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Factors associated with awareness, treatment and control of hypertension in a disadvantaged rural Indian population

Journal of Human Hypertension volume 31, pages 347–353 (2017)Cite this article

Subjects

Abstract

The aim of this study was to identify factors associated with awareness, treatment and control of hypertension in a rural setting in India. Following screening of the population, all individuals with hypertension (blood pressure (BP) ⩾140/90 mm Hg or taking antihypertensive medications) were invited to participate in this study. We measured BP, height, weight, skinfolds, waist and hip circumference, and administered a questionnaire to obtain information regarding socioeconomic and behavioural characteristics. Multivariable logistic regression was used to determine factors associated with awareness, treatment and control of hypertension. We recruited 277 individuals with hypertension. Awareness (43%), treatment (33%) and control (27%) of hypertension were poor. Greater distance to health services (odds ratio (OR) 0.56 (95% confidence interval (CI)) 0.32–0.98) was associated with poor awareness of hypertension while having had BP measured within the previous year (OR 4.72, 95% CI 2.71–8.22), older age and greater per cent body fat were associated with better awareness. Factors associated with treatment of hypertension were having had BP measured within the previous year (OR 6.18, 95% CI 3.23–11.82), age ⩾65 years, physical inactivity and greater per cent body fat. The only factor associated with control of hypertension was greater per cent body fat (OR 1.05, 95% CI 1.01–1.11). Improving geographic access and utilisation of health services should improve awareness and treatment of hypertension in this rural population. Further research is necessary to determine drivers of control.

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Introduction

Hypertension is the most important modifiable risk factor for mortality and burden of disease globally.1 Nearly two-thirds of the individuals with hypertension worldwide reside in low- and middle-income countries (LMICs).2 The prevalence of hypertension in India has increased nearly 10-fold in rural dwellers in the last three decades,3 but recent estimates of awareness (as low as 25%), treatment (25%) and control (11%) of hypertension in these settings are very low.4 It has been suggested that poor awareness, treatment and control of hypertension in LMICs may be attributed to competing priorities in health care such as infectious diseases, scarce resources, poor public health education, as well as poor availability and affordability of effective drugs.5 In addition, health perceptions, such as the belief that health changes are a natural consequence of aging, demographic and socioeconomic factors, attitudes towards taking medication and access to health care, may contribute to poor awareness, treatment and control of hypertension in LMICs.6

Importantly, better awareness and treatment of hypertension has been reported to result in improved control of hypertension.7, 8, 9 Improved awareness of hypertension is thus crucial to effective treatment and control of arterial blood pressure (BP) in the community10 and has been shown to increase the use of antihypertensive medication among individuals with hypertension.11

Despite evidence of poor awareness, treatment and control of hypertension in rural Indian populations,4 there are limited data regarding the factors that influence them in these populations, so little scope for improvement. Therefore, we aimed to identify factors associated with awareness, treatment and control of hypertension in a disadvantaged rural Indian population.

Materials and methods

Study area and study population

This study was conducted in a disadvantaged and rural community of the Rishi Valley Region. The Rishi Valley is located in Chittoor district near the south western border of Andhra Pradesh, India. The population of this area comprises about 38 000 residents, most of whom are subsistence farmers who have had little or no formal education.12

Sampling and recruitment of participants

Villages in the study area were stratified into three equal groups based on population size, that is, small, medium and large. From each stratified group, villages were selected using simple randomisation. A total of 63 villages were randomised and 57 of these were included in this study. As we have done previously,12 before commencement of the study, village leaders were contacted and informed about the purpose of the study. We sought their consent for establishing a screening site within their villages, along with their willingness to allow recruitment. Individuals with hypertension were identified by screening residents aged ⩾18 years, for BP and other factors. Those with a systolic BP ⩾140 mm Hg and/or diastolic BP ⩾90 mm Hg or taking antihypertensive medications were defined as having hypertension.

Following screening, individuals with hypertension were approached and invited to undertake comprehensive assessments. They were approached in the order in which they were first identified. Questionnaire-based, physical and clinical measurements for most participants were performed at a research unit, but for some participants, measurements were undertaken in their villages.

Data collection and measurements

Data were collected from August 2012 to August 2014. Trained health workers administered questionnaires and measured BP and anthropometric parameters. The instruments and measurements used for this study were in accordance with the recommendations from the World Health Organization (WHO) STEPwise approach to (non-communicable disease) risk factor surveillance (STEPS).13 These questionnaires have been previously validated in Indian populations.14, 15 The questionnaire was translated into Telugu, the native language, and then back translated into English to check for any errors that might lead to misinterpretation of either the questions or the answers. This questionnaire was used to collect information on sociodemographics, including age, sex, traditional social group, religion, marital status, income, educational attainment and type of work undertaken; lifestyle-related behaviours, including tobacco use, alcohol consumption and physical activity; and self-reported prior diagnosis and/or treatment of hypertension, routine habits for health check-ups and access to health care.

