Abstract
Introduction
We conducted this study among older adults with the following objectives: (1) To find out the prevalence, awareness, treatment and control of hypertension, (2) To understand the factors associated with hypertension prevalence and control.
Methods
A mixed-methods study employing a sequential explanatory design was conducted with a survey of 300 participants aged ≥60 years, and 15 in-depth interviews. Blood Pressure (BP) and waist circumference were measured using standard protocol. Survey data were analysed using univariate and multivariate procedures. In-depth interviews were analysed employing thematic analysis.
Results
Hypertension prevalence was 72.3% (95% CI = 67.1–77.2), 68.2% (CI = 61.8–74.2) were aware, 65.4% (CI = 59.0–71.6) were treated and 24% (CI = 18.6–29.9) achieved adequate control. Inadequate physical activity [(adjusted odds ratio (AOR)] = 2.34; CI = 1.19–4.59), current alcohol use (AOR = 2.28; CI = 1.06–4.91) and self-reported diabetes (AOR = 2.02; CI = 1.15–3.52) were associated with hypertension prevalence. Those who reported diabetes (AOR = 2.72, CI = 1.34–5.55), with education level up to high school (AOR = 2.58, CI = 1.11–6.00) and who were in the age group 60–70 years (AOR = 2.14, CI = 1.09–4.20) were more likely to have controlled hypertension compared to their counterparts. From the in-depth interviews it was found that availability and accessibility of services, family support, financial wellbeing, habits and beliefs and conducive environment played a role in hypertension diagnosis and management.
Discussion
Prevalence of hypertension was high in this population along with poor control. Efforts are required to improve hypertension control focussing on older adults with low education and those who are aged 70 years and above.
Keywords: Hypertension, Older adults, Prevalence, Awareness, Treatment and control, Kerala, India
1. Introduction
Although the global age standardized prevalence of hypertension remained stable at around 32% in women and 34% in men between 1990 and 2019, the number of people with hypertension doubled from 648 million in 1990 to 1278 million in 2019 because of population growth and ageing.1 Rajeev Gupta and others estimated that India had 207 million people with hypertension.2 Age is an independent risk factor for hypertension and its prevalence among older adults is significantly higher than younger adults.3 In the year 2019, hypertension prevalence among older adults aged 60 years and above in India was 63%.4 Close to half of these hypertensives (42.6%) were not detected and the detection rates were poorer in rural areas and men.5 A recent study reported that 40% of adults aged 45 years and older were suffering from hypertension, 60% were aware of their hypertensive status, 73% of those who were aware were taking treatment, and only 10.4% achieved adequate control of hypertension.6
Within India, Kerala is the most advanced state in epidemiological transition and has one of the highest prevalence of hypertension.7 There are a few studies on hypertension prevalence among the general population in Kerala providing prevalence rates of 28%,8 and 33%.9 A community-based study among older adults conducted in the late 1990s in Kerala reported hypertension prevalence, awareness, treatment and control of 52%, 45%, 43% and 11% respectively.10 A multicentre study including rural Kerala on hypertension among older adults conducted in the year 2000, reported prevalence, awareness, treatment and control of hypertension of 53%, 61%, 53% and 18% respectively in rural Kerala.11
There are no recent studies among the older adults in Kerala on hypertension prevalence, awareness, treatment and control. Moreover, there are no data on factors associated with control rates of hypertension which is quite low in Kerala.10,11 We conducted this study among older adults with the following objectives: (1) To find out the prevalence, awareness, treatment and control rates of hypertension, (2) To understand the factors associated with hypertension prevalence and control among older adults.
2. Methods
2.1. Study design
The study followed mixed-methods approach employing a sequential explanatory design.12 The study was conducted in two phases i.e., an initial quantitative phase followed by a qualitative phase. In the quantitative phase, we conducted a cross-sectional survey of 300 older adults aged 60 years and above selected through a multi-stage cluster sampling method. In the qualitative phase we conducted face-to-face in-depth interviews of 15 participants. The triangulation was conducted at the data collection and interpretation phases.
2.2. Study setting and study population
The study was conducted in Kasaragod (North) and Ernakulam (South) districts of Kerala. The study population were older adults aged 60 years and above. The participants of quantitative phase who gave consent for in-depth interviews were considered for qualitative phase of the study.
2.3. Sample size and selection process
For the quantitative phase, a sample size of 300 was estimated with an anticipated hypertension prevalence of 46.7%,13 95% confidence level, half width of the confidence interval as 7% and a design effect of 1.5. A multi-stage cluster sampling method (see Fig. 1 of supplementary file) was used to select clusters and households.14 Participants were selected through a door to door survey of the selected households.
