Socio Economic Factors Associated with Prevalence of Non-Communicable Diseases Among Adults In Punjab, Pakistan

Abstract

Background: Non-communicable diseases (NCDs) such as cardiovascular disease, cancer, chronic respiratory diseases, and diabetes are leading causes of global mortality and disability. Addressing the impact of NCDs aligns with sustainable development goals. Objective: The objective of this paper is to use individual data to investigate the risk factors for non-communicable diseases (NCDs) among adults in Pakistan. Study Design: Questionnaire-based cross-sectional study. Settings: A sample of 376 patients was selected using a single population proportion due to a lack of data. Participants were chosen through consecutive sampling in three cities: Sialkot, Faisalabad, and Layyah Pakistan. Duration: Over 14 months. Methods: Descriptive and multinomial logistic regression analyses were conducted to assess the relationship between various factors and the prevalence of specific non-communicable diseases (NCDs). Results: This study seeks to identify NCD determinants to inform effective prevention and intervention strategies. Age emerges as a primary predictor, with individuals aged 36-55 and above exhibiting higher odds of NCD prevalence than those under 35. Gender also matters, as females have a higher likelihood of NCDs. Urban living is linked to elevated NCD risk due to sedentary lifestyles. Income shows a positive association with NCD susceptibility, although it decreases at higher levels. Smoking, excessive caffeinated or carbonated drink consumption and eating out elevate NCD risk. Conversely, consuming fruits and vegetables, engaging in physical activity, and getting sufficient sleep lower susceptibility. A positive family NCD history increases the likelihood of experiencing NCDs. Conclusion: These findings underscore the need for comprehensive policy interventions to alleviate the NCD burden. Addressing modifiable risk factors like smoking and unhealthy diets is critical. Public awareness, community engagement, and regulatory measures are recommended. Collaborative efforts across sectors are essential for promoting health and preventing NCDs, while also addressing disparities and healthcare access. Overall, this study offers valuable insights for effective NCD combat strategies.

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APMC Vol. 17 No. 3 July – September 2023 275 www.apmcfmu.com
ORIGINAL ARTICLE
ANNALS OF PUNJAB MEDICAL COLLEGE
Socio Economic Factors Associated with Prevalence of Non-
Communicable Diseases among Adults in Punjab, Pakistan
Farhan Ahmad1, Sofia Anwar2
1
PhD Scholar, Department of Economics, Government College University Faisalabad, Faisalabad Pakistan
Conceived the study, prepared synopsis, data collection and analysis ,
CORRESPONDING AUTHOR
Dr. Sofia Anwar
Professor, Department of Economics, Government
College University Faisalabad, Faisalabad Pakistan
Email: sofia_eco@gcuf.edu.pk
Submitted for Publication: 05-09-2023
Accepted for Publication 30-09-2023
2
Professor, Department of Economics, Government College University Faisalabad, Faisalabad Pakistan
Supervised the study and guidance throughout the research,
How to Cite: Ahmad F, Anwar S. Socio Economic Factors Associated with Prevalence of Non-Communicable Diseases among Adults in Punjab, Pakistan. APMC
2023;17(3):275-280. DOI: 10.29054/APMC/2023.1500
ABSTRACT
Background: Non-communicable diseases (NCDs) such as cardiovascular disease, cancer, chronic respiratory diseases, and
diabetes are leading causes of global mortality and disability. Addressing the impact of NCDs aligns with sustainable
development goals. Objective: The objective of this paper is to use individual data to investigate the risk factors for non-
communicable diseases (NCDs) among adults in Pakistan. Study Design: Questionnaire-based cross-sectional study.
Settings: A sample of 376 patients was selected using a single population proportion due to a lack of data. Participants were
chosen through consecutive sampling in three cities: Sialkot, Faisalabad, and Layyah Pakistan. Duration: Over 14 months.
Methods: Descriptive and multinomial logistic regression analyses were conducted to assess the relationship between
various factors and the prevalence of specific non-communicable diseases (NCDs). Results: This study seeks to identify
NCD determinants to inform effective prevention and intervention strategies. Age emerges as a primary predictor, with
individuals aged 36–55 and above exhibiting higher odds of NCD prevalence than those under 35. Gender also matters, as
females have a higher likelihood of NCDs. Urban living is linked to elevated NCD risk due to sedentary lifestyles. Income
shows a positive association with NCD susceptibility, although it decreases at higher levels. Smoking, excessive caffeinated
or carbonated drink consumption and eating out elevate NCD risk. Conversely, consuming fruits and vegetables, engaging
in physical activity, and getting sufficient sleep lower susceptibility. A positive family NCD history increases the likelihood
of experiencing NCDs. Conclusion: These findings underscore the need for comprehensive policy interventions to alleviate
the NCD burden. Addressing modifiable risk factors like smoking and unhealthy diets is critical. Public awareness,
community engagement, and regulatory measures are recommended. Collaborative efforts across sectors are essential for
promoting health and preventing NCDs, while also addressing disparities and healthcare access. Overall, this study offers
valuable insights for effective NCD combat strategies.
Keywords: Non-communicable diseases (NCDs), Socioeconomic, Hypertension, Physical activity, Smoking, Pakistan.
INTRODUCTION
on-communicable diseases, such as cardiovascular
disease, stroke, cancer, chronic respiratory diseases,
and diabetes, are the primary cause of death and
disability worldwide1. NCDs were responsible for 41
million deaths worldwide, with more than 75 percent of
these in low and moderate income countries.2 The recent
increase in life expectancy and associated reduction in
fertility rates across South Asia, which is associated with
socioeconomic and economic modifications, resulted in a
higher incidence of NCDs. High blood pressure, raised
cholesterol levels, excess weight, insufficient intake of
fruits and vegetables, obesity, physical inactivity, an
unhealthy diet, and smoking are all risk factors for the
development of NCDs.3,4 These factors contribute
significantly to the occurrence of major NCDs, which is
generally referred to as the 'group of four' and are
responsible for 80% of NCD-related mortalities. It should
be noted that the vast majority of these risk factors are
changeable.5 The WHO Global Action Plan for NCD
Control and Prevention has committed to focusing on
nine independent global objectives with the aim of
achieving a relative decrease of 25% in NCDs-related
premature deaths by 2025.6
In Pakistan, similar to global trend NCDs are the main
cause of mortality with contribution about 67% in total
deaths ; showing a significant surge in recent decades 7,8.
Various studies have shown that in Pakistan, a large
N

