Prevalence of Selected Chronic, Noncommunicable
Disease Risk Factors in Jordan: Results of the 2007
Jordan Behavioral Risk Factor Surveillance Survey
Mohannad Al-Nsour, MD, MSc; Meyasser Zindah, MD; Adel Belbeisi, MD; Raja Hadaddin, MD;
David W. Brown, DSc, MScPH, MSc; Henry Walke, MD, MPH
Suggested citation for this article: Al-Nsour M, Zindah M, Belbeisi A, Hadaddin R, Brown DW, Walke H. Prevalence of
selected chronic, noncommunicable disease risk factors in Jordan: results of the 2007 Jordan Behavioral Risk Factor
Surveillance Survey. Prev Chronic Dis 2012;9:110077. DOI: http://dx.doi.org/10.5888/pcd9.110077 .
Noncommunicable diseases (NCDs) are the leading cause of illness and death in Jordan. Since 2002, the Jordan
Ministry of Health, in cooperation with the World Health Organization and the Centers for Disease Control and
Prevention, established the Jordan Behavioral Risk Factor Surveillance Survey to collect information on many of the
behaviors and conditions related to NCDs. The objectives of this study were to describe the prevalence of selected NCD
risk factors and the relationship between body mass index and selected health conditions among a nationally
representative sample of Jordanian adults aged 18 years or older.
We used a multistage sampling design to select 3,688 households, from which we randomly selected and interviewed 1
adult aged 18 years or older. A total of 3,654 adults completed the survey. We randomly selected a subsample of 889
interviewed adults and invited them to visit local health clinics for a medical evaluation; we obtained measurements,
including fasting blood glucose and blood lipids, from 765 adults. Data were collected between June 1, 2007, and
August 23, 2007.
Nearly one-third of participants smoked cigarettes, 18% reported having been diagnosed with high blood pressure, and
10% reported frequent mental distress. Compared with survey participants who did not participate in the medical
evaluation, those who participated were more likely to self-report high blood pressure, high blood cholesterol, and
diabetes and report lower levels of health-related quality of life. Among participants of the medical evaluation, an
estimated 11% reported they had been diagnosed with diabetes by a health professional, and 19% were diagnosed with
diabetes according to laboratory testing. Approximately one-third of participants of the medical evaluation were either
overweight (30%) or obese (36%). In the fully adjusted model, obese participants of the medical evaluation were nearly
3 times as likely to have high blood pressure and more than 2 times as likely to have high blood cholesterol as normal-
Diabetes, high blood pressure, high cholesterol, and obesity are a public health concern in Jordan. Adequate and
continuous monitoring of NCD risk factors in Jordan is needed, and the surveillance findings should be used in health
promotion and disease prevention activities.
Jordan, as in many middle-income countries, has witnessed a demographic change. In 2007, the infant mortality rate
decreased to 19 per 1,000 live births, and life expectancy increased for men (71.6 y) and women (74.4 y) (1). Jordan is
also undergoing an epidemiologic transition; the burden of infectious diseases has lessened, but the burden of
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noncommunicable diseases (NCDs) has increased. NCDs are the leading cause of death in Jordan; more than one-third
of deaths are attributed to cardiovascular diseases and 14% to cancer (2,3). According to World Health Organization
projections, NCDs will be responsible for two-thirds of deaths in the eastern Mediterranean region by 2030 (4). NCD
risk factors such as smoking, physical inactivity, obesity, and unhealthful diets are now serious public health problems
in Jordan (5,6).
Beginning in 2002, the Jordan Ministry of Health (MOH), in cooperation with the Jordan Department of Statistics (the
organization responsible for conducting national surveys in Jordan), the World Health Organization, and the Centers
for Disease Control and Prevention, established the Jordan Behavioral Risk Factor Surveillance Survey (BRFSS) to
collect data on health risk behaviors, clinical preventive health practices, and health care access that are associated
with leading causes of illness and death in Jordan. The Jordan BRFSS also collects data on many of the behaviors and
conditions related to NCDs and is useful for monitoring and evaluating the effectiveness of public health programs.
The Jordan BRFSS, a in-person household interview survey that uses a national sampling frame, was conducted a
second time in 2004. Results of the 2002 and 2004 Jordan BRFSS are published elsewhere (7,8).