For qualitative phase, participants were identified employing purposive sampling with maximum variation15 until theoretical saturation was reached. Informational redundancy was attained at 15 in-depth interviews.16
2.4. Data collection tools and techniques
In quantitative phase, data were collected using interview schedule administered at households of participants. Interview schedule was developed based on longitudinal aging study in India (LASI)17 & WHO STEPS questionnaires.18
Waist circumference was taken at the mid-point between lower margin of the last palpable rib and top of the iliac crest using SECA 201 ergonomic circumference measuring tape (Seca GmBH & Co Kg, Hamburg, Germany). Blood pressure (BP) was measured using Omron electronic sphygmomanometer (Omron M10-IT; Omron Healthcare Europe, Hoofddorp, Netherlands). We measured BP three times after the participant had rested at least for 5 min and average of the last two readings was taken as the final BP value.18 All the measurements were done by a trained Master of Public Health student.
The qualitative data were collected employing in-depth interviews using in-depth interview guide prepared based on behaviour explanations framework of Bertram19 and Anderson and Newman's framework of health services utilization.20 The interviews were conducted in Malayalam, the local language. The interviews were audio recorded with a prior consent from the participants.
2.5. Data analysis
The analysis and cleaning of survey data were done using STATA SE Version 12 & Statistical Package for Social Sciences version 27 (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp). Hypertension was defined as systolic blood pressure (SBP) ≥140 mm of Hg, diastolic blood pressure (DBP) ≥ 90 mm of Hg or being on medication for hypertension.21 Awareness on hypertension was defined as those who reported a prior history of hypertension. Those who were on medication for hypertension were considered to be on treatment for hypertension. Control of hypertension was defined as SBP <140 and DBP <90 mm of Hg. Binary logistic regression with standard errors adjusted for geographical clusters was conducted to identify the factors associated with hypertension prevalence and hypertension control. The model fit of the regression models was assessed using Hosmer–Lemeshow test.
The qualitative data analysis was conducted employing thematic analysis approach.22 Interviews were transcribed and translated from Malayalam to English. The interviews were deductively coded using Anderson and Newman's framework.20 Two authors independently read the interview transcripts and coded them. This process was undertaken to ensure consistency in findings. We manually coded the interviews and used Microsoft excel 2019 to list the codes and condense them. Coding tree was developed, and themes were generated.
2.6. Ethical considerations
Ethics approval was obtained from Institutional Human Ethics Committee of Central University of Kerala (Ref No: IHEC/CUK/2022/23). Informed consent from the participant was taken prior to quantitative and qualitative data collection. Privacy and confidentiality were maintained throughout the process of research and afterward.
3. Results
3.1. Quantitative results
Among the 300 older adults surveyed everyone completed the survey. More than 60% (n = 182) of the study sample were females and 44.7% (134) were aged more than 70 years (see Table 1). Prevalence of hypertension was 72.3% (n = 217) and 68.2% (n = 148) of hypertensives were aware of their hypertension status (Table 2).
Table 1.
Socio-demographic characteristics of the study participants (n = 300).
| Variables | Frequency | Percentage |
|---|---|---|
| Sex of the Participant | ||
| Male | 118 | 39.3 |
| Female | 182 | 60.7 |
| Age | ||
| 60–70 years | 166 | 55.3 |
| More than 70 years | 134 | 44.7 |
| Place of residence | ||
| Urban | 100 | 33.3 |
| Rural | 200 | 66.7 |
| Religion | ||
| Hindu | 161 | 53.7 |
| Muslim | 16 | 5.3 |
| Christian | 123 | 41.0 |
| Marital status | ||
| Currently Married | 169 | 56.3 |
| Widowed | 121 | 40.3 |
| Single | 10 | 2.4 |
| Education level | ||
| Less than primary schooling | 88 | 29.3 |
| Primary schooling to high school | 162 | 54.0 |
| College education and above | 50 | 16.7 |
| Occupational status | ||
| Currently working | 54 | 18.0 |
| Household work | 162 | 54.0 |
| Unable to work | 84 | 28.0 |
| Currently receiving any pension | ||
| Yes | 253 | 84.3 |
| No | 47 | 15.7 |
| Average monthly household expenditure | ||
| Less than INR 10000 per month | 162 | 54.0 |
| INR 10000 to 20,000 per month | 81 | 27.0 |
| More than INR 20000 per month | 57 | 19.0 |
| Living Arrangement | ||
| Living with spouse | 165 | 55.0 |
| Living alone or with others | 37 | 12.3 |
| Living with children | 98 | 32.7 |
INR= Indian Rupees.
Table 2.