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Ahmad F et al.
APMC Vol. 17 No. 3 July – September 2023 276 www.apmcfmu.com
proportion is suffering from hypertension, obesity,
diabetes and cardiovascular diseases.7,8,9
Various behavioral factors like tobacco usage, lack of
physical activity, and an unhealthy diet, in addition to the
effects of aging contribute to an increased susceptibility
to NCDs and the subsequent mortality linked to them.10
The global rise in urban populations, and financial
effluence lead to change in life styles that may lead to the
adoption of unhealthy behaviors.11,12
A connection is noted between the prevalence of NCDs,
and reduced physical activity12, inadequate consumption
of vegetables, coupled with excessive use of diets in
saturated fats, salt, and calories13 and an association14
between hypertension and excessive salt consumption is
also seen. The combined risk of these factors account for
nearly 95 percent of NCDs prevalence.15 Furthermore,
socio-demographic elements like gender, age,
educational attainment, and occupational status
significantly contribute to the emergence of NCDs.
Regrettably, the majority of these factors lie beyond an
individual's control.
Presently, there exists a pressing requirement for
comprehensive population-based assessments of NCDs
prevalence within the population. With this objective in
mind, the present study was conducted across three cities
in Punjab province of Pakistan. The objective of this paper
is to use individual data to investigate the risk factors of
non-communicable diseases NCDs among adults in
Pakistan.
METHODS
Sample size Determination and Sampling Technique:
The sample size was calculated based on single
population proportion due to lack of data.
Sample size = 󰇛󰇜 