BP was measured using a digital automatic BP monitor (OMRON HEM-907, OMRON Healthcare Company, Kyoto, Japan). Participants were seated for at least 15 min before the first BP measurement was taken. BP was measured from the right arm, where possible, with the arm supported at the level of the heart. At least three BP measurements were taken, with a rest period of 3 min between each measurement. BP measurements were taken until the last two measurements differed by <10 mm Hg for systolic BP and <6 mm Hg for diastolic BP, or until a total of five measurements had been taken, in accordance with the WHO STEPS surveillance protocol.13 The mean of the last two measurements was used to define the hypertensive status. This procedure was used both during the screening exercise and during the day of clinical testing.

Height was measured to the nearest 0.1 cm using a standard portable stadiometer (SECA 213, Seca, Hamburg, Germany). Weight was measured, in light clothes, to the nearest 0.1 kg using a standard calibrated portable electronic scale (Salter 9000SV3R, Salter UK, Kent, UK) placed on a hard-level surface. Waist and hip circumferences were measured using a constant-tension Gulick tape (Patterson Medical Supply Incorporation, Cedarburg, WI, USA). Waist was measured at the mid-point between the lowest rib and the upper point of the iliac crest, at the end of normal expiration. Hip circumference was measured at the maximum protrusion of the buttocks. Skinfold thicknesses were measured to the nearest 0.1 mm using the Holtain/Tanner-Whitehouse skinfold caliper (Holtain Limited, Croswell, UK). Triceps skinfold was measured at the mid-point on the back/posterior of the right upper arm, whereas the biceps skinfold was measured at the mid-point mark on the front/anterior of the right upper arm. The subscapular skinfold was measured at the back of the participant, on the inferior angle of the right scapula. The suprailiac skinfold was measured at the right hip of the participant, 2 cm anterior to the top of the iliac crest. Measurement of waist and hip circumference, and skinfolds, was conducted in privacy, behind a screen.

Definitions

Hypertension was considered to be present when, at screening assessment, the mean of the last two measurements was at least 140 mm Hg for systolic BP and/or at least 90 mm Hg for diastolic BP, or self-reported use of antihypertensive medications. Awareness of hypertension was defined as self-reported prior diagnosis of hypertension made by a health professional.16 Treatment of hypertension was defined as self-reported use of antihypertensive medications.16 Control of BP was defined as having a systolic BP <140 mm Hg and diastolic BP <90 mm Hg determined from the mean of the last two BP measurements taken during the day of clinical testing for this study.

Obesity was defined as body mass index (BMI) at least 25 kg m−2, overweight as BMI at least 23 kg m−2 and less than 25 kg m−2 and underweight as a BMI less than 18 kg m−2, based on the standard cutoff values for Indians.17 Waist circumference was dichotomised as ‘above normal’ expressed as >90 cm for men and >80 cm for women, and ‘normal’ when ⩽90 cm in men and ⩽80 cm in women.17 Per cent body fat was calculated using Durnin and Womersley’s general formula.18, 19 This incorporates the logarithm of skinfold thicknesses at four sites: biceps, triceps, subscapular and suprailiac. Physical inactivity was defined as work that involved mostly sitting or standing. Ever smokers comprised individuals who reported that they smoked any tobacco product including cigarettes and bidis (small hand-rolled cigarettes) at least daily and those who smoked at least daily in the past. Ever smokeless tobacco use was defined when tobacco products such as snuff, chewing tobacco and betel were used, at least daily either currently or in the past. Current alcohol consumption was defined as drinking alcohol at least once in the 12 months before the date of the survey.

Participants were categorised as ‘traditionally advantaged’ and ‘traditionally disadvantaged’ according to their traditional social group. These traditional groups have been shown to be strong determinants of socioeconomic position and poverty in the Indian context.20 Traditionally advantaged groups include people who are not eligible for ‘reservation benefits’ from the Government of India and were traditionally the teachers, lawmakers, warriors and landowners. Traditionally disadvantaged groups comprise individuals who are eligible for benefits from the Government of India and are traditionally and socioeconomically disadvantaged.

