Abstract
Background:
Indian tribes receive limited attention in provision of care toward non-communicable diseases (NCDs). As there has been an increasing prevalence of modifiable NCD risk factors among Indian tribes over the past three decades, the current study aimed to estimate the prevalence of NCD risk factors among the tribal population in Puducherry.
Methods:
We conducted a community-based cross-sectional survey to assess NCD risk factors in the period January–December of 2018. We purposively selected the survey location and adopted a systematic random sampling technique using alternative households to enroll tribal participants; children less than 5 years were excluded from the study. Data collection was carried out by trained research associates regarding sociodemographic parameters, health status, and disease profile.
Results:
The median age of participants was 28 (17–42) years, with the majority being females (58.8%). The prevalence of current tobacco use, alcohol consumption, and hypertension were 22.6% (95% CI: 19.2–26.3), 18.7% (95% CI: 15.5–22.2), and 9.1% (95% CI: 6.9–11.8), respectively. The prevalence of overweight and obesity was found to be 14.7% and 32.1%, respectively. The prevalence of tobacco and alcohol use was significantly higher among the elderly and males. The risk of having hypertension was twofold higher among the male tribes by PR: 2.10 (95% CI: 1.19–3.68) compared with female.
Conclusion:
The study concludes that there is a higher prevalence of behavioral and biological risk factors of NCDs among the tribal population in and around Puducherry.
Keywords: Alcohol, hypertension, non-communicable diseases, indigenous community, tobacco, tribal population
INTRODUCTION
Non-communicable diseases (NCDs) pose a significant threat to public health, causing various complications and imposing substantial burdens such as out-of-pocket expenditure, fragmented care, and inadequate service provision.[1] According to the World Health Organization (WHO), major NCDs encompass cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, collectively responsible for 74% of global deaths, with 77% occurring in low- and middle-income countries.[2,3] Extensive research has established that these chronic diseases predominantly manifest in individuals engaged in unhealthy lifestyle behaviors over prolonged periods, including physical inactivity, unhealthy diets, and alcohol and tobacco use.[4]
The “India: Health of the Nation’s States” study reported a concerning trend, indicating that NCD-related deaths in India escalated from 37.9% to 61.8% between 1990 and 2016, accounting for over two-thirds of global NCD deaths.[5] Notably, variations in NCD prevalence across states and in factors such as healthcare provision, utilization, out-of-pocket expenditure, continuum of care, and NCD screening have warranted further research in diverse settings and population subgroups to elucidate additional insights on the burden of NCDs and associated factors.[6]
In this context, the Indian tribes, despite constituting 8.6% of the total Indian population, with 11.3% residing in rural areas and 2.8% in urban areas, have received limited attention in NCD research.[7] The assumption that tribes are at lower risk due to their purported healthy lifestyles, physical activity, and favorable environments has been challenged by evidence suggesting an epidemiological transition in NCDs among tribal populations. A systematic review conducted in 2014 reported a pooled NCD prevalence of 16.1%[8] among tribes, with increasing prevalence over the past three decades. Notably, the Kani tribes in Kerala exhibited a higher prevalence of modifiable NCD risk factors compared to other tribal groups in India.[3]
Within Puducherry, the tribal population is predominantly dispersed across three regions, comprising distinct categories such as Irulars, Kattunaickens, Malaikuravars, Yerkulas, and Kurumans. While the 2011 census indicates a scheduled caste population of 15.73% in Puducherry, the scheduled tribe population is negligible, and few studies have focused on this group.[9] A recent study investigating NCD risk factor clustering in Puducherry revealed that 73% of the sample exhibited multiple risk factors, including high salt intake, increased waist circumference (WC), and insufficient fruit and vegetable consumption.[10] However, to generate robust data for policy changes and implementation, it is crucial to conduct further research specifically targeting vulnerable populations such as tribes. Therefore, we aimed to estimate the prevalence of NCD risk factors among the tribal population in Puducherry.
