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As the threat of non-communicable diseases grows, the World Health Organization (WHO) has suggested that every nation/country should establish surveillance systems for non-communicable disease (NCD). In light of the difference in resources of every nation/country, WHO proposed a stepwise strategy to build the NCD surveillance systems by considering mortality, morbidity, and prevalence of health risk factors. In Taiwan, the HPA has developed a comprehensive health surveillance system progressively, which encompasses population from different life-courses, to fulfill requirements of various health indicators necessary for policy implementation. Through routine, periodic health surveillance, the HPA collected national health data, which cannot be simply obtained through vital statistics or public reporting and registration systems, to strengthen the evidence-based health promotion policy-making and evaluate the efficacy of projects implemented.
Policy Implementation and Results
In order to establish systematic national health surveillance system on non-communicable diseases, we use community-based face-to-face survey, telephone survey, and in-school student self-administered questionnaire survey as platform to collect data. Surveys on whole population as well as on specific population of different lifecourse were conducted continuously to collect, analyze, and disseminate health surveillance data. In 2012, the health survey quality management system has passed the ISO9001 certification. In the aspect of surveillance system, we have established birth reporting system, cancer and other major disease registration. In 2012, we initiated a pilot study of birth defects and injury surveillance project. We also planned to improve surveys on breast feeding, nutrition, oral health, and vision. Step by step, we have gradually completed health surveillance system on non-communicable diseases to reinforce the provision of empirical data for policy making and program evaluations.
Various surveys that the HPA has conducted over the years and is planning to undertake in coming years are listed in Table 7-1. The face-to-face interview surveys conducted in 2012 were “Taiwan Birth Cohort Study”, “Child and Adolescent Behaviors in Long-term Evolution”, and “Taiwan Longitudinal Study on Aging”—would be carried forward into 2013. Based on self-administered questionnaires, the HPA completed two surveys on the health and smoking behaviors of junior high school students in 2012. Meanwhile, telephone surveys on the smoking behaviors and behavioral risk factors among adults aged over 18 were completed as well.
1. Taiwan Birth Cohort Study (TBCS)
Recognizing the significance of children’s living condition during a period of rapid social change and the potential consequences throughout the life course, the Taiwan Birth Cohort Study (TBCS) was initiated in 2003 under the auspices of the HPA. The study has three main goals: (1) to record and assess health and developmental trajectories of children in Taiwan; (2) to examine the early origins of adult health; (3) to investigate the impact of social environment on children’s wellbeing.
To gain experience for planning and implementation of the large-scale birth cohort survey, a random small-scale sample that comprised children born in November and December, 2003 were selected. This pilot sample was surveyed at 6 months, 18 months, 3 years and 5.5 years old, as well as a telephone interview at 7 years of age as planned for the large-scale sample. A rich set of data were thus available to understand health profile of Taiwan children in 21st century. To keep following up health status on children development and ensure applicability of the questionnaire, the 5th pilot survey was conducted at 8 years of age with a response rate of 90.7%.
The protocol developed from pilot study can be applied to the large-scale survey; then further use the data collected from the large-scale survey for policy making and program evaluation.
2. Child and Adolescent Behaviors in Long-term Evolution
Based on the ecological model and the multilevel influences from personal, family, school and community facts on child and adolescent health and lifestyle, the “ Child and Adolescent Behaviors in Long-term Evolution (CABLE)” study was initiated in 2001 by the National Health Research Institutes (NHRI). The results can provide information related to student’s health for education and health authorities policy making. Subjects were selected in 2001 among the first and fourth graders who attended 18 public elementary schools in Taipei City and Hsinchu County. During 2001 to 2006, the NHRI team undertook the project by self-administered questionnaires collected from the subjects who were either elementary or junior high school students. In 2007, as the participants got older, they would disperse throughout Taiwan due to schooling or employment. In turn, the NHRI began collaborating with the HPA to combine the efforts of research and administrative units. Follow-up surveys and studies are thus made possible on the HPA’s platform of community surveys. This collaboration has also facilitated the utilization of the research findings in policymaking. The 12th survey of the project was conducted during October 2012 and February 2013. Until the end of 2012, the project had accumulated longitudinal data for 11 years. These data have been further analyzed and interpreted for policy making and program evaluation.
3. Taiwan Fertility and Family Survey
For the reference of policy-making on population and health issues, national sampling surveys have been conducted every few years since 1965 to provide a database concerning the reproductive health related knowledge, attitude and practice of women of childbearing age. The 11th survey was conducted from July to December 2012. A total of 8,924 samples were interviewed (a response rate of 74.4%). This survey aims to enhance our understanding on current status and trends of the reproductive health related knowledge, attitude and practice of childbearing age population. To adopt the principle of gender mainstreaming, male samples were first recruited in this series of Family and Fertility Survey in 2012. This enabled the HPA to investigate marriage and childbearing related issues of the two genders. Main content of the survey included attitude of sharing household chores, smoking and exposure to secondhand smoke during pregnancy, views upon breastfeeding in public places and induced abortion. The results can be used for policy making or service planning.