󰇛󰇜 
 = 363 (at least)
Where,
N= Population Size (infinite population) ,
Z = 1.96 ,
e = 5 %
P = 38 % (prevalence of NCDs in Pakistan WHO, 2021)
Following above, a comprehensive total of 390
respondents were meticulously chosen to participate in
this research and excluding some responses owing to
incomplete information, 376 were included in analysis.
The study was conducted over the course of fourteen
months, from October 2021 to December 2022 following
consecutive sampling technique from three cities of the
Punjab region i.e. Sialkot, Faisalabad, and Layyah.
Variables: Patient-related data was meticulously
gathered from their medical records during hospital
admission or routine checkup visits. The comprehensive
dataset was acquired in face-to-face interviews of adult
respondents through a semi-structured questionnaire,
encompassing a wide array of aspects. These included
demographic particulars and socioeconomic indicators
such as gender, age, marital status, education, income, as
well as metabolic indicators like high blood pressure,
body mass index (BMI), and high blood cholesterol levels.
Furthermore, behavioral risk factors like smoking habits,
intake of fruits and vegetables, exercise and engagement
in physical activity, sedentary lifestyle were documented
carefully.
Multinomial Logistic Regression Analysis:
For the assessment of the strength and direction of the
relationship between NCDs and their potential correlates,
multinomial logistic regression was employed adjusting
the odds ratio; for eight specific NCDs, namely,
hypertension, diabetes, heart disease, high cholesterol,
kidney issues, psychiatric illness, and joint pain.
The dependent variable was categorized into three
distinct groups based on the number of NCDs suffered by
a person: a single NCD, having two NCDs, or more than
two NCDs. Within this model, a single category of the
dependent variable is selected as the reference point
(single NCD) against which all other categories are
contextualized and elucidated.16 The multinomial logit
model, encompassing both the dependent and
explanatory variables, can be concisely presented in
equation form as follows:
󰇛󰇜 󰇛  󰇜
󰇛  󰇜    󰇛󰇜

 󰇛󰇜󰇛󰇜
Where
Y=dependent variable like occurrence of NCD
N=a, b, c ; showing the categories of occurrence of NCD,
Here the probability of ith individual is determined who
is facing one of the jth outcomes i.e. occurrence of non-
communicable diseases
The log odd ratio is estimated by multinomial logit
model.
󰇛
󰇛󰇜  0 + 1X1+ 2 X2+ kXk…………..(2)
󰇛
󰇛󰇜  0 + 1X1+ 2 X2+kXk… ……..(3)

Socio Economic Factors Associated with Prevalence of Non-Communicable Diseases
Ahmad F et al.
APMC Vol. 17 No. 3 July – September 2023 277 www.apmcfmu.com
RESULTS
This study showed the prevalence of hypertension, in
majority of respondents followed by diabetes, and
cardiovascular disease while incidence of other NCDs
like kidney disease, Cholesterol level, Joint pain, was
reported by less than one third of respondents (Table 1).
The multivariable logistic regression analysis (Table 2)
showed that there are higher odds of NCDs in
respondents older than 35 years as compared to those less
than 35 years old. The respondent from age group 36-55
and above 55 years were 2 and 1.33 times more likely to
have the two NCDs respectively than respondents with
age less than 35 years. Age serves as the primary
predictor for the persistence of chronic illnesses, and the
global rise in NCDs prevalence can be attributed to the
aging phenomenon.17 In Pakistan, being a female
increases the likelihood of experiencing two or more than
two NCDs than male counterparts. These findings align
with the studies18,19 all of which establish a positive
correlation between the female gender and NCD
occurrence. The results also found that residents of urban
area are more likely to suffer from NCDs as compared to
people living in rural areas. A significant negative
coefficient for individual’s income level suggested that
households with higher income and higher education
tend to be less susceptible to NCDs.
Respondents with habit of smoking, caffeinated drinks,
and disturbed sleep order were more likely to suffer
NCDs. A strong association is shown between working
status and NCDs that may be explained in many ways.
The respondents with normal BMI were less likely to
have any of NCDs likewise those who have active life
style with physical activity at least more than 30 minutes
daily. Healthy eating also showed profound effect in
developing health of a person as respondents taking more
vegetables and fruits and with more preference of home
prepared food were less likely to have NCDs as compared
to others with contradictory preferences.
Table 1: Prevalence of Non-communicable Diseases in
Pakistan
Non-communicable
Diseases
Yes
Percentage
No
Percentage
Hypertension
182
48.66%
194
51.87%
Diabetes
225
60.16%
151
40.37%
Cardiovascular Disease
154
41.18%
222
59.36%
Kidney disease
86
22.99%
290
77.54%
Cholesterol Level
112
29.95%
264
70.59%
Joint pain
121
32.35%
255
68.18%
Psychological Health
157
41.98%
219
58.56%
Source: Author’s Own Computations (Survey Data 2021-22)
Table 2: Multinomial logistic regression showing
association between Non-Communicable Diseases and
its risk factors in Pakistan
Individual-level factors
Exp(β)
two diseases
more than two
dieses
Ref:(one NCD)
Age (in years) (ref: <35)
35-55
2.039 (0.368)
1.761** (0.384)
≥55
1.332* (0.325)
1.073 (0.343)
Gender (ref: Male)
Female
1.488 (0.315)
1.253** (0.337)
Marital Status (ref: Never married)
Currently married
1.016 (0.337)
1.083 (0.369)
Residence (ref: Rural)
Urban
1.246* (0.282)
1.959* (0.298)
Income Level (ref: < 50,000)
50,000-75,000
0.483** (0.33)
0.856 (0.358)
above 75,000
0.436* (0.371)
0.526 (0.405)
Education (ref: Higher)
No education/Primary
1.231 (0.353)
2.976 (0.386)
Secondary
1.049 (0.411)
3.271 (0.436)
Working status (ref: Not working /unemployed)
Working
2.345 (0.396)
1.512 (0.352)
Smoking status (ref: No)
Yes
1.503**
(0.351)
1.494** (0.38)
Caffeinated/Carbonated drink (ref: No/ occasionally)
Yes/often
1.354 (0.274)
1.513* (0.29)
BMI Range (overweight/underweight)
BMI range (ref: Normal)
0.768 (0.279)
0.568** (0.297)
Physical activity duration (less than 30 min.)
Physical activity duration
(up to 1 hr)
0.449* (0.288)
0.667** (0.311)
Sedentary lifestyle (ref: less than 4 hrs.)
More than 4 hrs.
0.832 (0.286)
0.733** (0.301)
Sleep (disturbed) (ref: No)
Yes
1.125* (0.285)
1.182* (0.297)
Sedentary lifestyle (ref: less than 4 hrs.)
More than 4 hrs.
0.832 (0.286)
0.733** (0.301)
Sleep (disturbed) (ref: No)
Yes
1.125* (0.285)
1.182* (0.297)
Fruit and/or vegetable consumption ek (ref: Less than five
servings per week)
Five or more servings per
week
0.939 (0.281)
0.692** (0.304)
Prefer eating foods prepared outside of a home (ref: No)
Yes
1.310* (0.371)
3.194* (0.359)
Family History of Disease (ref: No)
Yes
1.174 (0.314)
1.359** (0.32)
Constant
0.038 (0.753)
1.848 (0.833)
Source: Author’s Own Computations (Survey Data 2021-22), Standard errors
in parentheses * p<0.01, ** p<0.05