The objectives of this study were to describe the prevalence of selected NCD risk factors and the relationship between
body mass index (BMI) and selected health conditions among a nationally representative sample of Jordanian adults
aged 18 years or older.
The Jordan MOH conducted its third BRFSS in 2007. We used a multistage sampling design to select households in
which the survey was administered. We used the 2004 Jordan census to identify census enumeration blocks for the
master sampling frame, and we selected households from a sample of blocks, or primary sampling areas. This sampling
frame was stratified by governorate, major city, other urban area, and rural area into 30 strata that fit within 3 regions,
north, middle, and south. Geographic ordering of the blocks in the frame provided implicit stratification. In each
stratum, we systematically selected a sample of 461 blocks with probability proportional to Jordan’s total population
(Appendix). We selected 8 households from each block. In each household, we randomly selected 1 adult aged 18 years
or older and interviewed that person in Arabic. We conducted interviews between June 1, 2007, and August 23, 2007.
Of 3,688 households selected, 3,654 adults (99%) were successfully interviewed. The survey instrument (available on
request) included questions on demographics (eg, sex, age, educational status), health status, health care access,
tobacco use, physical activity, nutrition, hypertension and cholesterol awareness, and prevalence of heart disease,
diabetes, and asthma.
We defined respondents who smoked 100 cigarettes in their lives and who currently smoked as current smokers. We
assessed participation in moderate physical activity with the question, “Do you do any moderate-intensity sports,
fitness or recreational (leisure) activities that cause a small increase in breathing or heart rate such as brisk walking
and lifting light and moderate weights for at least 10 minutes continuously?” To assess consumption of fruits and
vegetables we asked, “How many cups of fresh or cooked vegetables did you have yesterday?” and “How many cups of
fruits or fresh juices did you have yesterday?” We considered people who responded yes to the question, “Have you
ever been told by a health professional that you have high blood pressure?” to have hypertension. We considered
people who responded yes to the question, “Have you ever been told by a health professional that your blood
cholesterol is high?” to have high blood cholesterol. We considered people who responded yes to the question, “Have
you ever been told by a health professional that you have diabetes?” to have diagnosed diabetes. Type of diabetes was
not assessed. Women who reported having gestational diabetes only were considered not to have diabetes.
We asked respondents the following questions related to health-related quality of life (HRQOL): “Would you say in
general your health is excellent, very good, good, fair, or poor?” On the basis of the response to this question, we
defined a dichotomous variable for fair or poor self-rated health status. We also asked respondents, “Now, thinking
about your physical health, which includes physical illness and injury, for how many days during the past 30 days was
your physical health not good?” and “Now, thinking about your mental health, which includes stress, depression, and
problems with emotions, for how many days during the past 30 days was your mental health not good?” We did not ask
respondents for specific underlying reasons of any reported unhealthy days. These questions and their construct
validity are described elsewhere (9,10). We calculated overall unhealthy days as the sum of physically and mentally
unhealthy days, not to exceed 30 days. We defined a dichotomous HRQOL variable as fewer than 14 or 14 or more
unhealthy physical days, unhealthy mental days, and unhealthy days (mental or physical). A total of 14 unhealthy days
is a meaningful cut point for participants reporting substantially impaired HRQOL.
All questions were translated from English into Arabic and then back translated to ensure accuracy. To ensure
consistency, we conducted pilot tests of the Jordan BRFSS for 2002, 2004, and 2007 under realistic field conditions
and used the same trained interviewers who were recruited to conduct the actual survey to implement the pilot tests.
The testing process accounted for all survey activities: approaching potential participants, seeking and obtaining
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informed consent, making arrangements/appointments for data collection, preparing the site, collecting all data,
identifying follow-up cases, and avoiding double data entry. Twenty male and female participants of different
educational and socioeconomic levels and varied ages were used for each pilot test. We summarized participants’
comments into a single report and made modifications to the survey instrument, ensuring intended meanings were
To compare self-reported health information to actual medical measurements, we selected a sample of 116 of the total
461 blocks and invited survey respondents to participate in a standard medical examination. Participants completed a
consent form, and the study design was approved by the Jordan MOH. Of the 889 survey respondents who were
invited to participate in the medical examination, 765 (86%) agreed to participate. Participants were evaluated at local
health clinics, where height, weight, waist circumference, and blood pressure measurements were obtained. A fasting
blood sample was obtained from each participant and sent to a central laboratory where total cholesterol and blood
glucose were measured. Standardized training was provided to the attending physicians of the participating local
health clinics, and all participating physicians used the same standard equipment for blood testing and for measuring
height and weight.
