Assessment of Prevalence of Hypertension and its Risk Factors among Adult Tribal Population Residing in Lohandiguda Block of Bastar District of Chhattisgarh

Abstract

Background:

Hypertension is known as the silent killer. It comprehends the top rank in non-infectious disease amongst adults; accountable for the deaths every year across the world. It is essential to consider the individual impact of risk factors and their impact on hypertension. This study thus elicited the socio-demographic characteristics, the prevalence of hypertension and associated risk factors, and its impact on adults with hypertension. To estimate the hypertension prevalence and its associated risk factors among adult tribal populations aged 25–60 years residing in Lohandiguda block of Bastar district of Chhattisgarh.

Material and Methods:

A community-based cross-sectional analytical study was used and the setting was done at the field practice area under the three primary health centers of Lohandiguda block, Bastar district of Chhattisgarh. It was carried out among 330 adult tribes residing for ≥1 year in the present locality. Data was collected by door-to-door visits through pre-designed, pretested, semi-structured questionnaire via face-to-face interview method and anthropometric measurement was done by using standard guidelines. The sampling method was multistage sampling. IBM SPSS STATISTICS-20.0 (IBM Corp., Armonk, NY, USA) software.

Results:

The overall prevalence of pre-hypertension and hypertension among tribal subjects was 34.9% and 47.3%, respectively. Of total hypertensive 27.3% were having stage-1 hypertension, 13.9% were having stage-2 hypertension and 6.0% were already diagnosed cases. Risk factors found in multivariate analysis are occupation (unemployed 0.012), frequency of smokeless tobacco used per day (0.,017) and central obesity (0.000).

Conclusions:

As hypertension is a multi-factorial disease the study found strong predictors like occupation, frequency of smokeless tobacco per day and having central obesity with significant difference.

INTRODUCTION

Hypertension is the major public health concern worldwide.[1] It was estimated that in the year 2000, nearly 972 million beings were having hypertension worldwide and among the adults, this prevalence was found to be 26.4% (men: 26.6%, women: 26.1%). It is predicted that, by 2025, this prevalence will be accelerated by 29.2% (men: 29.0%, women: 29.5%).[2]

Chhattisgarh is a young growing state that became separated from Madhya Pradesh on 1^st November 2000 and the major reason was considered an “Adivasi state”.[3] According to 2011 census, Bastar is the biggest tribal district of Chhattisgarh in Central India and is famous for its colorful tribes. The Bastar tribes constitute 70% of the total population; which constitutes 26.7% of the total tribal population of Chhattisgarh.[4] According to NFHS-5,[5] it includes the prevalence of hypertension of urban and rural populations but not providing magnitude data regarding tribal separately. Most studies in India have been done on the hypertension prevalence and related risk factors in the urban–rural population but very limited studies conducted on tribes in India.

Neither a single study nor authentic data source (NFHS 4 and 5) has been provided actual statistics on hypertension prevalence and related risk factors among tribes in the Bastar district. Thus the study provides information about tribal’s lifestyle patterns as well as the prevalence and related risk factors of hypertension in the Southern part of Chhattisgarh, Bastar region. This study has been conducted on focusing the primary objective to find the prevalence of hypertension and its associated risk factors in the adult tribal populations aged 25–60 years residing in Lohandiguda block of Bastar district of Chhattisgarh and the secondary objective is to find out the socio-demographic profile of the study subjects and make suitable study based recommendations for them.

SUBJECTS AND METHODS

The current community-based cross-sectional analytical study has been systematized in Lohandiguda block of Bastar district of Chhattisgarh. Data collection has been done in November 2018–February 2019. The study subjects were 25–60 years adult tribal populations; residing for ≥1 year in the present locality; as it is considered that the chances of migration is less after residing for such period. The adult tribal population participated in the study after giving informed verbal consent.

Non-tribal, adult tribes aged <25 and >60 years, visitors residing for <1 year, pregnant and lactating women, co-morbidity, severe illness, complication related to hypertension, deaf, mute, blind, and mentally unsound person were excluded from the study.

