|Year : 2016 | Volume
| Issue : 2 | Page : 41-47
A community-based comparative study of prevalence and risk factors of hypertension among urban and rural populations in a coastal town of South India
Imaad Mohammed Ismail1, Annarao G Kulkarni2, Anand D Meundi3, M Amruth4
1 Department of Community Medicine, Kannur Medical College, Kannur, Kerala, India
2 Department of Community Medicine, KVG Medical College, Sullia, India
3 Department of Community Medicine, BGS Global Institute of Medical Sciences, Bangalore, India
4 Department of Community Medicine, Shridevi Institute of Medical Sciences and Reasearch Hospital, Tumkur, Karnataka, India
|Date of Web Publication||9-May-2016|
Imaad Mohammed Ismail
Department of Community Medicine, Kannur Medical College, Anjarakkandy, Kannur - 670 612, Kerala
Source of Support: None, Conflict of Interest: None
Background: Hypertension is the new-era pandemic, which causes about 7.1 million deaths per year globally. Various risk factors are implicated in the development of hypertension and there are differences in these risk factors in urban and rural populations depending on the level of development and epidemiological transition. The present study was undertaken to estimate the prevalence of hypertension and to identify and compare some sociodemographic and lifestyle risk factors associated with hypertension in urban and rural populations of Sullia, Karnataka, South India. Materials and Methods: This was a community based cross-sectional study in which 300 adults each were randomly selected from urban and rural populations of the town of Sullia using modified cluster sampling method. Selected individuals were examined and interviewed using a semi-structured, pretested questionnaire. Results: The prevalence of hypertension was 21.0% (23.7% in the urban population and 18.3% in the rural population). Increasing age, sedentary occupation, higher socioeconomic status, extra salt intake, family history of hypertension, reduced physical activity, tobacco smoking, smokeless tobacco consumption, alcohol consumption, body mass index (BMI) ≥25 kg/m 2 , and high waist-hip ratio (WHR) were found to be significant risk factors of hypertension. Family history of hypertension, BMI ≥25 kg/m 2 , and high WHR were found to be predominant risk factors of hypertension in the urban areas, whereas smokeless tobacco consumption was a predominant risk factor in the rural areas. Conclusion: A high prevalence of hypertension was observed in both urban and rural populations of Sullia, Karnataka, South India. Hence, mass screening should be done for early diagnosis and treatment. Prevention and control activities should give higher priority toward obesity control in urban areas and smokeless tobacco control in rural areas.
Keywords: Hypertension, prevalence, risk factors, rural population, urban population
|How to cite this article:|
Ismail IM, Kulkarni AG, Meundi AD, Amruth M. A community-based comparative study of prevalence and risk factors of hypertension among urban and rural populations in a coastal town of South India. Sifa Med J 2016;3:41-7
|How to cite this URL:|
Ismail IM, Kulkarni AG, Meundi AD, Amruth M. A community-based comparative study of prevalence and risk factors of hypertension among urban and rural populations in a coastal town of South India. Sifa Med J [serial online] 2016 [cited 2017 Sep 21];3:41-7. Available from: http://www.imjsu.org/text.asp?2016/3/2/41/182001
| Introduction|| |
Hypertension is the new-era pandemic, which causes about 7.1 million deaths per year and 4.5% of the disease burden, which translates to 64 million disability adjusted life-years (DALYs) globally.  The WoHealth Organization (WHO) world health statistics report 2014 reveals that the worldwide prevalence of hypertension is 29.2% for males and 24.8% for females.  Hypertension has become an important worldwide public health challenge because of its high prevalence and concomitant risks of coronary artery disease, congestive heart failure, stroke, end-stage renal disease, dementia, and blindness. , People with hypertension possess two fold higher risk of developing coronary artery disease, four times higher risk of congestive heart failure, and seven times higher risk of cerebrovascular disease compared to normotensive people. 
India is experiencing an epidemiological transition and hypertension has emerged as a major threat to the health of the people. Hypertension is a significant public health problem in both urban and rural areas of India. According to the Register General of India, the prevalence of hypertension in urban and rural populations of India is 25.0% and 10.0%, respectively.  Cardiovascular diseases such as coronary heart disease and stroke are the largest cause of death in most developing countries.  Hypertension is directly responsible for 42.0% of coronary heart disease deaths and 57.0% of all stroke deaths in India.  As a result of changes in lifestyle, changes in environment, and increased life expectancy, the problem of hypertension is on the rise. Recent data suggests that noncommunicable diseases are already the most common cause of death in many parts of rural India. , This is plausible as apart from improvements in life expectancy, the greater interconnectedness increasingly allows rural populations to adopt urban lifestyles without migration to urban areas. ,
There are various risk factors associated with hypertension; some of the known risk factors for primary hypertension such as age, heredity, and gender are non-modifiable. However, the majority of the other risk factors such as tobacco use, alcohol use, unhealthy diet, physical inactivity, overweight, and obesity can be effectively prevented.  There are differences in these risk factors in urban and rural populations depending on the level of development and epidemiological transition.