For participants of the medical examination, we computed BMI as weight divided by the square of height (kg/m ).
Participants were classified as normal weight (BMI <25.0), overweight (BMI 25.0-29.9), and obese (BMI ≥30.0). We
defined high blood pressure as 140/90 mm Hg (systolic/diastolic), high blood cholesterol as ≥240 mg/dL, impaired
fasting glucose as 100 mg/dL to 125 mg/dL, and diabetes as ≥126 mg/dL. We considered the presence of
antihypertensive medications for high blood pressure, lipid lowering medications for high blood cholesterol, and
insulin or oral hypoglycemic medication for impaired fasting glucose and diabetes for these classifications.
For respondents who participated in the medical evaluation, we estimated the relative odds of overweight and of
obesity associated with selected health risk factors by using logistic regression analysis adjusted for sex, age, education,
smoking, physical activity, and fruit and vegetable consumption. We used STATA statistical software (STATA
Corporation, College Station, Texas) in all analyses to accommodate the complex survey sampling design.
Overall, nearly one-third of participants smoked cigarettes, 38% engaged in moderate physical activity, and 17%
consumed 5 or more servings of fruits and vegetables per day (Table 1). Approximately 18% of participants reported
having been diagnosed with high blood pressure, 7.5% with high blood cholesterol, and 10% with diabetes, and 10%
reported frequent mental distress. Approximately 78.8% (standard error [SE], 0.80%) of respondents had ever been
tested for high blood pressure, and 37.5% (SE, 0.88%) had ever had their cholesterol levels checked (data not shown).
Participants who agreed to participate in the medical examination were more likely to be female, older, and with lower
educational levels than those who participated in the household interview only. They also were more likely to have
been diagnosed with high blood pressure, high blood cholesterol, or diabetes and have lower levels of health-related
quality of life. Prevalence of overweight was 30.5% and prevalence of obesity was 36.0%, based on measured weights
and heights of participants of the medical evaluation (Table 1).
The percentages of participants in the medical evaluation who had high blood pressure, high blood cholesterol, and
undiagnosed diabetes were high (Table 2). Approximately 11% of participants reported they had been diagnosed with
diabetes, compared with 16% who were diagnosed by laboratory testing and 19% who were diagnosed by laboratory
testing or current use of insulin or an oral hypoglycemic medication. Approximately 23.9% (SE, 1.75%) of participants
had impaired fasting glucose (data not shown).
After adjusting for the full model, compared with adults of normal weight, obese adults were nearly 3 times as likely to
have high blood pressure, more than 2 times as likely to have high blood cholesterol, and 1.7 times as likely to report
fair or poor health (Table 3).
Our study shows a high prevalence of overweight and obesity, hypertension and diabetes among Jordanian men and
women. Consistent with previous findings from Jordan (6), our data show that a high percentage of people with
diabetes are not diagnosed. The high prevalence of diabetes and obesity coupled with high levels of undiagnosed
conditions and smoking, particularly among men (11), indicate the need for immediate implementation of programs to
prevent and control NCDs in Jordan.
Higher-than-normal BMI and weight gain are risk factors for diabetes (12), and other studies have indicated that
changes in BMI at the population level foreshadow changes in diabetes prevalence (13,14). Obesity and diabetes usually
are preventable. Previous studies have demonstrated that changes in lifestyle can prevent diabetes and obesity in
selected groups of adults who are at high risk (15,16).
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The diagnosed prevalence of diabetes among Jordanian adults aged 18 years or older increased from 6.4% in 2002 to
7.5% in 2004 and to 9.4% in 2007 (7,8). Between 2002 and 2004, the self-reported prevalence of obesity increased
50%, from 12.8% to 19.5%. The increasing prevalence of obesity and diabetes in Jordan most likely will continue to rise
in the years ahead, driven by both population aging (17) and rapid social and environmental changes, unless effective
interventions are implemented.