The sample size was estimated by applying the formula for determining the sample size n = Sample size

Z (1- α/2) = Standard normal deviate for α = 95% value is 1.96

p = Prevalence of hypertension

d = Allowable error d = 5%[6]

Sample size was determined by taking 26% as per prevalence of hypertension as per Central India ICMR study.[7]

n = 295

By using PPS Sampling method, the calculated sample size for the approximate population was 330. Sampling method was multistage sampling. Community Health Centre (CHC) Lohandiguda is having a heavily dense tribal population of 80,397 with five Primary Health Centres (PHCs). All PHCs were arranged in ascending order according to the distance from the CHC and numbered 1–5. After calculating the sampling interval, three PHCs were selected [Figure 1]. The WHO Epi Random Walk method was used to select households from each village.[8] So the primary and secondary sampling unit is community health center and primary health center, respectively and the sampling unit is households. A pre-designed, pre-tested, semi-structured questionnaire was used.

Figure 1.

Multistage sampling method

Blood pressure was recorded by using Automatic Blood Pressure Monitor Omron HEM-7111 by following ACC/AHA 2017 Guidelines. For anthropometric measurement standard guideline was followed and instruments were calibrated daily and had an accuracy of 0.1 kg for Virgo bathroom weighing machine and 0.1 cm for non-elastic, non-stretchable measuring tape. For calculating body mass index and waist hip Ratio; Asian classification and WHO STEPS surveillance manual were used respectively. Direct face-to-face interview technique was used.

Methodology- Study topic was approved by the Community Medicine department, Institutional Scientific and Ethics Committee of Pandit Jawaharlal Nehru Memorial Medical College Raipur Chhattisgarh (letter No./MC/Ethics/2019/44 Raipur, Dated 02/04/2019) before starting the study. Written permission has been taken from State Nodal Officer Non Communicable Disease (NCD) Control Programme Chhattisgarh. Written information has been sent to the Chief Medical and Health Officer (CMHO) and Block Medical Officer (BMO) Lohandiguda, district- Bastar Chhattisgarh. Age-sex wise details of village population have been possessed by the BMO Lohandiguda. Before starting the data collection one-day sensitization training of medical health personnel and field workers of Lohandiguda block has been done by the principal researcher. Before starting interview, the intent and process of study were elucidated and informed verbal consent was taken from the subjects. The subjects those who were screened out during this study and were already diagnosed have been sent to the CHC- Lohandiguda for further diagnosis and treatment. Those who were found to indulge in faulty lifestyle practices (high salt intake, tobacco and alcohol intake, low fruit and vegetable intake, etc.) have been given health education and promoted them to go to district rehabilitation center for quieting with the help of health personnel used to sensitize in training.

Statistical analysis

To maintain the quality, collected data was compiled and entered in Microsoft Excel sheet 2010 on the same day. Entered data were coded and has been checked for its completeness and correctness before analysis. Data were finally tabulated and analyzed useing IBM SPSS STATISTICS-20.0 (IBM Corp., Armonk, NY, USA) software. Descriptive statistics such as mean, frequencies, and percentages were used to evaluate the statistics.

According to the Joint National Committee-8 (JNC-8),[9] normal blood pressure is systolic BP < 120 and diastolic BP < 80 mm Hg, pre-hypertension is systolic BP between 120 and 139 mm Hg and diastolic BP between 80 and 89 mm Hg, hypertension stage-I is systolic BP between 140–159 mm Hg and diastolic BP between 90–99 mm Hg and hypertension stage-II is systolic BP ≥ 160 mm Hg and diastolic BP ≥ 100 mm Hg.

Normotensive (normal and pre-hypertension) and Hypertension (Stage I and II) were cross-tabled with independent variables. The association was found by using Pearson Chi-square (χ²) test. A binary variable was computed 0 for hypertension and 1 for normal/pre-hypertension.