Hypertension is an "iceberg" disease and scarcity of data is sometimes understood as nonexistence of the problem.  There is a paucity of data on hypertension prevalence in many parts of India, especially the rural areas. Thus, the burden of hypertension in these populations may be underestimated and might leave the disease undiagnosed and untreated. Estimating the prevalence of hypertension and its risk factors in both urban and rural populations is very crucial as this forms the basis for planning of primary and secondary preventions of hypertension. Hence, this community-based cross-sectional study was undertaken with the objectives of estimating the prevalence of hypertension and to identify and compare some sociodemographic and lifestyle risk factors associated with hypertension in urban and rural populations of Sullia, Karnataka, South India.
| Materials and Methods|| |
This was a community-based cross-sectional study conducted among urban and rural populations of Sullia, Karnataka, South India. Sullia is a coastal town located next to the Arabian Sea at latitude of 12.553 and longitude of 75.384 and has a population of 140,754. The study period was from October 2010 to August 2013. The rural population of Sullia refers to the people living in the 40 villages covered under the town of Sullia and the urban population of Sullia refers to the people living in nine urban election wards of the town of Sullia. These formed the sampling frames from which the samples were drawn.
The prevalence of hypertension has a range of 20.0-40.0% in urban areas in India and 7.0-17.0% in rural areas of India. ,,,, Based on this, a prevalence of hypertension of 25.0% in urban areas and 15.0% in rural areas was assumed for calculation of the sample size. The sample size was estimated based on 5% significant level and 80% power. This was calculated by the following formula n = (Zα + Z1–β) 2 (p 1 q 1 + p 2 q 2 )/(p 1 - p 2 ) 2 = 250. Assuming a nonresponse of 20% of the n, this was added to the sample, which led to a sample size of 300 for each group, that is, 300 for urban population group and 300 for the rural population group. Using modified cluster sampling, 300 subjects from the urban population (9 clusters/urban election wards of 34 subjects each) and 300 subjects from the rural population (30 clusters/villages of 10 subjects each) aged 20 years and above were selected from the sampling frame. In the selected clusters (villages/urban election wards), the streets/lanes were randomly selected using random numbers and all consecutive houses on the selected street were visited till the required number of the study subjects was obtained. Pregnant women and those individuals who were not willing to participate in the study were excluded from the study.
The data were collected using a pretested, semi-structured questionnaire. The questionnaire form collected information regarding sociodemographic characteristics such as age, gender, education, occupation, income, family type, family history of hypertension, marital status, and lifestyle risk factors such as consumption of tobacco and alcohol products, excessive salt intake, lack of physical exercise, and obesity. For classifying the population according to socioeconomic status, B.G. Prasad's socioeconomic classification was adopted and modified as per the All India Consumer Price Index (AICPI) for the year 2010.  The modified B.G. Prasad's classification based on the per capita income of the family in Indian rupees is as follows: upper class (>4,018), upper middle class (2,009-4,018), lower middle class (1,205-2,008), upper lower class (602-1,204), and lower class (<602). A person was considered to have a family history of hypertension if either one or both the parents of the subject had hypertension. A smoker was defined as a person who currently smoked any tobacco products such as beedi, cigarette, or cigar. Smokeless tobacco intake referred to the consumption of gutka, tobacco-lime, or tobacco in any other form. A person was considered to be an alcohol user if she/he had consumed alcohol in the past 30 days. Males were considered to be heavy drinkers if they consumed more than two drinks/day and females were considered to be heavy drinkers if they consumed more than one drink/day (two drinks equaled 670 mL beer or 280 mL wine or 85 mL 80 proof whiskey).  Excessive salt intake was defined as intake of more than 6 g of sodium chloride per day. Regular exercise was defined as regular aerobic physical activity such as brisk walking for at least 30 min per day and a minimum of 5 days per week. 