Our finding that Jordanian adults’ self-reported prevalence of 14 or more unhealthy mental days has increased, from
5.7% in 2004 (18) to 10.3% in 2007, is interesting. Historically, Jordanians have strong family bonds and a wide social
support network. Mental health services, such as counseling, are not widely available or easily accepted. With
globalization and the influence of Western culture, the extended family’s role is diminishing. The high rates of mental
distress in our study may indicate a shift in health needs in Jordan and the area.
Our findings are subject to several limitations. First, the survey is cross-sectional and was not conducted throughout
the year; therefore, some of the behaviors that vary seasonally (eg, dietary intake) may not be representative, and cause
and effect cannot be determined for the associations between BMI and selected health conditions. Second, some
variables were self-reported, which may have resulted in self-report bias. We did not compute measures of agreement
between self-reported conditions and those obtained from actual measurements. In contrast to prior estimates of
obesity in Jordan, which were based on self-reported weight and height and were, therefore, conservative (19),
estimates from the 2007 Jordan BFRSS were based on actual measurements among participant of the medical
examination. Although we selected the subsample of survey respondents randomly for medical evaluation from the
pool of people participating in the household interview, self-selection bias may have been a factor in the differences
noted between the group undergoing medical examination and the larger group that participated in the household
interview from which the subsample was selected. Finally, although our survey questions related to behavioral risk
factors have documented validity in English, the questions were translated into Arabic; validity of such questions in the
Arabic-speaking world have not been studied (20). Studies to develop better measures for mental health in the region
are also needed.
Despite these limitations and as NCDrisk factors continue to rise in Jordan, the need remainsfor reliable, transparent
information, such as that provided by the Jordan BRFSS, to supportevidence-based health policy and programs. The
high response rate (95%) to this survey reflects the hospitality of Jordanian culture and the skill of trained
interviewers, and the continued implementation of standardized methods in collecting risk factor surveillance data in
Jordan facilitates comparisons over time.
The prevalence of NCDs and NCD risk factors in Jordan is high. Adequate and continuous monitoring of NCD risk
factors in Jordan is needed, and the surveillance findings should be used in health promotion and disease prevention
activities. Programs to monitor and control risk factors and clinical services and a robust health care system are needed
to successfully improve NCD outcomes and reduce the burden of disease in Jordan. Reducing the prevalence of NCDs
requires a renewed commitment by governmental and nongovernmental institutions, by public health professionals
and clinical practitioners, and by communities and individuals to acknowledge the burden of NCDs and the need for
timely action. Moreover, stimulating, strengthening, and sustaining regional efforts and programs are necessary to
reduce the prevalence of NCDs through coordinated and integrated programs of health promotion and disease
prevention. These programs should involve networks for risk factor surveillance, information sharing, capacity
building, advocacy, policy development, and collaboration in generating, disseminating, and applying knowledge.
In collaboration with its partners, the Jordan MOH and the Jordan Applied Epidemiology Training Program are
developing and implementing a national chronic disease prevention and control plan. This plan will target primary risk
factors and behaviors associated with chronic diseases (eg, smoking, overweight, unhealthy diet, physical inactivity)
and call for collaboration among all governmental ministries, nongovernmental organizations, and the private sector.
This research received no specific grant from any funding agency in the public, commercial, or nonprofit sectors.
Corresponding Author: Mohannad Al-Nsour, MD, MSc, Ministry of Health, Dahiyat Al-Rasheed-Alwifaq St, Bldg no.
94, 1st Floor, Office no. 202, PO Box 963709, Amman 11196 Jordan. Telephone: 011-962-6-565-5086. E-mail:
Author Affiliations: Meyasser Zindah, Adel Belbeisi, Raja Hadaddin, Ministry of Health, Amman, Jordan; David W.
Brown, The Brown Consulting Group, Charlotte, North Carolina; Henry Walke, Centers for Disease Control and
Prevention, Atlanta, Georgia.
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Table1. Participant Characteristics, Household Interview and Medical
Examination, Behavioral Risk Factor Surveillance Survey, Jordan, 2007
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http://www.who.int/healthinfo/statistics/bodprojections2030/en/index.html. Accessed July 16, 2008.
