Table 1.

Overview of major existing international frameworks relavant for non-commumicable chronic diseases surveillance in low-income and middle-income countries

Surveillance framework	Year available	Country/Region covered	Accessibility	Strength	Limitation	information included	Further description
The WHO STEPwise approach to Surveillance (STEPS)	2005	African, North and South America, South-East Asia, European, Eastern Mediterranean and Western Pacific	http://www.who.int/ncd_surveillance/en/steps_framework_dec03.pdf	This allows for the development of an increasingly comprehensive and complex surveillance system depending on resources and local needs. STEPS data are being used to inform NCD policies and track risk factor trends.28	The STEPS surveys are conventionally household-based and interviewer-administered and falls short of institutional data.	It is based on sequential levels of surveillance of different aspects of NCDs, allowing flexibility and integration at each step by maintaining standardised questionnaires and protocols to ensure comparability over time and across locations.	The STEPwise approach to risk factor surveillance is implemented through STEPS instruments, which cover three different levels of ‘steps’ of risk factor assessment, including (1) a questionnaire, (2) physical assessments and (3) biochemical measurements.
The MEASURE Demographic Health Surveys (DHS) project	1984	Global	https://dhsprogram.com/what-we-do/survey-Types/dHs.cfm	It collects comparable population-based data on fertility, contraception, maternal and child health and nutrition.4 DHS data have expanded considerably, with new questions and modules on behaviours such as alcohol consumption, tobacco use and other biomarkers.	The DHS is proposed to take place once every 5 years. However, several countries have surveys at irregular intervals.29 More so, the high traditional focus on children and women is a limitation for its use for surveillance.30	Many countries including the poorest have conducted at least one DHS survey.30 For instance, of the 236 DHS conducted between 1985 and 2010, 49% were in Sub-Saharan Africa, 20% in Asia and 18% in Latin America and Caribbean.4	There is an opportunity to use the DHS platform for acquiring data for NCD surveillance (as a by-product), an approach already been used in some countries. For example, the 2002 DHS survey in Uzbekistan measured blood pressure and levels of other common CVD risk factors, including biological markers, and was subsequently used to describe their epidemiology in the country.31 32
The Global Tobacco Surveillance System (GTSS)	1999	Global	https://www.cdc.gov/tobacco/global/gtss/index.htm	The GTSS aims to enhance country capacity to design, implement and evaluate tobacco control interventions, and monitor key initiatives of the WHO Framework Convention on Tobacco Control and components of the WHO MPOWER technical package.33	The first Global Youth Tobacco Survey (GYTS) was conducted in 1999.34 Since then, other comparative reports, based on data from an increasing number of countries, have been made available5 33 35–43; however, this has not addressed the misuse of tobacco products.	The GTSS is the largest public health surveillance system ever developed and maintained.5	The GTSS includes four surveys: the GYTS; the Global School Personnel Survey (GSPS); the Global Health Professions Student Survey (GHPSS); and the Global Adult Tobacco Survey (GATS). The GYTS focuses on youth aged 13–15, and collects information in schools. The GSPS surveys teachers and administrators from the same schools that participate in the GYTS. The GHPSS focuses on third-year students pursuing degrees in dentistry, medicine, nursing and pharmacy. The GATS is a nationally representative household survey that monitors tobacco use among people aged 15 years and older.
The INDEPTH Network	1998	Global	http://www.indepth-network.org/	INDEPTH strengthens global capacity for Health and Demographic Surveillance Systems (HDSS), and mount multisite research to guide health priorities and policies based on scientific evidence.	There is a limited potential to monitor non-fatal NCDs-related health outcomes across INDEPTH sites.	The network comprised 48 HDSS sites operated by 40 centres in 20 countries across participating continents where about 3.2 million people were studied over time.6 44 45	The focus of INDEPTH on mortality is a huge asset for monitoring the contribution of CVD to overall mortality. The extent of data collection on NCD determinants also varies significantly across INDEPTH sites. While it is inexistent in some centres, few others have evolved with time into community-based laboratories for studying and monitoring NCDs.46–48
Living Standards Measurement Study (LSMS)	1980s	Global	http://surveys.worldbank.org/lsms	It collects household data useful to assess household welfare, understand household behaviour and evaluate the effect of various government policies on the living conditions of the population.7	The LSMS use complex multiple survey instruments to obtain data to ensure high-quality relevant data.	The health module has been expanded to incorporate questions on depression in order to measure its incidence and identify its links with other aspects of welfare and labour market participation.49	A potential utility of the LSMS survey in informing NCD research and surveillance is supported by the LSMS working paper number 131 on chronic illness and retirement in Jamaica.50
Survey of ageing and health	2004	Global	http://www.who.int/healthinfo/sage/en/	SAGE is a source of valuable information on the distribution of risk factors and health inequalities across participating countries.51–56	SAGE is limited to chronic diseases and risk factors.	The WHO Study on global AGEing and adult Health (SAGE) is an ongoing initiative by the WHO to compile longitudinal information on the health and well-being of adult populations and the ageing process.8	The core SAGE collects data on adults aged 50 years and older, including a smaller comparison sample of younger adults aged 18–49 years, from nationally representative samples. There are eight health and demographic surveillance sites in Bangladesh, Ghana, India, Indonesia, Kenya, South Africa, Tanzania and Vietnam, with an additional combined sample size of over 45 000 people as part of SAGE.8 57
The Global School-based Student Health Survey (GSHS)	2003	Global	http://www.who.int/ncds/surveillance/gshs/en/	The GSHS is a relatively low-cost, school-based survey which uses a self-administered questionnaire to obtain data on young people’s health behaviour and protective factors related to the leading causes of morbidity and mortality among children and adults.	The GSHS examines cardiovascular risk factors and is restricted to children and adolescents.	This is the largest surveillance enterprise worldwide examining cardiovascular risk factors among children/adolescents. The GSHS has contributed important data on the distribution of CVD risk factors (obesity, physical activity, tobacco use and dietary intake) and their clustering among adolescents in LMICs.58 The specificity of this surveillance endeavour is that it includes important data on lifestyle factors, namely physical activity and dietary intake.	The GSHS measures and assesses the behavioural risk factors and protective factors in 10 key areas (alcohol use, dietary behaviours, drug use, hygiene, mental health, physical activity, protective factors, sexual behaviours, tobacco use, violence and unintentional injury) among adolescents.
Global Burden of Disease (GBD) project	1991	Global	http://www.who.int/healthinfo/global_burden_disease/about/en/	This measures the health loss from disability or death from over 300 diseases in more than 100 countries. The GBD study continues to supply data to measure progress in the global efforts and set priorities for the control of increasing burden of NCD.59	This has not been implanted in some countries of the world for several reasons, specifically due to individual country factor.	The GBD study provided the latest synthesis of the evidence for risk factor exposure and the attributable burden of disease. The subnational and national assessments extending across about three decades informed debates on the need of addressing risks in context.	GBD is a comparative risk assessment framework developed for previous iterations of the GBD study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure for several environmental, behavioural and metabolic risk factors from 1990 to 2015. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is reducing.27

CVD, cardiovascular diseases; LMICs, low-income and middle-income countries; NCD, non-communicable diseases.