METHODOLOGY
Study setting
We conducted this study in Puducherry district, located along the eastern coast of southern India. The district has a population of 0.98 million, accounting for 76% of the total population of the union territory.[11] The majority of the population resides in urban areas. Puducherry has a sex ratio of 1.029, a life expectancy of 68.35 years, and a literacy rate of 85.44%. In terms of human development index, Puducherry ranks seventh among Indian states.[12] The study focused on indigenous communities residing in isolated geographic areas of Puducherry district, identified based on available census data, online resources, and community settlements.
Study design and sample size
We conducted a community-based survey to assess NCD risk factors during the period January–December 2018. We used OpenEpi (Version 3.01) to determine the required sample size, considering a prevalence of 50% for risk factors, a 95% confidence interval, and a design effect of 1. Assuming a 70% response rate among the tribal population the calculated sample size was 500, we included a total of 556 tribal participants of all age groups residing in and around Puducherry in this study.
Sampling method
As the survey targeted the tribal population, we purposively selected the survey location and adopted a systematic random sampling technique using alternative households. The household members were enrolled randomly, regardless of their age. Children less than 5 years old were excluded from the study.
Study permission and participants
We obtained approval from the Adi Dravidar and Tribal Welfare Departments of Tamil Nadu and Puducherry before commencing the study. The institute’s scientific advisory (JSAC/48/2017/75) and ethics (JIP/IEC/2017/0291) committees also granted approval. We visited the areas where the tribal population resided in and around Puducherry. Written informed consent or assent was obtained from all adolescents, older children, and adults residing in the study area.
Data collection tool
Trained research associates conducted home visits to enroll eligible participants and collect data using a pre-designed questionnaire. The questionnaire includes sections on sociodemographic parameters, health status, and disease profile. Before data collection, we piloted the questionnaire to ensure its validity and reliability. The assessment of risk factors was conducted in two steps. In the first step, behavioral risk factors such as tobacco use, alcohol consumption, physical inactivity, and inadequate fruit and vegetable intake were assessed. The second step involved physical measurements, including height, weight, and WC, to determine body mass index (BMI) and abdominal obesity. Height and WC were measured using appropriate techniques, The height of participants was assessed while standing barefoot and wearing light clothing. Measurements were conducted using a portable stadiometer for height and an electronic weighing scale for weight, recorded to the nearest 0.1 cm and 100 gm, respectively. Waist measurements were taken using a SECA constant tape. Blood pressure was measured using an electronic device (OMRON, HEM 7120, Omron Corporation, Kyoto, Japan) by taking a single reading, to determine the BP status.
Operational definitions
We defined current tobacco use as the use of tobacco (smoke/smokeless) in the last 30 days and current alcohol use as the consumption of one standard drink daily (100 mL wine or 285 mL beer or 30 mL spirit/toddy/arrack) within the past year by WHO STEPS guidelines.[13] The Asian cut-off BMI classification was used to classify overweight (23–24.99 kg/m²) and obesity (≥25 kg/m²). Abdominal obesity was identified as a WC of ≥90 cm for men and ≥80 cm for women. Raised blood pressure (hypertension) was defined as a systolic blood pressure (SBP) of ≥140 mmHg or diastolic blood pressure (DBP) of ≥90 mmHg, or the use of antihypertensive medication.
Statistical analysis
Data were entered into Microsoft Excel, and the analysis was performed using STATA version 14.0. Categorical variables such as age groups, gender, residence, marital status, education, occupation, and other sociodemographic characteristics were summarized as proportions, while continuous variables such as age were presented as mean (SD) or median (IQR). The prevalence of current tobacco use, alcohol consumption, hypertension, and abdominal obesity was reported with their respective 95% confidence intervals. Regression models were developed, considering the risk factors as dependent variables and sociodemographic characteristics as independent variables. Adjusted prevalence ratios with 95% confidence intervals were calculated. In the regression models, P values ≤ 0.05 were considered statistically significant.
RESULTS
The participation rate of the current study was 100%. The median age of participants was 28 (17–42) years, with the majority being female (58.8%), married (52.8%), and belonging to the scheduled caste (42.3%). Consanguineous marriage was reported among almost all married participants. More than one-third (35%) of participants had completed high school education, while around 30% were unemployed. More than 95% of the participants had an annual income of less than Rs. 10,000 [Table 1].
Table 1.