Mokdad AH. Health issues in the Arab American community. Chronic diseases and the potential for prevention
in the Arab world: the Jordanian experience. Ethn Dis 2007;17(2 Suppl 3):S3-55-6.
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Factor Surveillance System, 2004. Prev Chronic Dis 2008;5(1).
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diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.
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noncommunicable diseases in Jordan [letter]. Prev Chronic Dis 2009;6(2):A78.
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N Engl J Med 2001;
All Participants (n =
3,654), % (SE)
Participants in Household
Interview Only (n = 2,889),
Participants in Medical
Examination (n = 765), %
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Abbreviations: SE, standard error; NA, not assessed.
Note: Some categories do not total 100% because of rounding.
Attended or graduated.
Ever smoked ≥100 cigarettes in a lifetime and currently smoke every day or some days.
Height and weight measurements to determine body mass index obtained only from participants of the medical
Values apply only to participants of the medical evaluation.
Any recreational moderate activity (ie, activity that results in light sweating or small increases in breathing or heart rate).
Male 53.1 (0.87) 55.8 (0.94)42.9 (1.85)
Female 46.9 (0.87)44.2 (0.94)57.1 (1.85)
18-34 34.5 (0.85) 35.1 (1.00)31.8 (1.71)
35-49 35.3 (0.87)35.6 (0.97) 34.1 (1.95)
50-64 19.5 (0.73)19.0 (0.80) 21.5 (1.80)
≥6510.8 (0.58)10.3 (0.64)12.6 (1.31)
Never attended school11.4 (0.58)10.5 (0.64) 14.8 (1.47)
Primary school 32.0 (0.87)31.8 (0.97) 32.5 (1.96)
Secondary or technical
42.7 (0.87)43.4 (0.99)39.8 (1.83)
University or more13.9 (0.75) 14.2 (0.88) 12.9 (1.30)
Current smoker29.0 (0.84)30.3 (0.94)24.2 (1.76)
Body mass index, kg/m
25.0-29.9 (overweight)30.5 (1.86) NA 30.5 (1.86)
≥30.0 (obese)36.0 (1.85) NA36.0 (1.85)
Engages in moderate
37.8 (0.91)38.7 (1.05)34.1 (1.93)
Typical number of servings of fruits or vegetables per day
None5.3 (0.46)4.9 (0.50)6.6 (1.08)
1-478.1 (0.84)78.2 (0.95)77.5 (1.62)
≥516.7 (0.78)16.9 (0.88)15.9 (1.50)
High blood pressure17.8 (0.69)16.4 (0.72)23.0 (1.84)
High blood cholesterol7.5 (0.48)7.1 (0.51)9.1 (1.29)
Heart disease8.1 (0.50)8.2 (0.58)7.5 (1.00)
Diabetes9.9 (0.56)9.4 (0.61)11.5 (1.41)
Asthma6.8 (0.44)6.6 (0.48)7.7 (1.01)
Health-related quality of life
Fair or poor health status15.1 (0.64)13.7 (0.68)20.4 (1.49)
≥14 unhealthy physical
6.9 (0.47)5.9 (0.47)10.8 (1.18)
≥14 unhealthy mental
10.3 (0.55)8.6 (0.54)16.9 (1.39)
18.1 (0.73)15.4 (0.71)28.4 (1.79)
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During the 30 days prior to the survey.
Table 2. Chronic Disease Risk Factors Among Participants in Medical
Examination (n = 765), by Sex and Age, Behavioral Risk Factor Surveillance
Survey, Jordan, 2007
SE, standard error; Rx, prescribed medication.
Self-reported height and weight measurements were not obtained in 2007; only physical measures of height and weight
were obtained. Overweight defined as a body mass index of 25.0-29.9 kg/m and obese defined as a body mass index
≥30.0 kg/m .
Defined as 140/90 mm Hg (systolic/diastolic).
Defined as ≥240 mg/dL.
Defined as ≥126 mg/dL.