Distance to health services was estimated using network analysis, a Geographical Information Systems (GIS) method.21, 22 We mapped all health services in the study area and the participants’ residence or village centroid. The road network data set of the study area and neighbouring villages was obtained through digitisation of Google Maps Roads in ArcGIS 10 (Environmental Systems Research Institute, Redlands, CA, USA). Travel distance from each participant’s residence or village centroid to the nearest health service, along the road network, was calculated using network analysis. Distance to health services was then dichotomised into ⩽5 or >5 km, as it has been shown that people are less likely to travel further than 5 km for basic preventive and/or curative care.23

Statistical analysis

Descriptive statistics were used to compare participant characteristics including use of the χ2-test for categorical variables. The mean and s.d. were calculated for continuous variables that were normally distributed, whereas median and quartiles one and three were determined for continuous variables that failed a test of normality (Shapiro–Wilk test).24 We calculated the proportion of individuals with hypertension who were aware, treated and controlled (BP <140/90 mm Hg).

To identify factors associated with awareness, treatment and control of hypertension, we performed both univariable and multivariable logistic regression analyses. All relevant variables such as age, sex, marital status, traditional social group, educational attainment, occupation, BMI, per cent body fat, waist circumference, tobacco use, alcohol consumption, physical activity, last occasion of BP measurement and proximity to health services, were introduced into multivariable regression analyses in a backward stepwise manner. Apart from age and sex, which were forced in the model, only variables with a P-value <0.1 in backward stepwise selection were retained in the final models. Two-sided P-values ⩽0.05 were considered statistically significant in all analyses. All statistical analyses were performed using STATA (version 12; StataCorp, College Station, TX, USA).

Ethics

The study was approved by the Rishi Valley Education Centre, the Indian Council of Medical Research and the Human Research Ethics Committees of Monash University. Informed consent was obtained from each participant.

Results

Our study included 277 individuals with hypertension and of those identified with hypertension in the screening phase, 75% participated in the study. Twenty-six participants were included based on self-reported use of antihypertensive medications alone. The median age was 60 (Q1, Q3; 50, 70) years, 45% were women, 50% had no formal schooling, 51% undertook moderate to vigorous physical activity and 31% were overweight or obese (Table 1).

Table 1 General characteristics of individuals with hypertension
Full size table

The reasons for not including six of the randomised villages in the study are shown in Supplementary Table 1. There were no significant differences between individuals with hypertension who participated and those who did not participate in the study, except for median systolic BP, which was greater in those who participated (Supplementary Table 2).

Awareness, treatment and control

In general, awareness, treatment and control of hypertension were similar in men and women (Table 2). Across both genders, 43% were aware of their hypertensive status, 33% had ever been treated with antihypertensive medication and only 27% had their BP controlled (BP <140/90 mm Hg). Among those aware of their hypertensive status, 76% reported having ever been treated with antihypertensive medication, but only 55% were currently taking antihypertensive medication. Interestingly, women who were currently taking antihypertensive medications were nearly twice as likely (37.5% women versus 18.2% men) to have their BP under control than their male counterparts.

Table 2 Awareness, treatment and control of hypertension among individuals with hypertension
Full size table

Those who were aware of their hypertension were more likely to have had a health check-up or had their BP measured in the last 12 months, and were more likely to live ⩽5 km from their nearest health service, than those who were not aware of their hypertension (Table 3). In addition, those who were less active, were engaged in non-farming work and had a greater mean per cent body fat were more likely to be aware of their hypertension than those who engaged in moderate to vigorous physical activity, farmers and those with lesser mean per cent body fat. Utilisation of health services, physical activity, type of work undertaken and per cent body fat were similarly associated with treatment for hypertension. In addition, those aged ⩾65 years and those who had not consumed alcohol in the previous year were more likely to be treated for hypertension than younger individuals and those who had consumed alcohol in the previous year. Effective control of hypertension was more common in younger (<65 years) than older individuals and in those with greater body weight. There were some other apparent differences between individuals with controlled and those with uncontrolled BP such as traditional disadvantage, smoking and physical activity, although these did not reach statistical significance at conventional levels (Table 3). Importantly, no association could be detected between effective control of hypertension and geographic access or utilisation of health services.

Table 3 Characteristics of individuals with hypertension who were aware, treated and controlled for hypertension
Full size table

Participants who were aware of their hypertensive status reported general costs, price of antihypertensive medications and distance to health services as some of the barriers to managing their hypertension (Supplementary Table 3).