4. Surveys on Health and Smoking Behaviors among Adolescents
Since 2004, the HPA has followed the protocol of the Global Youth Tobacco Survey, developed by the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC), to monitor current situations and trends of changes associated with adolescent tobacco use. In 2006, the HPA further adopted the survey method of the CDC’s Youth Risk Behavior Survey (YRBS), and the WHO Global School-base Student Health Survey (GSHS) to initiate the Taiwan Youth Health Survey (TYHS).To address health behaviors that lead to death, disease, disability, or social problems, these surveys focus on substance use of the adolescent such as smoking, drinking, and betel quid chewing, and a variety of other lifestyles and health-related behaviors. With experience on student’s health survey and supports from the U.S. CDC, the HPA transited the TYHS to GSHS for better international comparison in 2012.
The aforementioned GYTS and GSHS surveys were conducted on junior or senior high school in every other year rotation. An anonymous self-administered questionnaire was completed by students of sampled classes. For better use on policy making reference, the GYTS was carried out on both junior and senior high school annually since 2011. We also cooperated with the US CDC for revision of survey protocol and questionnaire in 2012.
Two surveys had been completed on June 2012, 34,552 students completed the GYTS and the response rate is 91.62%, 6,801 students completed the GSHS and the response rate is 93.16%.
5. Surveys on Health and Smoking, and Drinking Behaviors among Adults
In 2004, HPA has launched the Telephone Survey on Adult Smoking Behavior (ASBS), which were taken a reference from the U.S. Behavioral Risk Factor Surveillance System (BRFSS), National Health Interview Survey (NHIS) and Global Adult Tobacco Survey (GATS). Since then, the HPA conducted the ASBS surveys from July to September annually. The range included the smoking behaviors of 18 years or older people from each county and city in Taiwan, the status of exposure second hand smoking, self-evaluated health conditions, and changing trend, in order to establish the adult smoking rate survey and statistical database.
In 2007, HPA referred to America’s BRFSS telephone survey, and planned the monitoring survey of hazardous behaviors for people over 18 years old, in order to monitor important diseases and health hazard behavior rates, and the use of preventive healthcare services. The range includes chronic diseases (diabetes, metabolic diseases, high blood pressure, and kidney diseases), tobacco, betel nuts, cancer screening, and other health behaviors or lifestyles.
In addition, WHO reported that the attributable mortality caused by drinking ranked as number 8 in 2009. The attributable DALYs of drinking ranked as number 3. In 2010, at the 63th World Health Assembly, the global strategy of reducing harmful use of alcohol was passed. In order to understand Taiwanese people’s drinking behaviors, opinions upon policies of alcohol, and the reference of policy planning and implementation. The first adult drinking behavior survey was conducted in 2012.
The ASBS and the BRFSS in 2012 had completed interview on 16,968 and 16,945 adults, with a response rate of 67.17% in ASBS and 62.96% in BRFSS respectively. The Adult Drinking Behavior Survey had completed telephone interview of 2,144 adults. The response rate was 79.40%.
6. Promotion of the “Online Health Indicators Data Query”
By adopting applicable information and internet technology, the HPA set up an online health indicators data query system in 2004. This data query website (https://olap.hpa.gov.tw/) serves as a platform at a reduced manpower requirement for descriptive analysis and provision of the health data generated from the birth reporting database to the general public, the media as well as health personnel. Currently the data from 8 health surveys—National Health Interview Survey, Taiwan Youth Health Survey of Junior High School Students, Taiwan Youth Health Survey of Senior High School Students, Global Youth Tobacco Survey of Junior High School Students, Global Youth Tobacco Survey of Senior High School Students, Adult Smoking Behavior Survey, Behavioral Risk Factor Surveillance System, and Taiwan Longitudinal Study on Aging, and Birth Reporting Database— is querying accessible on the website. It provides services for queries into a total of 649 health indicators for the general public, and the number of visitors average over 10,000 each year.
In order to improve the website’s accessibility and user-friendliness, it was first upgraded in 2007 to enhance capabilities of backend management, allow flexible inclusion of more inquiringly database or health indicators, and enable multi-year and geographic comparison. With expectation on better quality and utilization the online services, this website was upgraded again in 2009 by adding dual-language interfaces for data query, strengthening user-friendly design, as well as improving its function of geographic comparison.
The upgrade of the website in 2011 was to make it more useful and user-friendly by providing multiple paths for indicator selection, bilingual web pages and personalized services so as to further improve its service quality and frequency of use.
7. Applications of Survey and Research Data
The aim of the NCD surveillance is to provide the data for policy-making, program evaluation and strategy planning. To increase the utilization of these survey data, the HPA not only publishes the results by survey reports, but also conducts analyses and researches on specific topics. In 2012, a total of 45 papers were published.
In addition, we provided analytical results for the purposes of news release and for health education and advocacy. Furthermore, through online interactive data query website, we are able to provide descriptive statistics that generated from surveillance data.
In order to reach the goal of protecting privacy and adequate use of the data, Ministry of Health and Welfare established the collaboration center of health information application (CCHIA). Since 2012, we continued to provide a copy of the health survey data to the center for use application. Currently, data of a reporting database (the Birth Reporting Database) and 5 surveys (Taiwan Longitudinal Study on Aging, Taiwan Survey on the Prevalence of Hypertension, Hyperglycemia, and Hyperlipidemia, Global Youth Tobacco Survey of Junior High School Students, Global Youth Tobacco Survey of Senior High School Students, Adult Smoking Behavior Survey) are accessible at the collaboration center. It is hoped to enhance resource sharing and increase the overall utilization of the data.