The univariate and multivariate logistic regressions were calculated by considering unadjusted (UOR) and adjusted odd ratios (AOR) to determine the important risk factors associated with hypertension. The Confidence Interval was 95% and acceptable significance value was two-tailed P < 0.05. For the purpose of calculation form of smokeless tobacco has been categorized in the one form and > one form. Also, the frequency of smokeless tobacco used per day has been categorized into <3 and ≥3 categories. Waist circumference category I (F < 80.0 and M < 90.0) is considered as low-risk category and category II (F = 80.0–89.0 and M = 90.0-99.0), and category III (F > 90.0 and M > 100.0) is considered as high-risk category.

Limitations of the study

It included only one block with limited resources, sample size, and constant time to one geographic area; some areas were hard to reach and affected by left-wing extremism. The present cross-sectional study restricts to examining causal associations; absence of statistics on stress which is a significant risk factor in hypertension is lacking and could be an important limitation.

Strength of the study

The study is exploring about more prevalence of hypertension among the tribes of the southern part of Chhattisgarh state. Thus it is gives an indication to the policymaker to modify their policy according to the identified risk factors and predictors of this study.

RESULTS

A total of 1854 study population (tribal and non-tribal) were visited; of them, 1460 were tribal subjects; of them, 340 were eligible tribes; of them, 330 gave their consent for the participation with the response rate of 97.0%; the reason for non-response rate was not willing to participate in the study.

The present study shows that the mean age of study subjects was 41.6 years ± 10.2 SD. Table 1 is depicting about the socio-demographic profile of study participants. Figure 2a-c is describing the tobacco and alcohol consumption status.

Table 1.

Distribution of the study subjects according to their Socio demography characteristics

Variables	Frequency	Percent
Age group (years) (n=330)
25–30	55	16.6
31–40	112	34.0
41–50	77	23.4
51–60	86	26.0
Total	330	100.0
Sex (n=330)
Male	152	46.1
Female	178	53.9
Total	330	100.0
Marital Status (n=330)
Unmarried	22	6.7
Living in/Cohabiting	61	18.5
Married	229	69.4
Separated	02	0.6
Widow (er)	16	4.8
Total	330	100.0
Type of Marriage (n=247)
Consanguineous	63	25.5
Non Consanguineous	184	74.5
Total	247	100.0
Education status[Highest level of education] (n=330)
Illiterate	176	53.3
Literate	14	4.2
Primary School	54	16.4
Middle School	31	9.4
High School	21	6.4
Intermediate/Post High School Diploma	25	7.6
Graduate/Post Graduate	09	2.7
Total	330	100.0
Occupation (n=330)
Unemployed	21	6.3
Unskilled worker	31	9.4
Semi-skilled worker	05	1.5
Skilled workers	29	8.8
Clerical/Shop owner/Farmer/Self-employed/Small businessmen	234	71.0
Professional/semi-Professional	10	3.0
Total	330	100.0
Socio-economic Status (According to Modified B.G. Prasad Classification) (n=330)
Upper	37	11.2
Upper Middle	31	9.4
Middle	87	26.3
Lower Middle	93	28.1
Lower	82	24.8
Total	330	100.0

Figure 2.

Tobacco and alcohol consumption status of the study subjects (a) Tobacco and alcohol(each) consumption status (n=330), (b) Tobacco consumers according to the type of tobacco used (n=259), (c) Alcohol drinkers according to the type of aclcohal used (n=259)

The overall prevalence of pre-hypertension and hypertension among study subjects was 34.9% (29.7% to 40.0% at 95% C.I.) and 47.3% (41.9% to 52.7% at 95% C.I.) respectively. Of total hypertensive 27.3% had stage-1, 13.9% had stage-2 hypertension and 6.0% were already diagnosed cases.

