Assessment of risk factors and perceptions of noncommunicable diseases among adults in a rural area of West Bengal: A mixed method study

ABSTRACT

Introduction:

The burden of noncommunicable diseases (NCDs) like cardiovascular diseases, diabetes, hypertension, stroke, and cancers has been increasing in India. This rise of NCDs is mainly due to an increase in prevalence of various risk factors like tobacco use, alcohol intake, overweight, and physical inactivity.

Objective:

1) To estimate the proportion of different NCDs among study subjects, 2) to identify association of NCDs with various risk factors if any, and 3) to assess perceptions regarding risk factors and curative aspects of NCDs.

Materials and Methods:

A mixed method study (quantitative ◊ qualitative) was done in Hariharpara Rural Hospital from September 26, 2023 to November 6, 2023, and quantitative data were collected using predesigned pretested semistructured schedules framed on the basis of WHO STEPS framework from 224 patients who were satisfying inclusion criteria by complete enumeration in NCD clinics. Data were analyzed with SPSS version 23.0, and binary logistic regression was done to identify association of NCDs with various risk factors. Qualitative exploration was conducted by focused group discussion to know their perceptions regarding risk factors and curative aspects of NCDs.

Results:

In this study, 60.26% were hypertensive, 30.35% were diabetic, and 16.51% had other noncommunicable diseases. The binary logistic regression model was done and found geriatric age group study subjects had 4.26 times more chances than their below counterparts and alcoholics had 3.21 times more chances than nonalcoholics of having hypertension, which were statistically significant. In the case of diabetes, geriatric study subjects had 3.19 times more chances of having diabetes than their below counterparts, which was statistically significant. Qualitative analysis revealed there was more inclination toward curative than preventive aspects of NCDs.

Conclusion:

The rise of NCDs was more among the geriatric age group and study subjects who were alcoholic. The perceptions of study subjects were inclined more toward curative than preventive aspects of NCDs.

Introduction

Noncommunicable diseases (NCDs) are chronic diseases of long duration, generally with slow progression, and are the result of a combination of genetic, physiological, environmental, and behavioral factors. The burden of four main types of NCDs including cardiovascular diseases, diabetes, chronic respiratory disease, and cancer has been rising in developing countries such as India.[1] NCDs such as cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases kill 41 million people each year, equivalent to 74% of global deaths.[2] Of all NCD deaths, 77% occurred in low- and middle-income countries. The burden of NCD in India is nearly 55% of the disability-adjusted life years and approximately 60% of all deaths.[2] The main behavioral risk factors such as tobacco use, lack of physical activity, unhealthy diet, and excess of alcohol consumption facilitate the development of NCDs. They contribute to increased blood pressure (hypertension), increased blood sugar (diabetes), abnormal blood lipids (dyslipidemia), and obesity. NCDs threaten progress toward the 2030 Agenda for sustainable development, which aims to reduce the deaths mainly due to four NCDs between the ages of 30 and 70 years by one-third by 2030. It is estimated that by 2030, there will be 101 million diabetics and 218 million hypertensive individuals in India.[3] To prevent morbidity and mortality due to NCDs, the key focus must be on the reduction of major risk factors. The WHO has recommended surveillance of the risk factors with the ‘STEPS’ approach for collecting data and monitoring the trend of NCDs.[2] The National Programme for Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke launched in India in 2010[4] has been renamed the National Programme for Prevention of Non-communicable Diseases with the aim of preventing and controlling NCDs by means of behavioral changes, opportunistic screening of NCDs, and provision of NCD services through public health facilities. This study was conducted to observe the influence of various risk factors on the development of chronic NCDs. In this regard, the mixed method study provides an opportunity to understand the perception of patients regarding the risk factors and curative aspects of NCDs.

Objective

1. To estimate the proportion of different NCDs among study subjects.

2. To identify association of NCDs with various risk factors if any.

3. To assess perceptions regarding risk factors and curative aspects of NCDs.

Materials and Methods

A mixed method study (quantitative → qualitative) was performed at the NCD clinic in Hariharpara Rural Hospital in the Murshidabad district of West Bengal from September 26, 2023 to November 6, 2023. For quantitative data, 224 patients were selected; those who satisfied the inclusion criteria by the complete enumeration method from the NCD clinic were selected, and a sample size of 224 was calculated using prevalence rates of smoking 17% in an NCD study[5] at Delhi with a precision of 5% and a 95% confidence interval. Inclusion criteria were willingness to participate in the study, and the exclusion criteria were pregnant women and critically ill patients. Patients were interviewed using a predesigned pretested semistructured schedule framed on the basis of the WHO STEPS framework, while other study tools used for data collection were patients’ health records and the NCD clinic register. Qualitative exploration was conducted by two focused group discussions, each with eight study participants to understand their perceptions regarding risk factors and curative aspects of NCDs. Data collection was done until the saturation was reached. With the prior consent of the study participants for data collection, audio recordings were performed. Quantitative data were collected, compiled in MS Excel’10, and analyzed using SPSS version 23.0. Statistical tests such as binary logistic regression were performed to identify the association between NCDs and various risk factors. Qualitative data were transcribed verbatim in Microsoft Word (2016), and appropriate codes were generated. Thematic analysis was performed manually to derive appropriate themes. Ethical clearance was obtained from the Ethics Committee of Calcutta National Medical College.