Prevalence, awareness, treatment and control of hypertension and NCD risk factors among older adults in Kerala (n = 300).
| Variable | Frequency | % (95% CI) |
|---|---|---|
| Overall hypertension prevalence | 217 | 72.3 (67.1–77.2) |
| Awareness of hypertension | 148 | 68.2 (61.8–74.2) |
| Currently on treatment for hypertension | 142 | 65.4 (59.0–71.6) |
| Controlled hypertensiona | 52 | 24.0 (18.6–29.9) |
| Controlled HTN among treated | 52 | 36.6 (29.0–44.7) |
| Newly detected HTN | 69 | 31.8 (25.8–38.2) |
| Self-reported Diabetes | 122 | 40.7 (35.2–46.3) |
| NCD Risk Factorsb | ||
| Inadequate fruit and vegetable intake | 234 | 78.0(73.1–82.4) |
| Inadequate physical activity | 265 | 88.3(84.4–91.6) |
| Current alcohol use | 64 | 21.3(16.7–26.0) |
| Current tobacco use | 45 | 15.0(10.9–19.0) |
| Abdominal obesity | 213 | 71.0(65.7–75.9) |
CI = Confidence Interval; Hypertension (Systolic BP ≥ 140 mm Hg and/or DBP ≥90 mm Hg and/or on medication for hypertension); NCD = Non-Communicable Disease.
SBP< 140 and DBP< 90 mm of Hg.
The totals are greater than the sample size (n = 300) since some of the study participants had multiple risk factors.
Older age of more than 70 years (AOR = 1.66; 95% CI = 1.03–2.70), inadequate physical activity (AOR = 2.34; 95% CI = 1.19–4.59), alcohol use (AOR = 2.28; 95% CI = 1.06–4.91) and having diabetes (AOR = 2.02; 95% CI = 1.15–3.52) significantly predicated the odds of hypertension among the older adults (see Table 3).
Table 3.
Factors associated with hypertension among the elderly in Kerala: Results of logistic regression analysis (n = 300).
| Independent Variables | Prevalence (%) | Hypertension AOR (95% CI) |
|---|---|---|
| Age group | ||
| 60–70 years (ref) | 66.9 | |
| More than 70 years | 79.1 | 1.66 (1.03–2.70)∗ |
| Physical activity | ||
| Adequate (ref) | 48.6 | |
| Inadequate | 75.5 | 2.34 (1.19–4.59)∗∗ |
| Current alcohol use | ||
| No (ref) | 70.3 | |
| Yes | 79.7 | 2.28 (1.06–4.91)∗ |
| Self-reported Diabetes | ||
| No (ref) | 65.2 | |
| Yes | 82.8 | 2.02 (1.15–3.52)∗∗ |
AOR = Adjusted Odds Ratio; CI= Confidence Interval; ref = reference. Other variables included in the model and were not significant were, sex, residence, living arrangement, household expenditure, tobacco use, abdominal obesity, fruits and vegetable intake and pension status.
Among the hypertensive (n = 217) patients analysed, it was noted that those having diabetes (AOR = 2.72, 95% CI = 1.34–5.55), education level of primary schooling to high school (AOR = 2.58, 95% CI = 1.11–6.00), and belonging to age group 60–70 years (AOR = 2.14, 95% CI = 1.09–4.20) were significantly associated with hypertension control (see Table 4).
Table 4.
Factors associated with controlled hypertension: results of binary logistic regression analysis (n = 217).
| Independent Variables | Prevalence (%) | Hypertension AOR (95% CI) |
|---|---|---|
| Age group | ||
| More than 70 years (ref) | 17.9 | |
| 60–70 years | 29.7 | 2.14 (1.09–4.20)∗ |
| Education status | ||
| Less than primary schooling (ref) | 15.4 | |
| Primary schooling to high school | 29.8 | 2.58 (1.11–6.00)∗ |
| College education and above | 21.1 | 1.50 (0.48–4.68) |
| Self-reported Diabetes | ||
| No (ref) | 18.1 | |
| Yes | 30.7 | 2.72 (1.34–5.55)∗∗ |
AOR = Adjusted Odds Ratio; CI= Confidence Interval; ref = Reference. Other variables that were included in the model and were not significant were sex, residence and abdominal obesity.
3.2. Qualitative results
The analysis of interviews resulted in six themes which reflected on aspects pertaining to diagnosis, monitoring and management of hypertension among older adults. Fig. 2 in the supplementary file, outlines emergent themes and their inter-relationships.
3.2.1. Theme 1: awareness and availability
Knowledge of hypertension, and awareness about necessity of periodic health check-ups improved uptake of screening, diagnosis and management of hypertension among older adults.
“The doctor hasn’t advised me to check regularly. But I have decided myself to go and check periodically. I have read that all those who are 60 years and above should go and get checked. That is why I go regularly” (KSD076)
3.2.2. Theme 2: delayed diagnosis and infrequent monitoring
A common phenomenon observed among the respondents was delayed diagnosis of hypertension usually after they experienced symptoms such as fainting, headache, etc.