Table 2 depicts the increasing trend of hypertension with age. The percentage of hypertension was 57% in the age group 51-60 years, 50.6% in 41-50 years, 45.5% in 31-40 years and 30.9% in 25-30 years. The table describes advanced age is significantly (P = 0.021) associated with an upsurge in hypertension prevalence. The 49.0% of study subjects those who were eating extra salt-containing foods, 69.2% those who belonged to waist circumference category-3, 55.9% of subjects who were having central obesity and 52.0% of the smokeless tobacco users who were using any one form were showing hypertension and the association between hypertension and the above risk factors are statistically significant, i.e., (P = 0.046, 0.007, 0.000, and 0.046) respectively.

Table 2.

Distribution of the study subjects according to study variables with their status of hypertension

Age Group (n=330)	Hypertensive	Normotensive	Total
25-30	17 (30.9%)	38 (69.1%)	55
31-40	51 (45.5%)	61 (54.5%)	112
41-50	39 (50.6%)	38 (49.4%)	77
51-60	49 (57.0%)	37 (43.0%)	86
Total	156	174	330
χ2=9.64, df=3, P=0.021
Extra salt contains food (n=330)
Yes	147 (49.0%)	153 (51.0%)	300
No	09 (30.0%)	21 (70.0%)	30
Total	156	174	330
χ2=3.95, df=1, P=0.046
Waist circumference (n=330)
Category 1 (F<80.0 & M<90.0)	108 (42.7%)	145 (57.3%)	253
Category2 (F=80.0-89.0 & M=90.0-99.0)	30 (58.8%)	21 (41.2%)	51
Category 3 (F>90.0 & M>100.0)	18 (69.2%)	08 (30.8%)	26
Total	156	174	330
χ2=9.89, df=2, P=0.007
Central obesity (n=330)
Present (WHR M>0.90 & F>0.85)	124 (55.9%)	98 (44.1%)	222
Absent (WHR M<0.90 & F<0.85)	32 (29.6%)	76 (70.4%)	108
Total	156	174	330
χ2=19.01, df=1, P=0.000
Form of smokeless tobacco (n=257)
Any one form	92 (52.0%)	85 (48.0%)	177
>1 form	30 (37.5%)	50 (62.5%)	80
Total	122	135	257
χ2=3.95, df=1, P=0.046

Table 3 shows the significant risk factors with UOR were age (31–40 years, P = 0.003), living-in (P = 0.038), unemployed (P = 0.013), unskilled (P = 0.049), and skilled workers (P = 0.048), smokeless tobacco users with >1 form (P = 0.032) and ≥3 frequencies/day (P = 0.018), having central obesity (P = 0.000) and more risk category of waist circumference (P = 0.003). Although after adjustment significant risk factors were unemployed (P = 0.021), skilled workers (P = 0.039), clerical/shop owners/farmer/self-employed/small businessman (P = 0.035), smokeless tobacco users with ≥3 frequencies/day (P = 0.017), and having central obesity (P = 0.000).

Table 3.

Univariate and Multivariate analysis by Binary Logistic Regression, showing strength of association between dependent variable (hypertension) and independent variables