Weight was recorded using an electronic weighing machine (Venus, Round Thick Glass Digital Weighing Scale, China) and was rounded off to the nearest 0.5 kg. Height was measured with the subject standing on a level surface with the heels together and toes apart without shoes. Height was recorded to the nearest 0.5 cm. Waist circumference was measured with the subject in a standing position using a nonelastic plastic tape midway between the lower rib margin and the iliac crest to the nearest 1 mm. Hip circumference was measured around the widest portion of the buttocks, with the tape parallel to the floor. Body mass index (BMI) was classified according to the standard WHO criteria.  Those with BMI of ≥25 kg/m 2 was considered to be a high risk group for hypertension. The waist-hip ratio (WHR) cutoff points for the Indian population according to the national program for prevention and control of cancer, diabetes, cardiovascular disease, and stroke were followed. Accordingly, those with a WHR of ≥0.95 for males and ≥0.85 for females was considered to be a high-risk group for hypertension. 
The Joint National Committee 7 (JNC-7) criteria were used for the measurement and definition of hypertension.  Hypertension was defined as systolic blood pressure more than or equal to 140 mmHg and/or diastolic blood pressure more than or equal to 90 mmHg. Those individuals already diagnosed as hypertensive were also labeled as such. Two blood pressure readings were recorded in the sitting position in the right arm using a mercury sphygmomanometer (Diamond, Mercurial Deluxe, India) and the mean of the two readings was considered for analysis. The first reading was taken after at least 20 min of rest and the second reading was taken 20 min after the first reading. Ethical clearance was taken from the institutional ethical committee of KVG Medical College (ref. no. KVGMC/IEC/13/2010). Informed consent was taken from all the study subjects in the local language. Statistical analysis of the data was performed using the SPSS version 17 (SPSS Inc., Version 17, Chicago). Results on the continuous measurements are presented as mean and standard deviation and results on categorical measurements are presented in number and percentage. Student's t-test (two-tailed, independent) was used to find the significance of the study parameters on continuous scale and chi-square test and odds ratio were used to find the significance of the study parameters on a categorical scale. p value less than 0.05 was considered to be significant.
| Results|| |
The study had a total of 600 participants, which included 300 each from urban and rural areas. The mean [±standard deviation (SD)] age of the study subjects was 39.8 (±13.5) years and 41.5 (±14.9) years for urban and rural areas, respectively, and this difference was found to be statistically insignificant (t = −1.460; p = 0.145). The age distribution of the population was typical of a developing country with a large proportion of young people compared to the older people [Figure 1]. With regard to gender, 58.8% (n = 353) of the study participants were females [59.7% (n = 179) in the urban area and 58% (n = 174) in the rural area] and 41.2% (n = 247) were males [40.3% (n = 121) in the urban area and 42% (n = 126) in the rural area]. 15.0% (n = 90) of the participants were illiterate, 24.0% (n = 144) had received education up to primary school level, and only 6.5% (n = 39) had completed their graduation. Overall, most of the workforce was employed in the agricultural sector followed by people in elementary occupations such as street vendors, home-maids, and auto-drivers. Using modified B.G. Prasad's socioeconomic scale, the present study found that 58% (n = 348) of the participants belonged to the middle class [26.5% (n = 159) from the upper middle class and 31.5% (n = 189) from the lower middle class]. Regarding marital status of the study population, it was found that 482 out of 600 (80.3%) were currently married. Three-generation families were the most common (38.3%) followed by nuclear families (35.7%) and joint families (26%).
|Figure 1: Bar chart showing agewise distribution of urban and rural study populations|
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The prevalence of hypertension at 95% confidence interval with continuity correction in the present study was 21.0% (17.9-24.5%). A large proportion of the study participants (272 out of the 600; 45.3%) had prehypertension [Table 1]. The prevalence of hypertension was 23.7% and 18.3% in urban and rural areas, respectively, but this difference was found to be statistically insignificant (χ2 = 2.572; p = 0.109). Out of the total 126 hypertensives, 46 (36.5%) were known cases and the remaining 80 (63.5%) were newly diagnosed cases.