“I had a severe headache and went to the hospital. Then they checked everything and found that I have raised BP and blood sugar levels” (ERM021)
3.2.3. Theme 3: financial wellbeing
Financial wellbeing influenced the usage of health facilities and purchase of medicines. Interviews reflected that financial independence directly impacts healthcare decision making. An older female said
“Sometimes I face financial issues to access the healthcare services. So, I go to hospital when I get money” (KSD078)
3.2.4. Theme 4: family as a support structure
Family members played a key role with respect to accessing NCD services, monitoring of BP and facilitating and financing hospital visits of the older persons. A male respondent reported
“My wife checks my BP when I feel any discomfort. And she checks my blood sugar levels once a week.” (ERM026)
3.2.5. Theme 5: physical inactivity and beliefs
Habituation of risk factors such as physical inactivity, tobacco and alcohol consumption was a recurring theme. Respondents who were physically inactive despite receiving a doctor's advice reported that they never had a habit of exercising. One participant reported
“I have never done any exercises, and I am not interested in doing them. I don't have any health issues or difficulties in doing exercises. I have enough work in my home.” (ERM001)
3.2.6. Theme 6: conducive environment
Conducive environment (such as access to professional medical advice, diet and opportunities for exercise) was key for management of hypertension and associated risk factors. One participant reported
There is no place where I can do exercise. I wish for some facility in the neighbourhood. “But what to do?” There is none here. So, I can’t go (KSD078)
4. Discussion
In our study among 300 older adults, we found that 72% had hypertension, 68% were aware, 65% were treated and 24% achieved adequate control. Among treated hypertensives 37% achieved adequate control. Prevalence of hypertension in our study has increased from 52% in late 1990s10 and 53% in the year 200011 to 72% over a period of over 20 years. Our hypertension prevalence of 72% was similar to the prevalence of 73.8% among German older adults indicating that, hypertension burden among older adults in Kerala is close to the western world.23 Hypertension awareness and treatment rates in our study were higher than that of a nationally representative study among older adults in India that reported an awareness rate of 56–59% and a treatment rate of 43–48% in the age group of 60–75 plus years.24 Although the control rate of hypertension also improved from 11% in late 1990s10 to 24%, the improvement did not commensurate with the increase in hypertension prevalence. Our 24% control rate was similar to another study from Kerala that reported a control rate of 23.5% among adults aged 40–70 years.25 Hypertension control in our study was higher than the 12.6% control rate reported from a nationally representative sample of adults aged 18–69 years.26 One of the reasons for better control among older adults could be due to better compliance as reported in an earlier study from India.27 Hypertension was detected for the first time during our survey in 32% of the participants compared to the national average of 43%.5 This indicates the need for enhancing the population-based screening and detection of hypertension.
Inadequate physical activity was a predictor for hypertension in our study. Adequate physical activity is known to have protective effects against hypertension among older adults.28 Despite these benefits, 88% of our participants reported inadequate physical activity. Our qualitative findings were also in agreement with a 2015 systematic review report that reluctance to start a new habit (i.e., exercise), health status, fear of injuries, and environmental barriers impede physical activity among older adults.29 Our finding of higher hypertension prevalence among those who reported diabetes corroborate with the findings of other studies that hypertension and diabetes are among the common co-morbid NCDs.30,31 Higher prevalence of hypertension among alcohol users in our study is in line with a previous study from India.32
Older adults aged 60–70 years were two times more likely to achieve adequate control of hypertension compared to those aged 70 years and above. This could be due to financial problems and lack of family support as we found in our qualitative interviews. Those who had education up to high school were two and a half times more likely to have hypertension control compared to those who had less than primary school education, indicating the role of education in hypertension control as reported earlier.33 Interestingly, while individuals with diabetes have a higher odds of hypertension, the hypertensive individuals with diabetes have higher odds towards hypertension control. This paradoxical association requires further exploration. Some evidence points that treatment for hypertension was reported to be higher among hypertensive older adults with diabetes.6
Availability & accessibility of services, financial wellbeing, and awareness about hypertension were found to influence diagnosis, monitoring and treatment of hypertension among the elderly in our study, a finding in our qualitative study consistent with earlier published literature.33
4.1. Limitations
The study is cross-sectional and cannot account for the temporality of associations reported. The study is also limited by its coverage of only two districts in Kerala and a moderate sample size. However, these two districts were selected randomly and fairly represents the entire state.
4.2. What is already known
Hypertension prevalence among older adults is higher than younger adults. Awareness, treatment and control of hypertension among older adults are poor in India. Data on factors associated with hypertension control are limited in India.
4.3. What this study adds
Older adults who are better educated and those who are in the age group of 60–70 years are more likely to achieve adequate control of hypertension compared to those who are poorly educated and those who are aged 70 years and above.
Declaration of competing interest
None.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ihj.2023.03.004.
Appendix A. Supplementary data
The following is the Supplementary data to this article.
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