase in average life expectancy, and an epidemic rise in chronic non-communicable diseases such as heart disease, stroke, cancer, and chronic obstructive pulmonary disease (COPD).2, 3, 4 These diseases threaten a rapidly growing population of almost 600 million people in the region, most of whom are younger than 65 years and are within the most productive years of their lives. Many have insufficient resources to deal with chronic illness and premature death—a situation that threatens not only families, but also entire economies.1 Urgent action is needed and southeast Asia—represented by the geopolitical Association of Southeast Asian Nations (ASEAN)—is uniquely poised to take a strong and united stance against chronic non-communicable diseases.
Key messages
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Chronic non-communicable diseases are a major public health problem in southeast Asia
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These conditions (and their risk factors) are strongly linked to poverty, and are a major drain on the economy because of avoidable morbidity and mortality
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Modifiable risk factors are increasing in low-income populations because of unplanned urbanisation, marketing of unhealthy food, and inadequacies in public health policies
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Surveillance of chronic non-communicable diseases and their risk factors needs to be improved, along with monitoring of the policy environment, to enable countries to keep track of the effects of interventions
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Health-care systems have to be strengthened to address the needs of chronic non-communicable diseases through primary health care and appropriate referral systems
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All branches of government and all sectors of society need to be involved in creating an environment that is conducive to healthy living, in which healthy choices become easy choices
Despite the importance of knowledge about the patterns and burden of chronic non-communicable diseases and the risk factors that predict them, such data are sparse for southeast Asian countries. We attempt to provide information that will help draw attention to the problem and direct efforts to curb the epidemic (see panel for search strategy5, 6, 7, 8, 9, 10, 11). Our specific objectives are: to characterise and compare the burden of chronic non-communicable diseases and their risk factors in southeast Asia, with special attention to disadvantaged populations; to describe national responses in line with global and regional initiatives; and to suggest feasible and comprehensive approaches to prevention and control of non-communicable disease in this region.
In this paper, we use the term chronic non-communicable disease to refer to major chronic disorders such as heart disease, stroke, cancer, and COPD. These diseases share common, modifiable risk factors, as shown in the causal pathway in figure 1. Neuropsychiatric disorders (other than stroke) and chronic illnesses related to infectious processes (such as hepatitis B or human papillomavirus infection) are not covered in this paper. Mortality, morbidity, and the economic burden of chronic non-communicable diseases will be described and comparable estimates of prevalence of key modifiable biological and behavioural risk factors will be presented. Environmental risk factors such as globalisation, urbanisation, and poverty have been discussed in the first paper1 in this Lancet Series on health in southeast Asia. We will also investigate to some extent their role in the non-communicable disease epidemic.
On the basis of World Bank income groups, the ten countries in the southeast Asian region include four economies with low incomes (Cambodia, Laos, Myanmar, and Vietnam), three with lower middle incomes (Indonesia, the Philippines, and Thailand), one with an upper middle income (Malaysia), and two with high incomes (Brunei and Singapore). These countries have large disparities in social, political, and economic conditions,1 ranging from Myanmar, which has a gross national income of 1290 international dollars, to Brunei, which has a gross national income of 49 900 international dollars.
Section snippets
Death, disability, and economic burden
On the basis of Global Burden of Disease projections, an estimated 2·6 million people from the ten ASEAN countries died from chronic non-communicable diseases in 2005. The numbers were similar for men and women, and accounted for nearly 61·5% of the total deaths in these countries. With the ageing of these populations and increasing exposure to risk factors for non-communicable diseases, the numbers are projected to increase to 4·2 million deaths in 2030.13 When adjusted for age, the
Risk factors
A small number of risk factors17, 18 account for a large proportion of the global burden of chronic non-communicable diseases (figure 1). Data from the Asia-Pacific Cohort Studies Collaboration suggest that these risk factors have the same effects in Asian populations as in others.19 These risk factors include raised blood pressure,20 high body-mass index (BMI) or waist-to-hip ratio,21, 22, 23, 24, 25 raised blood sugar concentrations,26, 27 and abnormal serum lipid concentrations.28 All four
Responses to chronic disease in southeast Asia
Several WHO initiatives have drawn attention to the high burden of non-communicable diseases and the importance of intervention to curb this epidemic. The global call for prevention and control of non-communicable diseases has been spearheaded by the Framework Convention on Tobacco Control38 and the Global Strategy on Diet, Physical Activity and Health,39 and, more recently, the WHO 2008–2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases.40 This
Discussion
We have reported the burden from chronic non-communicable disease and its risk factors in southeast Asia. Although studies show that the relative importance of these risk factors are similar in countries around the world, some aggravating factors in the southeast Asian population might be worth emphasising. First, diabetes prevalence is peaking faster in many Asian countries than it is elsewhere. Between 1970 and 2005, the prevalence of diabetes quadrupled in Indonesia, Thailand, India, and
The way forward
Because of the effect on health and productivity of the population, the epidemic of non-communicable disease in southeast Asia requires urgent attention. Many countries in the region are still trying to cope with old infectious diseases as well as new and emerging infections. If neglected, however, chronic non-communicable diseases could threaten national development and ultimately jeopardise the capacity of nations to respond to health needs at large. Therefore, a comprehensive and coherent
Search strategy and selection criteria
We did a Medline search to identify relevant studies published during the past 10 years that used representative samples to measure the burden of non-communicable diseases or their risk factors in countries in southeast Asia. Medical Subject Heading (MESH) terms used for non-communicable diseases were: “cancer”, “stroke”, “myocardial infarction”, “cardiovascular diseases”, “pulmonary disease, chronic obstructive”, “diabetes mellitus”, “hypertension”, “obesity”, “dyslipidemias”, “smoking”, “food
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2024, The Lancet Regional Health - Western Pacific
The WHO Western Pacific region bears disproportionate deaths from non-communicable diseases (NCDs), with increased overall NCD proportional mortality over the past two decades. The disease burden of mental health increased, resulting from rapid ageing, enhanced stress, and the COVID-19 pandemic, but it was largely neglected. The highly diverse cultures, religions, political systems, socioeconomic contexts, lifestyles, and environmental factors probably have led to massive disparities across countries in NCD mortality, risk factors, and NCD management. Geographically, East Asia had the lowest NCD mortality whilst Pacific islands had the highest. Economic booms, ageing, nutrition transition, social stress, prevalent tobacco use, and fast-increasing obesity and hyperglycaemia are important drivers of NCDs. Men tended to have more adverse behavioural and metabolic risk factors. Rural residents are catching up with their urban counterparts in metabolic risk factors and conditions. Sustainable strategies tailored to NCD patterns are needed to fight the NCD epidemic and related disparities.