|Table 1: Distribution of study subjects based on JNC-7 classification of hypertension|
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The prevalence of hypertension increased with advancing age; it was 6.0% in the age group of 20-29 years, which rose to 52.4% for people of aged ≥70 years [Table 2]. There was a sharp increase in the prevalence after the age of 50 years. With regard to gender, the prevalence of hypertension was 22.3% in males and 20.1% in females but this difference was found to be statistically insignificant (χ2 = 0.406; p = 0.542). The study found sedentary occupations such as managers, senior officials, professionals, technicians, shop sales workers, and housewives to have a higher prevalence of hypertension (25.5%) compared to people involved in nonsedentary occupations such as coolie workers, agriculture, fishery, craft, and trade-related workers (15.8%). This difference was found to be statistically significant (χ2 = 8.355; p = 0.004). Hypertension was found to be more common in the upper socioeconomic class compared to the lower socioeconomic class [Table 3]. The pattern of hypertension according to socioeconomic status was similar in both urban and rural areas.
|Table 2: Distribution of subjects according to blood pressure status and age|
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|Table 3: Distribution of subjects according to blood pressure status and socioeconomic class|
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Increasing age, sedentary occupation, higher socioeconomic status, extra salt intake, family history of hypertension, reduced physical activity, tobacco smoking, smokeless tobacco consumption, alcohol consumption, BMI ≥25 kg/m 2 , and high WHR were found to be significant risk factors of hypertension [Table 4]. Family history of hypertension, BMI ≥25 kg/m 2 , and high WHR were found to be predominant risk factors of hypertension in the urban areas, whereas smokeless tobacco consumption was a predominant risk factor in the rural areas [Table 5].
|Table 5: Comparison of risk factors of hypertension in urban and rural populations|
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| Discussion|| |
Following JNC-7 criteria, the prevalence of hypertension in the present study was 21.0%. Only 33.7% of the population had blood pressure in the normal range and 45.3% of the population had prehypertension. The findings of the study are comparable to WHO estimates, which gives a 23.0% prevalence of hypertension in India.  The prevalence of hypertension in urban areas was 23.7% and this rate are similar to those given by the Office of the Register General of India (25.0%) and WHO (23.1%). , Based on the difference in the methodology used and place of study, other researchers have found a prevalence of hypertension in the urban Indian population ranging 20-40%. ,,, The prevalence of hypertension in rural areas was 18.3% and this rate differed from those given by the Office of the Register General of India (10.0%) and WHO (22.6%). , Other researchers have found a prevalence of hypertension in the rural Indian population ranging 7.0-19.0%. ,,,
The present study found increasing age to be an important nonmodifiable risk factor for the development of hypertension. The increase in blood pressure with age was found to be similar in both the urban and rural areas. The main reason for increase in blood pressure with increase in age is that arteries and arterioles become less elastic due to atherosclerotic changes as people age. Changes in lifestyle and stress are also important contributors.
Sedentary occupations such as managers, professionals, and technicians had a higher prevalence of hypertension compared to nonsedentary occupations. In the rural areas, the prevalence of hypertension was low in people working in the agricultural sector (13.8%) and among those having nonsedentary elementary occupations such as maids, dhobis, and daily wage coolie workers (10.5%). Similar results were also observed by Rajashekar et al. in Puducherry, India where they found that people involved in sedentary occupations were at an increased risk of developing hypertension compared to those in nonsedentary occupations. 
Hypertension was found to be more common in the upper socioeconomic class compared to the lower socioeconomic class. The prevalence of hypertension was highest in the upper socioeconomic class (32.5%) followed by the upper middle class (27.1%) and was least in the lower class (13.8%). The higher prevalence of hypertension in the upper class is due to their lifestyle, which usually involves a sedentary type of job, higher mental stress, lack of physical activity, and high prevalence of obesity. Similar findings of a higher prevalence of hypertension in the upper socioeconomic class have been reported in populations of Puducherry and in the states of Maharashtra and Telangana in India. ,, On the contrary, there are some studies that show that in many populations, hypertension is more prevalent in the lower socioeconomic class, especially in the underdeveloped countries. 
The occurrence of hypertension was significantly higher among those who had a family history of hypertension (30.0%) as compared to those who did not (19.8%). Genetic studies have pointed out toward a possible polygenic inheritance of hypertension.  A family history of hypertension was more common in people from urban areas as compared to their rural counterparts (38.6% vs 14.3%). This could be attributed to the fact that the prevalence of hypertension is more in urban areas as well as early diagnosis of hypertension in urban individuals' parents owing to the superior health infrastructure in urban areas and better access to it both financially and geographically.
