ABSTRACT
Purpose/Background:
Hence, this comparative study of risk assessment was carried out among out patients visiting urban and rural health centers. This study aimed to find out and compare the risk factors for NCDs among out-patients visiting urban and rural health centers.
Methods:
This cross-sectional study was carried out in Urban health centre Rukmini Nagar and Rural health centre Vantamuri. Using convenient universal sampling, 200 out-patients from urban area and 200 from rural area were selected. The data were entered into MS-EXCEL and analyzed using SPSS software.
Results:
In urban area, males were more common (53.7%), whereas females were more common in rural areas (53.8%). Maximum study participants were laborers in urban area (24.5%), whereas home makers were common in rural area (40.5%). Most people in urban areas (11.5%) were indulged in smoking, whereas only 5% smoked in rural area. Participants in urban area had higher waist circumference (20.5%) than those in rural area (17.5%). Physical inactivity was more in rural area (68%), as compared to urban area (47%). 29.5% of participants were found to be at risk for NCDs in urban area, whereas 30% of those were found to be at risk in rural area.
Conclusions:
Awareness regarding ill effects of risk factors: smoking, alcohol consumption, physical inactivity, and obesity should be created among the community through health education and behavioral change communication to prevent its progression as a disease in future.
Keywords: Noncommunicable diseases, primary care level, risk factors
Introduction
In India, noncommunicable diseases (NCDs) contribute to around 5.87 million deaths, accounting for 60% of all deaths.[1] Most NCDs can be identified and managed at primary care level.[2]
An epidemiological health transition has resulted in the increased risk factors for NCDs among Indian population.[3] NCDs contributed to 53.6% deaths in 1990 and by 2016, it has increased to 61.8%.[4] The young adult population is mostly affected due to NCDs—73.2% of deaths in the age group of 40–69 years is due to NCDs.[5] NCD risk factors include: dietary risks, tobacco use, alcohol use, decreased physical activity, and high body mass index.[6]
With the increasing burden of NCDs in India primary health-care approach with efficient access and usage of resources offers the best solution.[7,8] Recent researches have reported high prevalence of NCD risk factors, and the need to strengthen healthcare systems and delivery, improved access to NCD screening, diagnosis, and treatment.[9,10,11] A community-based model of NCD risk factor surveillance has also been proposed by researches, using the frontline workers of public healthcare system; still, the best preventive strategy is the lifestyle modifications at the individual level.[12,13] WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020 is to use people-centered primary health care and universal health coverage to strengthen and orient health systems to address the prevention and control of NCDs and their underlying social determinants.[14] This study sets out to find if early identification of the risk factors and appropriate treatment can be started at the primary care level itself and by what methods they could be done. Hence, this comparative study of risk assessment was carried out among out patients visiting urban and rural health centers to find out and compare the risk factors for NCDs among these populations.
Material and Methods
Study setting
This cross-sectional study was carried out in Urban health centre, Rukmini Nagar, and Rural health centre, Vantamuri, which are under the field practice area of a medical college in Belagavi.
Study duration
Study duration is- 1 October, 2020 to 30 November, 2020.
Study design
Cross-sectional study.
Sample size and sampling
Using convenient universal sampling, 200 out-patients from urban area and 200 from rural area were selected. Subjects residing in urban and rural practice area for more than 6 months with age more than 30 years were included in the study. Subjects with impairment of speech, hearing, vision, and cognition were excluded from the study. Verbal consent was taken from all the participants; a verbal explanation was given regarding the nature and the details of the study in the language comprehensible by the participants. Ethical approval was obtained from the Institutional Ethics Committee. A questionnaire was prepared based on the existing data and literature search on the topic.
Data collection
Data was collected for a period of 2 months, from October 1, 2020 to November 30, 2020.
The pretested questionnaire was administered to the participants and no time limit was allotted to answer the questions. Once the participant had finished answering, the questionnaire was collected back. Utilizing the opportunity, patients were also educated regarding the incorrect responses and the ill-effects of the risk factor behaviors.
Data analysis
The collected data was entered into MS-EXCEL and analyzed using SPSS software.
Guidelines for reporting
The reporting of this study adhered to the Strengthening the reporting of observational studies in epidemiology (STROBE) checklist.
Results
In urban area, males were more common, whereas females were more common in rural areas [Table 1]. In the urban area, majority were Hindus, and in the rural area the majority were Muslims [Table 2]. In urban area, most of the participants had got a degree, whereas in the rural area most of them had not received formal education, but were able to read and write [Table 3]. Maximum study participants were laborers in urban area, whereas home makers were common in rural area [Table 4]. Most people in urban areas were single, and it was significantly associated with their risk of NCD. Whereas, in rural areas most were married [Table 5]. The number of people that consumed alcohol was similar in urban and in rural areas [Table 6]. Participants in urban area had higher waist circumference than those in rural area [Table 6]. Physical inactivity was more in rural area, as compared to urban area [Table 6]. Family history of NCDs was found to be more in rural population than in urban [Table 6]. On applying multiple logistic regression test for sociodemographic variables it was found that males were having higher risk for NCDs than females, which was statistically significant [Table 7]. Almost equal number of people in both urban and rural areas were found to be at risk for NCDs [Table 8].