Sociodemographic characteristics (n=556)
| Personal characteristics | Male (n=229) n (%) |
Female (n=327) n (%) |
|---|---|---|
| Age Categories | ||
| <18 | 78 (34.1) | 66 (20.2) |
| 18–29 | 72 (31.4) | 75 (22.9) |
| 30–60 | 65 (28.4) | 160 (48.9) |
| >60 | 14 (6.1) | 26 (7.9) |
| Religion | ||
| Hindu | 228 (99.6) | 326 (99.7) |
| Muslim | 1 (0.4) | 0 (0) |
| Christian | 0 (0) | 0 (0) |
| Caste/communities | ||
| Kuruman | 42 (18.3) | 60 (18.3) |
| Scheduled caste | 101 (44.1) | 136 (41.6) |
| Narikuravar | 52 (22.7) | 46 (14.1) |
| Malaikuravan | 24 (22.7) | 47 (14.4) |
| Irular (Vettaikaran) | 9 (3.9) | 33 (10.1) |
| Irular | 0 (0) | 5 (1.5) |
| OBC-Vanniar | 1 (0.4) | 0 (0) |
| Marital status | ||
| Married | 92 (40.2) | 202 (61.7) |
| Unmarried | 136 (59.4) | 98 (30.0) |
| Divorce | 0 (0) | 1 (0.3) |
| Widow | 1 (0.4) | 26 (7.9) |
| No. of children (Min–Max) | (1–7) | (1–9) |
| Educational status | ||
| No Formal education | 55 (24.0) | 129 (39.4) |
| Primary | 40 (17.5) | 62 (19.0) |
| High School | 94 (41.1) | 100 (30.6) |
| Higher Secondary | 29 (12.6) | 27 (82.3) |
| Graduate and above | 11 (4.8) | 9 (2.7) |
| Occupation | ||
| Student | 73 (31.8) | 68 (20.8) |
| Unemployed | 40 (17.5) | 115 (35.2) |
| Hunting | 1 (0.4) | 1 (0.3) |
| Farming | 6 (2.6) | 20 (6.1) |
| Self-employed | 9 (3.9) | 16 (4.9) |
| Laborer | 99 (43.2) | 105 (32.1) |
| Others | 1 (0.4) | 2 (0.6) |
| Income (Rs.)/Annum (n=258) | ||
| Up to 10,000 | 107 (93.0) | 140 (97.9) |
| 10,001–20,000 | 5 (4.4) | 3 (2.1) |
| 20,001–30,000 | 2 (1.7) | 0 (0) |
| Above 30,000 | 1 (0.9) | 0 (0) |
Among the tribal population, the mean (SD) SBP and DBP values were 110.5 (18.7) and 69.7 (12.6), respectively. The median (IQR) number of days of fruit and vegetable consumption was 2 (1–2). The mean (SD) BMI was 23.2 (6.2) kg/m2.
The prevalence of current tobacco use and alcohol consumption among the tribal population was 22.6% (95% CI: 19.2–26.3) and 18.7% (95% CI: 15.5–22.2), respectively. These rates were significantly higher among males, older individuals, and laborers within the tribal community. The prevalence of hypertension was 9.1% (95% CI: 6.9–11.8) and was significantly higher among the elderly, unemployed, and laborers. Obesity (32.1%, 95% CI: 28.3–36.2) was more prevalent than overweight (14.7%, 95% CI: 11.9–17.9). Among the risk factors, the prevalence of abdominal obesity was 33.1% (95% CI: 29.1–37.1) and was significantly higher among those aged ≥18 years and females [Tables 2 and 3].
Table 2.