Socio Economic Factors Associated with Prevalence of Non-Communicable Diseases
Ahmad F et al.
APMC Vol. 17 No. 3 July – September 2023 278 www.apmcfmu.com
Figure 1: Prevalence of Non- Communicable Diseases in
Pakistan
DISCUSSION
Several social, behavioral, and biological risk factors
influence the likelihood of suffering from NCDs.
Diabetes was found to be the major NCD along with
hypertension in Pakistan. When considered other factors
like age this phenomenon becomes more clear that
prevalence of NCDs increases with age17 having link with
burden of responsibilities that increase after marriage and
in working age. Concurrently, the importance of this
association is underscored by indications of early aging
within the adult population in terms of health conditions.
Chronic stress, repeated exposure to infectious diseases,
and persistent sickness stemming from harsh living
conditions potentially contribute to the premature aging
of organs and bodily systems, consequently influencing
the incidence of NCDs. These study findings align with
research by,20,21 as they highlight the age-related increase
in biological risk.
Women exhibit higher odds of NCDs prevalence in
comparison to men. The primary driver behind the
escalating burden of NCDs among women18,19 could be
attributed to both biological and societal distinctions22
existing between men and women. The latter aspect is
particularly pronounced within Pakistani society, which
remains entrenched in traditional norms that often
marginalize women from a young age. This
marginalization frequently hampers their psychological
well-being, leading these women to perceive themselves
as secondary family members, thereby ignoring their own
health and wellbeing. Urban residents are associated with
a significantly high-risk factor group that enhances the
likelihood of having a NCD because of insufficient levels
of exercise and physical activity in an urban lifestyle.23 ,24
Lower income respondents were more likely to suffer
from NCDs and these findings align with the
conclusions25,26 who concurred that poorer families face
greater vulnerability to behavioral factors associated with
NCDs compared to wealthier counterparts. The former
engage in detrimental practices such as excessive
smoking27, unhealthy dietary habits, and limited access to
healthcare and knowledge regarding NCDs prevention
and treatment.
Better eating behavior may lead to better health and less
prevalence of NCDs. On contrary higher consumption of
soft drinks can lead to change in the BMI owing to high
risks of weight gain and diabetes that further associated
with higher risk of more than one NCDs.28,29 Insufficient
fruit and vegetable intake contributes to around 41
percent of NCDs, including conditions like coronary
heart disease and ischemic stroke while higher vegetable
and fruit consumption2,30 can decrease the risk of NCD
development.
The findings reveal that individuals who were physically
active have less probabilities of developing a NCDs.31
while physical inactivity is linked to various indicators of
excess body weight, elevating overall mortality risk and
susceptibility to conditions such as diabetes, heart
disease, stroke, cancers, and chronic kidney disease. 32
Moreover, the study finds positive association between
sleep disturbance and the likelihood of suffering from
NCDs. Deprivation and poor sleep quality have been
connected to a range of metabolic disorders, including
obesity and type 2 diabetes. Inadequate sleep and sleep
disruptions may trigger pathological processes and
contribute to disease onset, with a stronger focus on
cardiovascular diseases.33,34
Food consumed away from home conventionally refers to
food items that are obtained, although not exclusively,
from restaurants, cafeterias, food trucks, street outlets, or
vending machines35 and is associated with an increased
risk of non-communicable diseases. Such diets can lead to
obesity due to their high calorie, sugar, and fat content.
Processed foods in these meals may raise the risk of type
2 diabetes by causing insulin resistance. Cardiovascular
disease risk rises due to unhealthy fats and a sodium in
restaurant meals. Additionally, diets rich in additives
found in such foods might heighten the risk of certain
cancers. A balanced diet centered on whole, unprocessed
foods is crucial for NCD prevention.36
The findings additionally indicate that individuals
possessing a positive family history of disease are
associated with a 1.359 times higher likelihood of
experiencing a non-communicable diseases (NCDs).
Family history stands as a predictive factor for
heightened vulnerability to diseases due to interplay
between genetic traits, environmental influences, and
behaviors. These factors are shared to a greater extent
within families than across the general population,
making their disentanglement notably challenging.37
182
225
154
86
112
121
157
050 100 150 200 250
Hypertension
Diabetes
Cardiovascular Disease
Kidney
Cholesterol Level
Joint pain
Psychological Health
Prevalence (number)