Table 1.
Distribution of study participants according to gender
| Sex/Place | Urban | Rural | Total | Chi-Square value | P |
|---|---|---|---|---|---|
| Male | 109 (53.7) | 94 (46.3) | 203 | 1.965 | 0.161 |
| Female | 91 (46.2) | 106 (53.8) | 197 | ||
| Total | 200 | 200 | 400 |
Table 2.
Distribution of study participants according to religion
| Urban | Rural | Total | Chi – Square (Fishers Test) | P | |
|---|---|---|---|---|---|
| Hindu | 166 (51.7) | 155 (48.3) | 321 | 1.985 | 0.375 |
| Muslims | 32 (43.2) | 42 (56.8) | 74 | ||
| Christians | 2 (4) | 3 (6) | 5 | ||
| Total | 200 | 200 | 400 |
Table 3.
Distribution of study participants according to education
| Education/Place | Urban | Rural | Total | Chi-Square value | P |
|---|---|---|---|---|---|
| Illiterate | 69 (57) | 67 (49.3) | 136 | 28.69 | < 0.001*** |
| Read & write | 21 (28) | 54 (72) | 75 | ||
| Standard 1-4th | 9 (36) | 16 (64) | 25 | ||
| Standard 5-8th | 20 (50) | 20 (50) | 40 | ||
| 10-12/Diploma | 61 (63.5) | 35 (36.5) | 96 | ||
| Degree/Post graduate | 20 (71.4) | 8 (28.6) | 28 | ||
| Total | 200 | 200 | 400 |
***There is significant association between place and education asP<0.05
Table 4.
Distribution of study participants according to occupation
| Occupation/Place | Urban | Rural | Total | Chi-Square value | P |
|---|---|---|---|---|---|
| Farmer | 41 (50) | 41 (50) | 82 | 19.06 | 0.008 ** |
| Laborer | 49 (67.1) | 24 (32.9) | 73 | ||
| Self-Employee | 21 (43.8) | 27 (56.2) | 48 | ||
| Govt Employee | 15 (62.5) | 9 (37.5) | 24 | ||
| Private Employee | 12 (60) | 8 (40) | 20 | ||
| Retired/Pensioner | 3 (25) | 9 (75) | 12 | ||
| Home Maker | 59 (42) | 81 (57.9) | 140 | ||
| Others | 0 () | 1 (100) | 1 | ||
| Total | 200 | 200 | 400 |
**There is significant association between Place and Occupation as P<0.05
Table 5.
Distribution of study participants according to marital status
| Marital/Pace | Urban | Rural | Total | Chi-Square value | P |
|---|---|---|---|---|---|
| Single | 46 (83.6) | 9 (16.4) | 55 | 36.29 | <0.001*** |
| Married | 152 (45.9) | 179 (54.1) | 331 | ||
| Separated/Divorced | 2 (40) | 3 (60) | 5 | ||
| Widow/widower | 0 | 9 (100) | 9 | ||
| Total | 200 | 200 | 400 |
***There is significant association between Place and Marital Status as P<0.001
Table 6.
Distribution of study participants according to risk factors
| Range | Urban | Rural | ||
|---|---|---|---|---|
| Age | 30-39 | 33 (16.5) | 79 (38) | |
| 40-41 | 111 (55.5) | 44 (22) | ||
| >50 | 56 (28) | 77 (38.5) | ||
| Smoking | Never | 146 (83) | 145 (72.5) | |
| Sometimes | 31 (15.5) | 45 (22.5) | ||
| Daily | 23 (11.5) | 10 (5) | ||
| Alcohol | No | 160 (80) | 162 (81) | |
| Yes | 40 (20) | 38 (19) | ||
| Waist Circumference | Female | Male | ||
| <80 | <90 | 19 (9.5) | 11 (5.5) | |
| 20 (10) | 10 (5) | |||
| 80-90 | 90-100 | 47 (23.5) | 88 (44) | |
| 73 (36.5) | 56 (28) | |||
| >90 | >100 | 26 (13) | 16 (8) | |
| 15 (7.5) | 19 (9.5) | |||
| Physical Activity | At least 150 minutes per week | 106 (53) | 64 (32) | |
| Less than 150 minutes per week | 94 (47) | 136 (68) | ||
| Family History | No | 90 (45) | 86 (43) | |
| Yes | 110 (55) | 114 (57) | ||
Table 7.