The prevalence of hypertension was 29.3% among smokers and 18.8% among nonsmokers. Most of the smokers smoked the beedi predominantly (77.6%) and the rest predominantly smoked cigarettes. The mean duration of smoking was found to be 14.8 years. The odds of smokers developing hypertension was 1.68 times that of nonsmokers. Tobacco smoke contains various toxic substances such as nicotine, tar, acetone, benzene, hydrogen cyanide, and carbon monoxide, which are known to increase the blood pressure by their vasoconstriction action. The frequency and duration of use are also important factors, which influence the development of hypertension in people who smoke. Consuming smokeless tobacco products (chewing tobacco, consuming pan with tobacco) is a cultural practice in villages of Sullia, Karnataka, South India. One hundred and nineteen out of the 300 individuals in the rural sample consumed smokeless tobacco products and 39 (32.7%) among them have hypertension. 12.8% of the study population consumed alcohol and the odds of developing hypertension among those consuming alcohol was 1.73 times that of nonalcoholics. Around 1/3 rd of those who consumed alcohol were heavy drinkers (more than 670 mL beer or 280 mL wine or 85 mL 80-proof whiskey per day for males and half of these amounts for females). The mean duration of alcohol consumption was 17.1 years. The prevalence rates for development of hypertension with regard to alcohol consumption were similar in urban and rural areas. The mechanisms by which alcohol causes elevation of blood pressure include a direct pressor effect of alcohol on the vessel wall, a sensitization of resistance vessels to pressor substances, stimulation of sympathetic nervous system, and increased production of adrenocorticoid hormones. 
In the present study, 41.0% of the participants consumed salt in excess and this was found to be a significant risk factor for the development of hypertension. The prevalence of hypertension based on salt intake was found to similar in both the urban and rural areas. Sodium is predominantly an extracellular ion and is a primary determinant of extracellular fluid determinant. When NaCl intake exceeds the capacity of kidney to excrete sodium, the vascular volume initially expands and cardiac output increases; this in turn increases the blood pressure.  The INTERSALT international study, which was conducted in 32 countries across the world also found high salt intake to be a risk factor for the development of hypertension.  The present study found that people who were engaged in regular physical activity had less probability of developing hypertension compared to those who rarely did any physical activity. Exercise causes the release of nitric oxide from the endothelial cells of the blood vessels, which causes vasodilatation and reduces peripheral vascular resistance. People who exercise regularly have lower resting heart rates and they are able to consume greater volumes of oxygen that in turn lower their systolic blood pressure. Studies have shown that regular physical activity reduces the systolic blood pressure by 4-9 mmHg.  Apart from this, regular exercise reduce atherosclerosis by lowering low-density lipoprotein (LDL) and increasing high-density lipoprotein (HDL).
Around 22% of the study population was found to be obese/preobese (BMI ≥25 kg/m 2 ). Hypertension was found to be more prevalent among urban obese/preobese (45.9%) individuals when compared to their rural counterparts (26.2%) and this difference was found to be statistically significant. Obesity causes hypertension by activating the renin-angiotensin-aldosterone system, increasing sympathetic activity, promoting insulin resistance and leptin resistance, increasing cholesterol levels, increasing procoagulatory activity, and by endothelial dysfunction. Further mechanisms include increased renal sodium reabsorption, causing a shift to the right of the pressure natriuresis relationship, and resulting in volume expansion.  High WHR (≥0.85 in females and ≥0.95 in males) was also a significant risk factor of hypertension and more so in the urban population. The findings of the current study are comparable to a study conducted by Mahmood et al. in Bareilly, Uttar Pradesh, India where they found a WHR of more than 0.9 for males and 0.8 for females to be a significant risk factor for hypertension. 
| Limitations of the Study|| |
A person was considered to be diabetic only if he/she had already been diagnosed as diabetic (self-reporting) and no screening test was applied to identify the undiagnosed cases.
| Conclusion and Recommendation|| |
A high prevalence of hypertension was observed in both urban and rural populations of Sullia in Karnataka, South India. As 63.5% of the hypertensives were newly diagnosed cases, which were hidden in the community, a mass screening should be done for early diagnosis and treatment. Around 45% of the study population had prehypertension; hence, lifestyle modifications such as regular exercise, low salt diet, and abstinence from alcohol and tobacco products are the best option available to bring down their blood pressure to the normal range. Prevention and control activities should give higher priority toward obesity control in urban areas and smokeless tobacco control in rural areas. As tobacco and alcohol consumptions were found to be important risk factors in both urban and rural areas, the government should consider banning these products.
We sincerely acknowledge the Management of KVG Medical College for providing a vehicle to conduct the research. We thank the medicosocial workers of the Department of Community Medicine for their unrelenting support during the entire study period.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]