Results

In this study, most of the study participants were <60 years old, female, and Muslims; had education up to the primary level; and belonged to a lower socioeconomic class (according Modified B. G. Prasad Scale 2021). The sociodemographic distribution of study participants is shown in Table 1.

Table 1.

Distribution of study subjects according to sociodemographic characteristics (n=224)

Sociodemographic characteristics	Number (%)
Age
35-40	10 (4.46%)
41-45	28 (12.50%)
46-50	55 (24.55%)
51-59	43 (19.19%)
≥60	87 (38.83%)
Gender
Male	102 (45.54%)
Female	122 (54.46%)
Religion
Hindus	56 (25%)
Muslims	168 (75%)
Education
Illiterate	36 (16.10%)
Primary	94 (42%)
Middle-school	45 (20.08%)
Secondary	23 (10.26%)
Higher Secondary	18 (8.03%)
Graduate and above	5 (2.23%)
Occupation
Skilled Agricultural Workers	68 (30.35%)
Service worker & Sales workers	10 (4.46%)
Technicians	6 (2.67%)
Craft and relate workers	12 (5.35%)
Machine operators	5 (2.26%)
Elementary occupations	123 (54.91%)
Socio-economic status according Modified B.G. Prasad Scale 2021
Upper	8 (3.57%)
Upper middle	12 (5.35%)
Middle	25 (11.17%)
Lower middle	67 (29.91%)
Lower	112 (50%)

Table 2 shows that the study participants were mostly nontobacco users (53.13%), were nonalcoholic (90.63%), had a normal BMI (74.55%), and did not have adequate physical activity (61.16%).

Table 2.

Distribution of various risk factors among study subjects*

Risk factors		Frequency	Percentage
Tobacco	Tobacco user	105	46.87%
	Tobacco nonuser	119	53.13%
Alcohol intake	Alcoholic	21	9.37%
	Nonalcoholic	203	90.63%
BMI	Normal	167	74.55%
	Excess weight	52	23.22%
	underweight	5	2.23%
Physical activity	Adequate	87	38.83%
	Inadequate	137	61.16%

(*Multi response table) Inference: Maximum study subjects were tobacco nonusers and nonalcoholics, had normal BMI, and never did adequate physical activity

Table 3 shows, most of the study participants were suffered from hypertension (60.26%) followed by diabetes (30.35%) and other NCDs like COPD, thyroid disorder, CHD, and stroke (16.51%), Binary logistic regression was conducted to find associations between different risk factors for hypertension and diabetes, which were the most common NCDs in this study [Tables 4 and 5, respectively].

Table 3.

Distribution of study subjects according to the type of NCDs

Noncommunicable diseases	Numbers	Percentage
Hypertension	135	60.26%
Diabetes	68	30.35%
Other NCDs like cardiovascular diseases, stroke, and other chronic neurological diseases, COPD, cancer, and thyroid disorder	37	16.51%

(*Multiple response table). Inference: Most of the study participants were suffered from hypertension (60.26%) followed by diabetes (30.35%) and other NCDs like COPD, thyroid disorder, CHD, and stroke (16.51%), it has been shown in Table 3

Table 4.

Binomial logistic regression analysis for association of different risk factors with hypertension

Variables	Sig. (P)	AOR	95% C.I. (for Exp B)
			Lower	Upper
Age (≥60 years)	0.003		3.194*	1.49	6.83
Education (Below secondary)	0.855	0.939	0.477	1.84
Alcohol (Alcoholic)	0.105	2.58	0.819	8.14
Tobacco (Tobacco user)	0.077	1.97	0.929	4.19

Inference: Geriatric age group study subjects had more chances of hypertension than their younger counterparts did

Table 5.

Binomial logistic regression analysis for association of different risk factors with diabetes

Variables	Sig. (P)	AOR	95% C.I. (for Exp B)
			Lower	Upper
Age (≥60 years)	0.000	4.26*	2.37	7.65
SES (lower)	0.235	1.44	0.786	2.67
Physical Activity (inadequate)	0.391	0.769	0.422	1.40
Alcohol (Alcoholic)	0.028	3.20*	1.13	9.05

Inference: Geriatric age group study subjects and alcoholic study subjects had a higher risk of diabetes than those aged ≤60 years and nonalcoholic study subjects

Two FGDs were carried out among the study participants to determine their perceptions regarding the risk factors and control of NCD. Each FGD had 8 participants. In FGD-1, 4 patients had hypertension, 2 had both hypertension and diabetes, and 2 had only diabetes. In FGD-2, 5 had hypertension and 3 had hypertension and diabetes. Qualitative analysis revealed that the perception of modifiable risk factors for the development of NCD was inadequate. However, they had some knowledge regarding the control and follow-up of the disease. The perceptions of the participants are presented in Table 6.