Prevalence of various risk factors of NCDs among tribal population (n=556)
| Variables | Current tobacco use % (CI) | Current use of alcohol % (CI) | Hypertension %(CI) |
|---|---|---|---|
| Age (in years) | |||
| <18 | 3.4 (1–7) | 2.7 (0.7–6.9) | 1.3 (0.1–4.9) |
| 18–45 | 22.4 (15.9–30.0) | 25.8 (18.9–33.7) | 9.7 (6.6–13.7) |
| 45.1–69 | 29.3 (23.4–35.7) | 22.6 (17.3–28.7) | 15.6 (9.0–24.4) |
| >69 | 55 (38.4–70.7) | 27.5 (14.6–43.8) | 25.0 (8.6–49.1) |
| Gender | |||
| Male | 27.5 (21.8–33.7) | 35.4 (29.1–41.9) | 10.9 (7.1–15.6) |
| Female | 19.2 (15.1–23.9) | 7.0 (4.5–10.3) | 7.9 (5.2–11.4) |
| Occupation | |||
| Student | 4.2 (1.5–9.0) | 0.7 (0–3.8) | 2.1 (0.4–6.0) |
| Unemployed | 28.4 (21.4–36.1) | 16.7 (11.2–23.6) | 12.9 (8.0–19.2) |
| Self-employed | 32.1 (20.2–45.9) | 16.1 (7.6–28.3) | 3.5 (0.4–12.3) |
| Laborer | 28.4 (22.3–35.1) | 33.3 (26.9–40.2) | 12.7 (8.4–18.1) |
| Overall | 22.6 (19.2–26.3) | 18.7 (15.5–22.2) | 9.1 (6.9–11.8) |
Table 3.
Prevalence of biological risk factors of NCDs among tribal population (n=556)
| Variables | Overweight % (CI) | Obesity % (CI) | Abdominal obesity % (CI) |
|---|---|---|---|
| Age (in years) | |||
| <18 | 6.2 (2.8–11.5) | 3.4 (1.1–7.9) | 6.2 (2.8–11.5) |
| 18–45 | 17.5 (13.4–22.3) | 43.2 (37.5–49.0) | 37.5 (31.9–43.2) |
| 45.1–69 | 18.7 (11.5–28.0) | 42.7 (32.6–53.2) | 59.3 (48.8–69.2) |
| >69 | 15.0 (3.2–37.8) | 25 (8.6–49.1) | 35.0 (15.3–59.2) |
| Gender | |||
| Male | 11.7 (7.9–16.6) | 29.6 (23.8–36.0) | 17.0 (12.3–22.5) |
| Female | 16.8 (12.9–21.3) | 33.9 (28.839.3) | 44.3 (38.8–49.9) |
| Occupation | |||
| Student | 6.3 (2.9–11.7) | 9.2 (5.0–15.2) | 9.2 (5.0–15.2) |
| Unemployed | 19.3 (13.4–26.4) | 29.0 (22.0–36.8) | 37.4 (29.7–45.5) |
| Self-employed | 26.7 (15.8–40.3) | 32.1 (20.2–45.9) | 50.0 (36.3–63.6) |
| Laborer | 13.7 (9.3–19.2) | 50.4 (43.4–57.5) | 41.6 (34.8–48.7) |
| Overall | 14.7 (11.9–17.9) | 32.1 (28.3–36.2) | 33.1 (29.1–37.1) |
Sociodemographic correlates of various NCD risk factors are given in Table 4. Tobacco and alcohol use was significantly higher among the elderly population, with PR: 7.09 (95% CI: 1.61–31.11) and PR: 4.05 (95% CI: 1.16–14.15), respectively. Similarly, both prevalence of tobacco and alcohol use were higher among males (PR: 2.01, 95% CI: 1.47–2.79 and PR: 5.96, 95% CI: 3.83–9.29, respectively). Abdominal obesity was significantly higher among the age group of 45–69 years, with PR: 3.21 (95% CI: 1.22–8.44), and among females, the probability of having abdominal obesity was 95% (PR: 1.95, 95% CI: 1.43–2.65).
Table 4.