Variables	Total n	Hypertensive n (%)	Unadjusted Odds Ratio 95% C.I. (Lower-Upper)	P	Adjusted Odds Ratio 95% C.I. (Lower-Upper)	P
Age in completed years (n=330)
25–30	55	17 (30.9%)	Reference	-	Reference	-
31–40	112	51 (45.5%)	2.9 (1.4–6.0)	0.003	2.2 (0.9–5.4)	0.067
41–50	77	39 (50.6%)	1.5 (0.8–2.7)	0.111	1.6 (0.8–3.2)	0.140
51–60	86	49 (57.0%)	1.2 (0.6–2.3)	0.419	1.2 (0.6–2.6)	0.504
Marital status (n=330)
Unmarried	22	5 (22.7%)	Reference	-	Reference	-
Living in/Cohabiting	61	27 (44.3%)	4.2 (1.0–16.6)	0.038	3.3 (0.6–17.1)	0.145
Married	229	114 (49.8%	1.5 (0.5–4.5)	0.401	1.8 (0.5–6.4)	0.364
Separated/Widowed/Widower	02	10 (55.6%)	1.2 (0.4–3.3)	0.638	1.2 (0.4–4.0)	0.672
Occupation (n=330)
Unemployed	21	6 (28.6%)	10.0 (1.6–61.4)	0.013	14.9 (1.5–148.9)	0.021
Unskilled Worker	31	13 (41.9%)	5.5 (1.0–30.4)	0.049	7.6 (0.6–86.9)	0.100
Semi-skilled Worker	05	2 (40.0%)	6.0 (0.5–63.9)	0.138	16.2 (0.9–271.4)	0.052
Skilled workers	29	12 (41.4%)	5.6 (1.0–31.5)	0.048	10.5 (1.1–98.9)	0.039
Clerical/Shop owner/Farmer/Self-employed/Small Businessmen	234	115 (49.1%)	4.1 (0.8–19.9)	0.076	8.8 (1.1–67.8)	0.035
Professional/semi-professional	10	8 (80.0%)	Reference	-	Reference	-
Form of smokeless Tobacco used (n=257)
> one form	80	30 (37.5%)	0.5 (0.3-0.9)	0.032	0.5 (0.2–1.0)	0.058
Any one form	177	92 (52.0%)	Reference	-	Reference	-
Frequency of smokeless tobacco used per day (n=257)
≥3	140	57 (40.7%)	0.5 (0.3–0.9)	0.018	0.4 (0.2–0.8)	0.017
<3	117	65 (55.6%)	Reference	-	Reference	-
Central Obesity (n=330)
Present	222	124 (55.9%)	3.0 (1.8–4.9)	0.000	3.0 (1.6–5.4)	0.000
Absent	108	32 (29.6%)	Reference	-	Reference	-
Waist Circumference (n=330)
Less Risk	253	108 (42.7%)	Reference	-	Reference	-
More Risk	77	48 (62.3%)	2.2 (1.3–3.7)	0.003	1.8 (0.8–4.1)	0.122

DISCUSSION

The existing study illustrates that the overall prevalence of pre-hypertension and hypertension amongst the study participants was about two fifth (34.9%) and approximately half (47.3%) respectively. Out of total hypertensive more than half (27.3%) had stage-1 hypertension, one-third (13.9%) had stage-2 hypertension, and one-eighth (6.0%) were already diagnosed cases. Similar study conducted by Manimunda SP et al.[10] among the Nicobarese tribes of Car Nicobar Island, Kandpal V et al.[11] among the Rang Bhotia tribes of Uttarakhand and Sanjeev P et al.[12] among the Kani tribes of Thiruanantpuram which shows the total prevalence of hypertension was 50.5%, 43.3% and 48.3% respectively. The findings are similar to our study findings.

A study by Radhakrishnan S. et al.[13] among tribal populations of Tamilnadu, Laxmaiah A et al.[14] among all tribes of nine states of India and Gupta V. K et al.[15] among all tribes of Mandala (M.P.) which shows the total prevalence of hypertension was 31.1%, 26.4%, and 27.1% respectively. Contrast findings in comparison with our study.

The current study is illustrating that UOR and AOR are statistically significant with the risk factors of unemployed, smokeless tobacco users for ≥3 frequencies/day and among those who were having central obesity. A study was done by Tripathy J.P. et al.[16] in the Northern part of India which shows analogous findings with the statistically significant risk factors central obesity and contrary findings with older age, male, social groups, marital status, salt intake >5 g/day.

In comparison with the socio-demographic variable, in the present study maximum (34%) study participants belonged to the middle-aged (31–40 years) tribe groups, more than half (53.9%) study subjects were female and illiterate (53.6%), approximately one-fifth (16.4%) had completed their primary school education, almost three-fourth (71%) of the study subjects belonged to occupation category clerical/shop owner/farmer/self-employed/small businessman and 9.4% were unskilled workers. Similar study by Chakma et al.[7] has been done among tribes of Mandla District, Central India, which shows the similar findings with age and education status but literate were lower than our study findings. And contrary finding with occupation and sex where non-skilled laborers and male subjects were more than in our study.