To translate and validate the Thai Self-Care of Chronic Illness Inventory version 4.c (Thai SC-CII v4.c) in individuals with chronic illnesses.
A scale translation and cross-sectional validation study was conducted. The English version was translated for Thai involved nine steps: preparation, forward translation, reconciliation, back-translation, back-translation review, harmonization, cognitive debriefing, review of cognitive debriefing and finalization, and proofreading. A cross-sectional study was conducted from July to November 2022 at 16 primary care centers in southern Thailand, involving 410 participants with at least one chronic condition. Validity assessments included structural, convergent, and discriminant validity. Concurrent validity examined correlations between SC-CII v4.c with the Self-Care Self-Efficacy Scale (SCSES) and self-perceived health. Internal coherence reliability was calculated using Cronbach’s α coefficient, item-total correlation coefficients, and the composite reliability (CR) index.
Thai SC-CII v4.c demonstrated excellent translational validity (κ = 0.99). The specified Self-Care Maintenance model fit well, with minor differences in health promoting behavior and illness-related behavior items compared to the original model. The original Self-Care Monitoring, and Self-Care Management models fit well with Thai data. Simultaneous confirmatory factor analysis confirmed a satisfactory fit of the full SC-CII v4.c. Convergent validity had partial support (average variance extracted = 0.23–0.51), and discriminant validity was established (heterotrait-monotrait ratios = 0.37–0.88). Concurrent validity was supported by positive correlations between each scale and overall SC-CII v.4c with SCSES (r = 0.25–0.65) and self-perceived health (r = 0.09–0.35). The Cronbach’s α coefficient were adequate for all scales except the Self-Care Maintenance scale (Cronbach’s α = 0.68), but the CR estimate improved the reliability of all three scales (ranging 0.80–0.82). All items had satisfactory item-total correlation coefficients (ranging 0.34–0.71), except the one pertaining to sleep.
The Thai SC-CII v4.c is valid and reliable for assessing self-care in various chronic illnesses. Further testing is recommended for patients with specific diseases.
Increasing development in countries is bringing an “epidemiological transition,” whereby early deaths due to communicable diseases are replaced by late deaths from noncommunicable diseases.2 The number of NCDs deaths is projected to increase to 4.2 million in 2030.3 The age-adjusted death rates per 100,000 population are greatest in low-income countries such as Myanmar, Cambodia, Lao People's Democratic Republic (Lao PDR), and Vietnam.3
Pharmacy education programs prepare graduates to promote health for patients with noncommunicable disease (NCDs), but there is limited information concerning Association of South East Asia Nations (ASEAN) countries. The study aim was to synthesize academic staff's, alumni's, and alumni supervisors' perspectives on preparation for students to provide pharmaceutical care in NCDs.
A qualitative research design was used. In-depth interviews with structured questions following the Context, Input, Process, and Product/Outcomes model framework were conducted with four academic staff, three alumni, and three alumni supervisors from six study sites in six countries. Interview questions were constructed in Thai and translated to English by using forward and backward translation. Verbatim transcriptions were used to perform thematic analysis with investigator triangulation.
Sixty participants were included. The context showed three main themes related to Burden of NCDs, Pharmacist Roles in NCDs, and Goals. The input showed three main themes of Teaching Methods, Development Plans for Academic Staff, and Budgets and Infrastructure. The process showed one main theme of Struggles in Teaching Methods. The outcomes/outputs showed three main themes of Individual, Organizational, and Professional Levels. Schools need curricula that focus on NCDs, pharmacist competency and skills, and academic preparation of students for practice. Gaps limiting achievement of goals included lack of well-trained academic staff, limited learning facilities, self-learning opportunities, acceptance from other health professionals, and career ladders.
The preparation of pharmacy students varied in six ASEAN countries. Pharmacy education programs must address existing gaps that limit achievement of goals related to NCDs.