Table 3. Relationship Between Body Mass Index and Selected Health
Conditions Among Participants in Medical Examination, Behavioral Risk
Factor Surveillance Survey, Jordan, 2007
Sex, % (SE) Age, % (SE), y
Overweight35.0 (2.72)27.1 (2.56)28.8 (3.56)31.0 (2.52) 34.8 (3.96)26.0 (5.08) 30.5 (1.86)
Obese 27.4 (2.38)42.4 (2.51)18.2 (2.87) 40.5 (2.81) 50.6 (4.63)43.6 (5.83) 36.0 (1.85)
High blood pressure
Self-reported20.0 (2.61) 25.3 (2.66) 4.2 (1.33)12.7 (2.54) 47.1 (4.68)57.8 (6.02) 23.0 (1.84)
Measured25.9 (2.35) 16.7 (2.04)4.1 (1.34)14.1 (2.33) 42.4 (4.20)43.2 (5.53)20.7 (1.45)
Measured + Rx31.5 (2.79) 28.5 (2.54) 4.5 (1.38)19.7 (2.65) 61.8 (4.44)66.3 (5.62)29.8 (1.79)
High blood cholesterol
Self-reported6.8 (1.61)10.8 (1.70) <1 (0.25)5.0 (1.42)17.7 (3.76) 27.4 (5.79) 9.1 (1.29)
Measured8.2 (1.67)11.3 (1.62) 4.9 (1.44) 8.0 (1.57)19.0 (3.36) 12.5 (3.64)10.0 (1.21)
Measured + Rx10.9 (1.88)16.2 (1.98) 5.2 (1.44)9.1 (1.67)29.7 (3.84)22.3 (5.28) 13.9 (1.39)
Self-reported10.0 (1.80)12.6 (2.08)1.1 (0.66)6.4 (1.94)28.2 (4.73)22.3 (3.89)11.5 (1.41)
Measured15.0 (2.32) 16.8 (2.20)5.3 (1.96)10.4 (2.28)32.4 (4.18)30.3 (5.06)16.0 (1.47)
Measured + Rx17.9 (2.28)20.7 (2.26) 6.4 (2.06)12.5 (2.35)39.7 (4.57)37.1 (4.58)19.5 (1.48)
Body Mass Index (BMI), kg/m
<25.0 (Normal, n =
25.0-29.9 (Overweight, n = 235), OR
≥30.0 (Obese, n = 281), OR
High blood pressure
1 [Reference]1.87 (1.10-3.19)2.45 (1.32-4.55)
1 [Reference]1.92 (1.11-3.33)2.85 (1.49-5.44)
High blood cholesterol
1 [Reference]1.82 (0.88-3.79)1.73 (0.89-3.35)
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Abbreviations: OR, odds ratio; CI, confidence interval.
Fully adjusted data are adjusted for sex, age, education, smoking, fruit and vegetable consumption, and physical activity.
Measured; defined as 140/90 mm Hg (systolic/diastolic).
Measured; defined as ≥240 mg/dL.
Measured; defined as 100-125 mg/dL.
Measured; defined as ≥126 mg/dL.
Appendix. Jordanian Population by 5-Year Age Group and
Medium Variant 2005
1 [Reference]2.23 (1.08-4.62)2.15 (1.06-4.35)
Impaired fasting glucose
1 [Reference]1.21 (0.84-1.76) 1.60 (1.01-2.53)
1 [Reference]1.12 (0.78-1.62)1.43 (0.88-2.33)
1 [Reference] 1.60 (0.91-2.84)1.24 (0.65-2.34)
1 [Reference]1.52 (0.85-2.71) 1.08 (0.54-2.15)
1 [Reference]1.16 (0.48-2.77) 1.62 (0.75-3.48)
1 [Reference]1.29 (0.55-3.01) 1.71 (0.79-3.70)
Fair or poor health
1 [Reference] 0.78 (0.43-1.42)1.32 (0.77-2.29)
1 [Reference]0.98 (0.51-1.89)1.72 (0.99-3.00)
0-4 684 350 334
10-14 614 315299
15-19 606 312294
20-24 559 290 269
25-29 481 252229
30-34 426 226 200
35-39 340 182 158
40-44 255 133121
45-49174 88 86
50-54 12463 61
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Numbers may not sum due to rounding.
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World
Population Prospects: The 2010 Revision, http://esa.un.org/unpd/wpp/index.htm. Accessed June 1, 2011.
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