Correlates of various risk factors of NCDs in the tribal population in and around Puducherry
| Variables | Current tobacco use | Current alcohol use | Hypertension | Overweight/obesity | Abdominal obesity |
|---|---|---|---|---|---|
| aPR (95% CI) | aPR (95% CI) | aPR (95% CI) | aPR (95% CI) | aPR (95% CI) | |
| Age (in years) | |||||
| <18 | 1 | 1 | 0.29 (0.04–1.97) | 1 | 1 |
| 18–45 | 3.30 (0.87–12.52) | 2.55 (0.88–7.37) | 1 | 4.16 (2.11–8.18)* | 2.49 (0.96–9.40) |
| 45.1–69 | 6.16 (1.55–24.50)* | 2.09 (0.67–6.45) | 1.40 (0.77–2.53) | 3.81 (1.89–7.69)* | 3.21 (1.22–8.44)* |
| >69 | 7.09 (1.61–31.11)* | 4.05 (1.16–14.15)* | 2.01 (0.82–4.94) | 2.71 (1.16–6.28)* | 2.06 (0.70–6.05) |
| Gender | |||||
| Male | 2.01 (1.47–2.79)* | 5.96 (3.83–9.29)* | 2.10 (1.19–3.68)* | 1 | 1 |
| Female | 1 | 1 | 1 | 1.00 (0.84–1.19) | 1.95 (1.43–2.65)* |
| Occupation | |||||
| Student | 1 | 0.05 (0.00–0.53) | 1 | 1 | 1 |
| Unemployed | 2.76 (0.86–8.88) | 1 | 2.02 (0.48–8.51) | 1.08 (0.67–1.76) | 1.18 (0.57–2.43) |
| Self-employed | 2.50 (0.75–8.38) | 0.77 (0.42–1.39) | 0.42 (0.05–3.02) | 1.09 (0.65–1.83) | 1.36 (0.64–2.90) |
| Laborer | 2.26 (0.70–7.20) | 1.25 (0.83–1.87) | 1.54 (0.32–7.29) | 1.24 (0.77–1.99) | |
| Marital status | |||||
| Married | 1.38 (0.85–2.24) | 1.29 (0.88–1.88) | 2.37 (0.93–6.05) | 1.47 (1.11–1.93)* | 2.09 (1.28–3.42)* |
| Unmarried | 1 | 1 | 1 | 1 | 1 |
*Statistically significant
The risk of having hypertension was twofold higher among the male population, with PR: 2.10 (95% CI: 1.19–3.68) compared with females. The prevalence of being obese or overweight was significantly higher among the age groups of 18–45, 45.1–69, and >69 years, with prevalence ratios of 4.16, 3.81, and 2.71, respectively.
DISCUSSION
We conducted an NCD survey among the tribal population located in and around Puducherry. The study reveals that the prevalence rates of current tobacco and alcohol use in the present study were 23% and 19%, respectively. Both were significantly higher among men and older age adults. Our findings also state that around one in ten tribes were hypertensive, around 32% of them were obese, and almost the same proportion had abdominal obesity (33%).
When comparing our results with those of a study conducted among tribes in West Bengal, it was observed that the prevalence of both alcohol and tobacco usage was higher in West Bengal. However, other biological risk factors such as obesity and abdominal obesity were found to be similar. The differences between the two studies could potentially be due to variations in the geographical distribution of the populations.[14] Tobacco use among Puducherry tribes was twice as high compared to the tribes in Tamil Nadu (9%) and similar to tribes in central parts of India (19.1%–22%). In contrast, the prevalence of tobacco use among tribes in northern India was considerably higher than our findings.[15,16] This variation in prevalence could be attributed to geographic differences in the prevalence of smoke and smokeless forms of tobacco across India, as evidenced by the recent Global Adult Tobacco Survey (GATS) conducted in 2017.[17] Comparing the general population of Puducherry district (12.3%),[10] tobacco use was higher among Puducherry tribes. It is important to note that the latest round of GATS (2017) has shown a significant reduction in tobacco use prevalence among the general population. However, the higher prevalence among the tribal population highlights the need for tobacco control interventions specifically targeting this subgroup in Puducherry district to prevent tobacco-related morbidity and mortality among Puducherry tribes.
Alcohol use among Puducherry tribes (18.7%) was comparable to the general population of Puducherry district (18.5%)[10] and considerably lower compared to tribes in other parts of India such as Tamil Nadu (24.8%), Assam (67%), Bihar (51%), Kerala (36.2%), and Rajasthan (36%), and also with NFHS-4 survey, where the survey reports that almost 50% of the tribal men in the age group of 15–54 years were alcoholic.[3,15,16,18,19] Various factors contribute to these variations in alcohol use prevalence among tribal populations compared to Puducherry tribes. Factors such as cultural acceptability of alcohol use, awareness of the harmful effects of alcohol, and the availability and affordability of alcohol vary across geographic regions in the country.[20] Additionally, the implementation level of health system interventions for alcohol prevention and control differs across states, leading to varying levels of alcohol use. These variations highlight the importance of studying alcohol use prevalence and associated factors among tribal populations to develop region-specific, evidence-based interventions for the prevention and control of alcohol use in these communities.