Multiple logistic regression tests for socio demographic variables
| Crude Odds Ratio | P | Adjusted Odds Ratio | P | |
|---|---|---|---|---|
| Sex (M) | 2.143 (1.378 to 3.33) | 0.001 ** | 5.681 (2.139-15.085) | <0.001*** |
| Religion | 0.065 | 0.012 * | ||
| Muslims | 0.554 (0.30-1.023) | 0.059 | 0.389 (0.189-0.797) | 0.010 * |
| Christians | 3.267 (0.53-19.85) | 0.198 | 3.623 (0.515 - 25.49) | 0.196 |
| Education | 0.097 | 0.13 | ||
| Illiterate | 1.236 (0.50-3.02) | 0.642 | 2.991 (0.848-10.54) | 0.088 |
| Read & Write | 0.625 (0.23-1.69) | 0.355 | 0.910 (0.244-3.386) | 0.888 |
| Standard 1 – 4th | 1466 (0.530-5.24) | 0.382 | 3.031 (0.703-13.07) | 0.137 |
| Std 5 – 8th | 1.84 (0.65-5.18) | 0.244 | 3.197 (0.826-12.37) | 0.092 |
| 10 – 12th Diploma | 0.833 (0.32 - 2.13) | 0.704 | 0.921 (0.29-2.921) | 0.889 |
| Occupation | 0.012 * | < 0.001 *** | ||
| Laborer | 0.663 (0.315 - 1.397) | 0.280 | 0.555 (0.24 -1.266) | 0.162 |
| Self Employed | 2.36 (1.122 - 4.964v) | 0.024 | 4.634 (1.798-11.94) | 0.001** |
| Govt. Employee | 1.283 (0.483-3.404) | 0.617 | 2.355 (0.641 - 8.65) | 0.197 |
| Private Employee | 5.13 (1.408 - 18.7) | 0.784 | 1.35 (0.364 - 5.00) | 0.654 |
| Retired/Pensioner | 0.855 (0.279 - 2.623) | 0.013 | 11.14 (2.29 - 54.21) | 0.03 * |
| Home- Maker | 0.888 (0.481 - 1.639) | 0.704 | 4.73 (1.59 - 14.07) | 0.05 |
significant <0.001*** 0.012* 0.010* 0.001** 0.03*
Table 8.
Association between rural and urban population based on risk assessment score
| Total Score CC | Total | Chi- Square | P | ||
|---|---|---|---|---|---|
|
| |||||
| Not at Risk | At Risk | ||||
| Urban | |||||
| Count | 141 | 59 | 200 | 0.012 | 0.913 |
| Expected Count | 140.5 | 59.5 | 200 | ||
| % within Place | 70.50% | 29.50% | 100.00% | ||
| % within Total Score CC | 50.20% | 49.60% | 50.00% | ||
| Rural | |||||
| Count | 140 | 60 | 200 | ||
| Expected Count | 140.5 | 59.5 | 200 | ||
| % within Place | 70.00% | 30.00% | 100.00% | ||
| % within Total Score CC | 49.80% | 50.40% | 50.00% | ||
| Count | 281 | 119 | 400 | ||
| Expected Count | 281 | 119 | 400 | ||
| % within Place | 70.20% | 29.80% | 100.00% | ||
| Total | |||||
| % within Total Score CC | 100.00% | 100.00% | 100.00% | ||
Discussion
The lacuna
There are only a few studies that have reported the prevalence of risk factors of NCDs in urban and rural areas of India. The present study adds evidence regarding the prevalence of risk factors for NCDs among the urban and rural populations.
Prevalence of risk factors
Smoking and alcohol
This study has found that more people in urban area (11.5%) smoke daily than those in the rural area (5%). And, more people in the rural area than those in urban area have said that they smoke sometimes (22.5% and 15.5%, respectively). The high prevalence of smoking among people in rural area compared to those in urban area is comparable with the findings of a ICMR-WHO study in Delhi.[15] These results are also comparable to the ICMR study conducted at Kerala, which reported that 24.3% rural people were indulged in smoking.[16] However, a limitation of this study is that it did not consider the use of smokeless tobacco which is equally or sometimes even more dangerous than bidi/cigarette smoking, leading to oral and oropharyngeal cancers. The prevalence of alcohol usage was almost same in both populations.
Physical inactivity
Physical inactivity was more in rural area (68%) as compared to urban area (47%). This is in contrast to other studies.[17,18] This might be because of the cut-off range we have taken for physical activity- at least 150 minutes per week. Since most of the people in rural area are engaged in farming or other types of manual labor, they may not take time for physical activity as a separate function, and this may have resulted in the reduced physical activity seen among rural people than those in urban in the present study.
Waist circumference
The present study reports that people in urban area had higher waist circumference (20.5%) than those in rural area (17.5%). This is consistent with the findings of other studies.[19,20] This can be explained by the fact that in spite of doing physical activity, the sedentary lifestyle and poor eating habits have resulted in the increased waist circumference in the urban people.
At risk for NCDs
In conclusion, the prevalence of risk factors for NCDs are almost the same in both urban and rural areas—29.5% of participants were found to be at risk for NCDs in urban area, whereas 30% of those were found to be at risk in rural area. This is in line with other studies.[21] Family history of NCDs was also similar in both urban (55%) and rural (57%) populations. This is a worrisome finding. Various studies and literature have proved that at least 80% of heart disease, stroke, and type 2 diabetes and 40% of cancer could be avoided through healthy diet, regular physical activity, and avoidance of tobacco-use.[22]
Conclusion
Proper strategies must be setup for early identification of the risk factors and for appropriate treatment to be started at the primary care level itself. Awareness regarding ill effects of risk factors should be created among the community to reduce the prevalence of the same and its progression as disease in future. It can be achieved through health education and behavioral change communication.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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