Factors associated with awareness of hypertension

In univariable analysis, having had BP measured within the past year, physical inactivity, not being a farmer and greater per cent body fat were associated with awareness of hypertension (Table 4). When adjusted for all relevant potentially confounding variables, living >5 km from a health service was associated with poor awareness of hypertension (odds ratio (OR) 0.56, 95% confidence interval (CI) 0.32–0.98), whereas having had BP measured within the past year (OR 4.72, 95% CI 2.71–8.22), age ⩾65 years (OR 1.93, 95% CI 1.08–3.44) and greater per cent body fat (OR 1.05, 95% CI 1.00–1.11) were positively associated with awareness of hypertension (Table 4).

Table 4 Factors associated with awareness, treatment and control of hypertension
Full size table

Factors associated with treatment of hypertension

In univariable analysis, having had BP measured within the preceding year, older age, physical inactivity, greater per cent body fat, not being a farmer and having not consumed alcohol in the previous year were associated with treatment for hypertension (Table 4). When adjusted for potentially confounding factors, having had BP measured within the past year (OR 6.18, 95% CI 3.23–11.82), age ⩾65 years (OR 2.15, 95% CI 1.10–4.20), physical inactivity (OR 2.15, 95% CI 1.15–4.02) and per cent body fat (OR 1.07, 95% CI 1.02–1.13) were associated with treatment for hypertension (Table 4).

Factors associated with control of hypertension

Individuals <65 years of age and those who had greater per cent body fat had a greater likelihood of having controlled BP in univariable analysis. In multivariable analysis, per cent body fat was the only factor associated with better control of BP (OR 1.05, 95% CI 1.01–1.11; Table 4).

Discussion

Our findings demonstrate poor awareness, treatment and control of hypertension in this rural Indian population. More than half of our study population were unaware of their hypertensive status. Even fewer had ever been treated for hypertension or had their BP controlled. Importantly, it appears that similar factors drive awareness and treatment of hypertension in this population.

An important finding of our analysis was that the major barrier to awareness and treatment of hypertension in this setting was geographic access and utilisation of health-care services. Indeed, the finding that awareness of hypertension was significantly better in individuals who lived 5 km or less from a health service may reflect increased utilisation of health services by individuals who reside within close proximity of health services.25, 26, 27 Our findings in rural India are consistent with those in rural Nigeria, where people tend to not travel further than 5 km for basic preventive and/or curative care.23 It is possible that geographic access to health services improves awareness via greater frequency of contact with the health-care system, thereby leading to greater likelihood of diagnosis.28 Indeed, the finding that participants who had their BP measured within the preceding year had better awareness provides support for this notion. However, the fact that geographic access was associated with awareness, independent of the frequency of measurement, indicates that other mechanisms are also involved. Our findings highlight the need for provision of more health services in rural regions to reduce disparities in access in these rural populations.

The finding that awareness and treatment of hypertension were greatly influenced by frequency of BP measurement is not surprising. This finding is consistent with evidence from other populations29, 30 and highlights the importance of regular BP screening. This finding further suggests that future public health policy should put more emphasis on provision of preventative primary health-care services that encourage people to have their BP monitored more regularly, and also receive treatment when diagnosed with hypertension. Furthermore, BP measurement should be recommended as a routine procedure for clinical visits.

Our findings support the need for provision of more health services in rural regions in order to improve awareness of hypertension. Given scarce resources in most LMICs, construction of new health facilities might not be practical. Therefore, in order to overcome the problem of distance to health services and improve frequency of BP measurement, outreach programmes comprising trained non-physician health workers might be beneficial in improving awareness and treatment of hypertension. A similar model of care has been found to be effective in the management of cardiovascular diseases in other rural populations in India.31, 32 The non-physician health workers such as the Accredited Social Health Activists could also be trained and equipped with BP machines to undertake outreach programmes in remote communities that have poor access to health centres. Outreach programmes aimed at BP monitoring and health education in rural and remote populations are likely to help improve awareness and treatment of hypertension in these communities.

The finding that physical inactivity was independently associated with treatment is rather surprising. However, because physical inactivity was defined as work that involved mostly sitting or standing, individuals who were physically inactive were likely to have had office or white-collar jobs. Therefore, it is possible that occupation (non-farmers), a proxy of higher socioeconomic position, may explain the independent association observed between physical inactivity and treatment of hypertension in this population, as these people may be more likely to have better access to health services and afford medications.33 However, when we added the variable occupation (farmer or non-farmer) into the model, the effect size was not attenuated, indicating that there are other factors that may explain the association between physical inactivity and treatment for hypertension in this population.