Table 6.

Perception of study participants after conducting FGDs regarding the risk factors and curative aspects of NCDs

Themes	Codes	Verbatims
Overweight with NCD	No association between obesity and NCD	“.... never heard overweight causes hypertension, diabetes, heart diseases”
Association of physical activity with NCD	Not getting time due to daily workload	“.... daily extreme workload so not getting time for exercise”
	Physical problems	“…no energy for exercise, having body ache, joint pain weakness”
Influence of addictions on NCD	Social support for quitting tobacco	“…due to influence of friends, colleagues, neighbours
		“. family members pressurizedfor quit addiction”
Influence of diet on NCD	Eat healthy to remain healthy	“…healthy food essential to keep good health”
	No special diet to control any specific disease	“… never heard about special diet”
Medication	Regular intake of medicines	“…regular intake of medicinesdiseases”
	Poor compliance	“… due to lack of money can't purchase medicines”
Follow up	Follow up required	“.....check BP & blood sugar time to time”
	Poor financial condition	“. no money to visit doctor & do lab investigations for follow up”

Inference: The perceptions of the study subjects were more inclined toward curative than preventive aspects of NCDs

Discussion

In this study, more than half were females (54.19%), the majority were aged <60 years (60.29%), most had a primary level of education (42.85%), and half of the study participants had a lower socioeconomic status. A study by Garg A et al. at Delhi[5] found similar results: Most of the study participants were females, most of them had education only until the primary level or less, and half of the study participants belonged to a lower socioeconomic status. A study done by Ross S et al.[6] at Bihar found most of the study participants were <60 years age group and the majority of them were engaged in elementary profession, which are similar to findings of the present study. A study by Ramamoorthy T et al.[7] found the prevalence of tobacco use (45.7%), alcohol use (22.3%), and low physical activity (49.6%). In a study by Sivanantham et al.,[8] nearly half of the study subjects (49.5%) had low physical activity, which is similar to the results of this study. In this study, 46.8% were tobacco users, only 9.37% were alcoholic, and 61.6% had a low level of physical activity. In a study at North Bengal, Kala S et al.[9] found the prevalence of tobacco use was 57.5% and alcohol 12.5%, but in comparison in this study, the prevalence of tobacco use was less, but alcohol intake was higher. A study by Sivanantham P et al. at Puducherry[8] revealed hypertension and diabetes mellitus were present among 33.6% and 26.7% of the study population, respectively. A study done at South India[10] by Chobe et al. found the prevalence of hypertension was 40.4%, followed by diabetes 31.2%, and a study by Mahajan M et al.[11] among rural women in India found NCDs such as hypertension, diabetes, and cancer were main threats, hypertension and diabetes were prevalent at 26.2% and 15.5% in a study done by J S Thakur at Haryana, respectively,[12] and the present study found 60.26%and 30.75% study participants were hypertensive and diabetic, respectively. A study conducted by Agarwal G et al.[13] found that NCDs were greater among alcoholic adults (1.36, P < 0.10), similar to the results of this study. The prevalence of diabetes was higher among alcoholic adults (3.20, P < 0.02). A study conducted by Singh A et al.[14] at Delhi found increasing age increased prevalence of risk factors for NCDs, which is similar to the result of the current study. Here, hypertension and diabetes were found more among geriatric age study participants. A study by Makamu-Beteck et al.[15] in North West province of South Africa found participants’ understanding and perceptions of NCD risk factors was poor, which was similar to this study result. Similar to the results of this study, Dutta et al.[16] at the South 24 Parganas district of West Bengal found that most of the study participants had inadequate knowledge regarding the role of risk factors for the development of NCD but had some perceptions regarding the requirement of medications for the control of diseases.

Conclusion

In this study, most of the study participants were <60 years old, female, and Muslims; had education up to the primary level; and belonged to a lower socioeconomic class. Hypertension was the most frequently observed NCD in the present study. The maximum number of study participants were non tobacco users and nonalcoholic; had a normal BMI; and never had adequate physical activity. This study revealed that hypertension and diabetes are more common in geriatric patients than in adults and that hypertension is more common among alcoholic than in nonalcoholic individuals. The perceptions of study subjects were inclined more toward curative than preventive aspects of NCDs. NCDs can be prevented by reducing the major modifiable factors, such as tobacco use, harmful use of alcohol, unhealthy diets, and physical inactivity. Develop and implement effective legal frameworks on the sale of tobacco items, alcohol, and food items containing high trans-fat and saturated fat. Effective implementation and monitoring of the National Programme for Prevention and Control of Non-communicable Diseases are required for health promotion, early detection, and management of NCDs.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.