Why WHO STEPs instruments for NCD risk factor survey needs validation in Nepal?

The World Health Organization (WHO) designed the Step Wise Approach to Surveillance (STEPS) instrument to collect core data on the established non-communicable disease (NCD) risk factors, which is being used globally [1]. Nepal also adopted the same tool in WHO STEPwise approach to non-communicable disease (NCD) risk factor surveillance conducted in 2007 and 2013. I have also applied it, incorporating some modules, in my recent cardiovascular disease risk factors surveys [2,3]. Personally, I came across several loopholes, particularly in Step 1 of STEPs instrument. The questionnaires related to fruit and vegetable consumption, and physical activities needs modification in the Nepalese context.

 Fruit and Vegetable consumption

STEPs instrument has four food frequency questions for assessing the amount and pattern fruits and vegetables consumption in a typical week [1].

  1. In a typical week, on how many days do you eat fruit?
  2. How many servings of fruit do you eat on one of those days?
  3. In a typical week, on how many days do you eat vegetables?
  4. How many servings of vegetables do you eat on one of those days?

In 2011, we obtained data on fruits and vegetables consumption in Sindhuli district applying the above mentioned questions. We identified that sufficient fruits and vegetables consumption (5 servings/day) was lacking in the majority (96.6%) of the respondents. Mean number of days of fruits and vegetables consumed per week were 2.4 and 4.3 days respectively [3]. The proportion seemed to be overstated. Latter, we applied 72 hours dietary recall method for the same purpose [2]. Findings suggested that the aforementioned four dietary STEPs questionnaires were not sufficient to measure the dietary pattern in Nepal. The reasons were

  1.  In contrast to western practice, most of the Nepalese only take two major meals (morning and evening) +/- some snacks in the afternoon. The questions related to “Servings per day”, therefore, mostly under report the situations causing inflation in insufficient intake rate. But, while applying dietary recall method, proportions of insufficient fruits and vegetables consumption was reduced to 85 %. The latter survey considered consuming at least 400 gm fruits and vegetables per day as sufficient intake. This reduction in proportion was due to the fact that, despite less number of meals (twice a day), the amount per serving was large.
  2. Our study demonstrated the majority of people from semi-urban and rural areas did not consume fruit regularly. They rarely bought it from market. Instead, they completely relied on seasonal fruit available in their field. Our study revealed that amount of fruit consumption was exceptionally high during its seasons. People were even replacing their major meal with fruits during that period. Therefore, it is doubtful that the food frequency questions can assess fluctuating patterns of fruit consumption accurately in the Nepalese community.
  3. Nepalese have unique culinary custom. We rarely make any curry without potatoes. More than that, most of the Nepalese prefer to eat mix vegetables curry soup in their major meal. But, potatoes and mix vegetables cannot be counted as vegetables. Then, how can we measure vegetables consumption among Nepalese with a single question?

 Physical activity

STEPs tool contains physical activity questions related to work, travel and recreational activities. These questions intend to assess and measure sedentary, moderate and vigorous physical activities. During our latest survey in Kathmandu, we modified the questionnaires and recorded seven day history of each physical activity of respondents and took the reference value for METs of each activity from 2011 Compendium of Physical Activities. Study traced out comparatively higher proportions of insufficiently physically active (defined as < 600 MET-minutes per week) persons (21%) than that reported in NCD risk factor survey 2013 (3.5%) [4]. Nevertheless, we still cannot claim the accuracy of data because

  1.  We do not have validated METs of physical activities in Nepal.
  2. Even though we follow the STEPs instrument to record physical activity level, presence of vast geographical variability will be big hurdle in acquisition of accurate physical activities data in Nepal. Slow walking is a light activity if we walk in low land. But how about walking slowly in hilly and mountainous region, will it have same MET value?  Definitely, answer is no. Every activity might have a different METs value in Terai, Hilly and Mountainous regions in Nepal. Unless, we validate the METs of each activity in Nepal, we cannot guarantee the accuracy of data.

Considering these facts, accuracy WHO STEPs instrument is undeniably questionable and its validation would be utterly essential in Nepal.


1. http://www.who.int/chp/steps/STEPS_Instrument_v2.1.pdf

2. Dhungana, R.R., Prevalence of Cardiovascular Risk Factors Selected Community of Kathmandu, Nepal, in Epidemiology and Biostatistics. 2014, Dhaka University Dhaka.

3. Dhungana, R.R., et al., Prevalence of cardiovascular health risk behaviors in a remote rural community of Sindhuli district, Nepal. BMC cardiovascular disorders, 2014. 14(1): p. 92.

4. World Health Organization, Nepal Health Research Council, Non Communicable Diseases Risk Factor, STEPS Survey 2013 Nepal, Fact Sheet. 2013.

My education includes training in medicine, public health, clinical research, biostatistics and health response in complex emergency. I have more than seven years of experiences in health research (Survey, Case control studies, Randomised Controlled Trials (RCT), Health Policy and Systems Research). My areas of expertise also include the project management particularly in health sector. I have also experience and interest to work in health emergency in large population in disaster setting.

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