In the present study more than half (69.4%) of subjects were married, one-fifth (18.5%) were living in/cohabiting, among married approximately three-fourth (74.5%) subjects were having non-consanguineous marriage. Similar study conducted by Hathur B. et al.[17] among Kuruba tribes of Mysore, which shows similar findings with marital status but contrary findings with type of marriage where more than half were having a consanguineous marriage.

The present study shows that more than one-fourth of each belonged to lower middle (28.1%), middle (26.3%) and lower (24.8%) socio-economic status. Similar study was conducted by Gupta V.K. et al.[15] among the tribal population of Mandla District, which shows that only one-fifth study subjects belonged to upper middle and upper classes which is very lesser than our study.

In our study, more than three fourth (78.5%) of study subjects were used to consume tobacco and alcohol each. Of them, more than three-fourth (88.5%) were using smokeless form, among smokers about two fifth (40%) were consuming > one form, among smokeless tobacco users more than one-third (29.1%) were consuming tobacco lime and the rest were using other forms. Among alcohol users, more than three fourth (81.4%) were current drinkers, more than half (60.3%) each used to consume for >10 years and with frequency of >4 times per month and more than three fourth (79.1%) were consuming ≥180 ml alcohol per day.

As per the Report of High Level Committee by Ministry of Tribal Affairs, Government of India,[18] the prevalence of tobacco and alcohol use among the tribal population was 72% and 67%, respectively, found to be higher in State Chhattisgarh. The current study findings are higher than these findings. One of the reasons might be alcohol consumption is a part of social rituals in many tribal communities.

The contemporary study shows that increasing trend of hypertension with advanced age. The prevalence of hypertension was 57.0% among 51–60 years age group, 49.0% among those who were eating extra salt-containing foods, 52.0% among smokeless users of any one form, 69.2% and 58.8% among those who belongs to the category-3 and 2 of waist circumference respectively and 55.9% with the subjects were having central obesity with statistically significant association (P = 0.021, 0.046, >0.031, 0.007, and 0.000 respectively). One of reasons might be changes in their food habits and sedentary lifestyle.

A similar study showed by Prabhakaran D. et al.[19] in urban population of Delhi and Kokiwar P.R et al.[20] in rural population of central India which shows that the pattern of prevalence of hypertension with age was similar to our study findings. Brahmankar T.R. et al.[21] conducted a study showing almost similar findings of the prevalence of hypertension approximately (50%) with extra salt-containing food users among the urban population of Western Maharashtra.

Singh S. et al.,[22] Bhadoria et al.[23] and Ismail IM et al.[24] conducted a study shows less prevalence of hypertension (32.1%) among the urban tobacco users of Varanasi, lower prevalence of hypertension (14.9%) among the urban subjects of category-3 waist circumference of Jabalpur and more prevalence of hypertension (76.1%) among the urban subjects with central obesity of Sullia (T.N.) with statistical significance respectively.

Thus concluding that age, living in/cohabitant, unemployed, smokeless tobacco users, extra salt-containing foods, waist circumference, and having central obesity were showing their individual impact with a higher risk of hypertension with significant difference. As hypertension is a multi-factorial disease the study found strong predictors like occupation, smokeless tobacco frequency, and present central obesity were showing their multivariate effect with significance on hypertension. Thus study indicating about the alarmingly raised prevalence of hypertension among the ancestral of the southern part of Chhattisgarh, taking for an instant attention.

The author recommends that the State government should implicate adequately visible and explicable “pictorial health warning on the salt packets and extra salt containing food packets” and “pictorial display of adequate amount of salt intake” especially focused on consumer level in comprehensible language at least in tribal belt of Chhattisgarh. Also, there should be more health promotion towards the wellness activity in the affected part.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.