The prevalence of obesity among Puducherry tribes (33%) was substantially higher compared to studies conducted in Trivandrum (0.7%), Nagaland (3%), and West Bengal (26.2%) in India.[3,14,21] In our study, the prevalence of overweight was approximately 15%, lower than the study conducted in Tamil Nadu (17%) and substantially lower than studies conducted in other parts of southern India (20.3%–26%) and north-eastern India (52.2%–56.6%).[19,22,23] These variations in obesity and overweight prevalence can be attributed to well-established differences in physical activity levels and dietary habits across states and geographic regions in the country.[24]
About one-third of the population (33%) had abdominal obesity. This condition was notably more prevalent among individuals aged 45–69 years, women, and those who were married. Our findings align with studies conducted among tribes in Uttarakhand (33.7%), Nagaland (35%), and Tamil Nadu (36.5%), although the prevalence was lower than that observed among the tribal population of Tripura, where nearly half of the tribes had abdominal obesity. Studies conducted in other geographic regions such as Assam (11%), Trivandrum (22.1%), and West Bengal (26.2%) reported lower prevalence compared to our study.[19,21,25] When compared to the general population (68.2%),[10] the prevalence of abdominal obesity among Puducherry tribes was nearly half. Furthermore, the prevalence of abdominal obesity among Puducherry tribes was higher than that of the general population in the neighboring state of Tamil Nadu (36.5%). The higher prevalence among Puducherry tribes, compared to tribes in other states, can be attributed to geographic variations in factors contributing to abdominal obesity, such as levels of physical activity and dietary habits. The lower prevalence compared to the general population may be attributed to differences in lifestyle, livelihoods, and dietary patterns between these population groups.
We observed a hypertension prevalence of 9% among Puducherry tribes, which was substantially lower than that among tribes in the neighboring state of Tamil Nadu (36.5%)[19,26] and other parts of India (14.8%–43.4%).[3,15,21,23,25] Furthermore, the prevalence in our study was considerably lower than that among the general population of Puducherry district (33.6%).[10] The significant variation in prevalence between our study and others can be attributed mainly to methodological differences in hypertension assessment. The World Health Organization (WHO) guidelines recommend measuring blood pressure three times with a 10-minute interval between each reading and averaging the last two readings to estimate hypertension prevalence in a population.[27] In our study, due to feasibility constraints, we measured blood pressure once to determine hypertension. In contrast, studies conducted among tribal populations in Uttarakhand, Nepal, Tamil Nadu, and West Bengal used two readings, while studies in Trivandrum, Tripura, and Rajasthan followed the WHO STEPS guidelines. The notable disparity in prevalence compared to the general population of Puducherry district may be attributed to the latter study’s adherence to the WHO-recommended methodology for determining hypertension prevalence.
Strength and limitations
The study attained a response rate of 100%, a notable strength considering it targeted the tribal population residing in specific areas of Puducherry. The population under study was exceptionally scarce; the provision of incentives and as well as the study consisting of only an interview-based method enhanced the participation rates. There may have been underestimation of behavioral risk factors due to socially desirable biases. The assessment of these risk factors relied on participants’ ability to recall their health behaviors, introducing the possibility of recall bias. Additionally, the prevalence of hypertension was estimated based on a single reading, which may have introduced measurement bias in the prevalence estimates. However, it is important to note that the interviews were conducted by trained investigators, which helped mitigate these biases.
CONCLUSION
The study highlights the higher prevalence of behavioral and biological risk factors of NCDs among the tribal population in and around Puducherry. Nearly one in four tribes in Puducherry district use tobacco (22.6%), and there is also a higher prevalence of alcohol use (18.7%) among the tribes in this area. Furthermore, approximately 30% of the tribes in the region have obesity and abdominal obesity, with females being particularly affected. These findings emphasize the urgent need for multi-sectoral, population-based health promotion interventions among the tribal population in and around Puducherry to effectively control and prevent NCDs in the district.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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