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Ahmad F et al.
APMC Vol. 17 No. 3 July – September 2023 279 www.apmcfmu.com
CONCLUSION & POLICY RECOMMENDATIONS
This paper examines factors related to NCDs to provide
insights into the strategies to be adopted by individuals,
policymakers, and researchers in addressing the
escalating prevalence of NCDs and their profound impact
on households.
The estimation reveals notable risk factors like high BMI,
sedentary behavior, sleep disturbances, insufficient
intake of fruits and vegetables, cigarette smoking, and
excessive consumption of caffeinated/carbonated
beverages. Furthermore, socio-economic and
demographic facets, including income, age, urban
residency, education, gender, and family medical history,
exert influence on NCD prevalence in Pakistan.
This investigation emphasizes the imperative for the
Pakistani healthcare system to establish mechanisms
prioritizing preventive NCD care. The implementation of
effective prevention strategies that target NCD risk
factors is preferable over costly and prolonged treatment
methods. Policy intervention in the form of regulatory
measures addressing carbonated drink and cigarette
consumption is necessary along with introduction of
interventions like public awareness regarding healthy
lifestyles, encompassing balanced use of fruits and
vegetables coupled with physical activity. Increase in the
number of sports and health clubs is highly required to
reduce not only obesity, cardiovascular diseases but also
for reduction in hypertension. Healthy social networks
and activities can play better roles in the endeavor to
moderate NCDs for which diverse stakeholders,
including health, education, sports, environment, and
media entities, must collaborate to devise plans. Health
promotion initiatives have the potential to influence
lifestyle factors, further facilitated by improved education
and augmented by policies that regulate tobacco,
carbonated beverages, and fast-food consumption.
LIMITATIONS
1. This study was conducted only in three districts and
for more precision, this study needs to be extended in
further regions of the country.
2. The respondents were mostly taken from hospitals or
clinics and sample taken from general population
may have different results.
CONFLICT OF INTEREST / DISCLOSURE
All the respondents were well informed about the study
and their confidentiality is well maintained. Further, no
conflict of interest exists between authors.
ACKNOWLEDGEMENTS
Authors consulted various medical experts in developing
conceptual framework and questionnaire of this study.
We are highly thankful for the support provided by Dr.
Abdul Shoaib Randhawa , Professor of Medicine, PGMI,
and Dr. Aitisam Waheed, General hospital Lahore.
We would like to express our appreciation for the
assistance provided by the management of hospitals and
the patients participating in the study, for their gracious
cooperation in facilitating the collection of data.
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