Although geographic access (that is, distance to health services) and utilisation of health-care services (that is, having BP measured within the last year) appear to be drivers of awareness and treatment in this setting, these factors seem to have little impact on the control of BP. Instead, socioeconomic factors seem to influence the control of BP. While the mechanisms underlying the association between greater per cent body fat and better control of BP are not clear, it is possible that greater per cent body fat may be a proxy for socioeconomic position in this population. Adiposity is positively associated with socioeconomic position in LMICs.34 Therefore, it is possible that people of greater adiposity are financially better able to access health-care services and afford the ongoing cost of medications, thereby increasing the likelihood of control of hypertension. This hypothesis is supported by evidence from the WHO’s Study on Global Aging and Adult Health in which control of BP was better in Indians in the richest wealth quintile than those in the poorest wealth quintile.33 It is also likely that other factors contribute to the poor control of hypertension in rural southern India. Identification of these factors should be a priority for public health in this region.

There are potential limitations of the present study that should be considered in the interpretation of our findings. It is recommended that hypertension should be defined based on the average of at least two BP readings taken at two or more visits.8, 35 In the current study, we used an average of BP readings taken at a single visit to diagnose hypertension. Use of a single visit to diagnose hypertension might have resulted in either misclassification bias or detection of white-coat hypertension. Nevertheless, our method is in accordance with the recommendations from the WHO STEPwise approach to surveillance of chronic diseases in population-based surveys.13 The WHO STEPS methods have been used in many population-based surveys. Thus, our findings are comparable to those generated in other studies from India, as well as other parts of the world. A second limitation of our work relates to the potential for our findings to be subject to both recall bias36 and responder bias,37 particularly for self-reported factors. These biases may have influenced the results by either overestimating or underestimating the effect sizes. Because of the observational nature of our study, we cannot rule out reverse causation in that the frequency of BP measurement might be a consequence of awareness of hypertension. The assumption of our spatial analysis, that people always attend the nearest health service, may not be applicable to some individuals. Nonetheless, it has been suggested that in rural areas, where the choice of health services is very limited, the nearest health facility is often the most likely to be used.38 This is likely to be the case in our study population as there are very few health facilities. Lastly, our study is limited by the relatively small sample size, and observational nature that precludes inference of causality.

The above limitations notwithstanding, we have demonstrated that access and utilisation of health services as well as frequency of BP measurement are important factors for improving awareness and treatment of hypertension in this rural Indian population. Given that the prevalence of hypertension is increasing in rural populations,3 efforts to improve awareness and treatment of hypertension focused on fundamental changes in health systems, are required. There is potential for our findings to be generalised to similar populations in India and other LMICs, where similar characteristics are observed.

In conclusion, improving geographic access and utilisation of health services should improve awareness and treatment of hypertension in this rural population. Further research is necessary to determine drivers of control.

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Acknowledgements

We gratefully acknowledge the health-care workers and study staff, who undertook the fieldwork and data collection for this study. DB is grateful for financial support received from the Monash University Postgraduate Publications Award. The project was funded by project grants from the National Health & Medical Research Council (NHMRC), Australia (1005740 and 1040030). AGT was supported by a senior research fellowship from the NHMRC, Australia (1042600). VKS was supported by an NHMRC Career Development Fellowship (1061457) and a Heart Foundation Future Leader Fellowship (100089). DB was supported by a Monash Faculty of Medicine International Postgraduate Scholarship and a Monash Graduate Scholarship.

Author information

Affiliations

  1. Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia

    D Busingye, S Arabshahi, V K Srikanth, M A Riddell, O Suresh & A G Thrift

  2. Department of Physiology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia

    R G Evans

  3. Rishi Valley Rural Health Centre, Rishi Valley, Andhra Pradesh, India

    K Kartik, K Kalyanram & O Suresh

  4. School of Earth, Atmosphere and Environment, Monash University, Clayton, Victoria, Australia

    X Zhu

  5. Florey Neuroscience Institutes, Melbourne, Victoria, Australia

    A G Thrift

Authors
  1. D Busingye
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  2. S Arabshahi
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  3. R G Evans
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  4. V K Srikanth
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  5. K Kartik
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  6. K Kalyanram
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  7. M A Riddell
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  8. X Zhu
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  9. O Suresh
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  10. A G Thrift
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Corresponding author

Correspondence to D Busingye.

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The authors declare no conflict of interest.

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Supplementary Information accompanies this paper on the Journal of Human Hypertension website

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Busingye, D., Arabshahi, S., Evans, R. et al. Factors associated with awareness, treatment and control of hypertension in a disadvantaged rural Indian population. J Hum Hypertens 31, 347–353 (2017). https://doi.org/10.1038/jhh.2016.85

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  • DOI: https://doi.org/10.1038/jhh.2016.85

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