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BRIEF RESEARCH ARTICLE
Year : 2016  |  Volume : 60  |  Issue : 4  |  Page : 298-301  

Hypertension treatment and control in a rural cohort in Thiruvallur, Tamil Nadu, India


1 Scientist D, Division of Health Systems Research, National Institute of Epidemiology (Indian Council of Medical Research), Chennai, Tamil Nadu, India
2 Technical Officer (A), National Institute of Epidemiology (Indian Council of Medical Research), Chennai, Tamil Nadu, India
3 Technical Assistant (Research), Division of Biostatistics, National Institute of Epidemiology (Indian Council of Medical Research), Chennai, Tamil Nadu, India
4 Technical Officer (A), Division of Computing and Information Science, National Institute of Epidemiology (Indian Council of Medical Research), Chennai, Tamil Nadu, India

Date of Web Publication15-Dec-2016

Correspondence Address:
Prabhdeep Kaur
National Institute of Epidemiology (Indian Council of Medical Research), # R-127, 3rd Avenue, Tamil Nadu Housing Board, Ayapakkam, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.195861

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   Abstract 


Hypertension is a public health problem with low detection and treatment rates in India. We resurveyed 1284 patients with hypertension already identified in baseline survey of the cohort in Thiruvallur district, Tamil Nadu, India. The objective was to estimate the proportion of patients with drug treatment, hypertension control and lifestyle modification at follow-up (median follow-up 27 months). Overall, only 19.9% of the patients took drugs and 45.3% had blood pressure under control. Among 256 patients on drugs, 179 (69.9%) were on a single drug, 71 (27.7%) on two drugs, and six (2.3%) on three drugs. Commonly prescribed drugs based on the prescription review were beta blockers (50.4%), calcium channel blockers (36.7%), angiotensin-converting-enzyme inhibitor (18.4%), and diuretics (11.7%). Salt reduction was reported by 49.7% of the patients. There is a need for strengthening the health systems for effective management of hypertension and patient education to ensure active involvement in the long-term care.

Keywords: Cohort, control, hypertension, India, treatment


How to cite this article:
Kaur P, Rao SR, Venkatachalam R, Kaliaperumal K. Hypertension treatment and control in a rural cohort in Thiruvallur, Tamil Nadu, India. Indian J Public Health 2016;60:298-301

How to cite this URL:
Kaur P, Rao SR, Venkatachalam R, Kaliaperumal K. Hypertension treatment and control in a rural cohort in Thiruvallur, Tamil Nadu, India. Indian J Public Health [serial online] 2016 [cited 2018 Dec 12];60:298-301. Available from: http://www.ijph.in/text.asp?2016/60/4/298/195861



The prevalence of hypertension in the developing countries based on various national surveys ranged from 16% to 37%.[1] Overall prevalence in India was 29.3% based on systematic review. There were significant differences in treatment and control of patients with hypertension in rural and urban areas. The proportion of patients on treatment among diagnosed was 24.9% and 37.6% in rural and urban areas, respectively. Overall hypertension control was 10.7% and 20.2% in rural and urban India, respectively.[2]

A community-based study from rural Tamil Nadu in 2005–2007 estimated 21.4% prevalence of hypertension with 20% of the patients on treatment and only 6.6% with blood pressure (BP) control. Only one-third of the treated hypertension patients had BP under control.[3] This study formed the baseline for a cohort that was followed up to understand the changing trends in hypertension treatment and control. The prevalence of noncommunicable disease risk factors and hypertension at the baseline survey has been published elsewhere.[3],[4] At baseline, all adults aged 25–64 years were considered eligible for the study. We resurveyed a cohort of patients with hypertension and cardiovascular disease identified in the baseline survey of the cohort. The objective was to estimate the proportion of patients with hypertension who took drug treatment, adopted lifestyle modification, and achieved BP control.

We conducted a resurvey of patients with hypertension identified in the baseline survey (2005–2007) of the cohort in the five villages from March 2008 to October 2009. Baseline survey was done in the villages in the field practice area of the institution in Thiruvallur district, Tamil Nadu. The villages were purposely selected considering the access and feasibility of long-term follow-up.

We collected data using a structured questionnaire at baseline and follow-up. We collected the data regarding sociodemographic characteristics, disease history, and drug treatment at the baseline survey.[3],[4] We used similar methodology and same data collection tools to collect data at follow-up. In addition, we collected data regarding various lifestyle changes, namely, increased physical activity, reduced consumption of rice, salt/pickles/other salty foods, oil/oily food, and increased consumption of fruits and vegetables. We measured BP from the right arm twice after the patient had been sitting for at least 5 min using electronic automatic BP apparatus (Omron MX3). Field investigators were trained to do measurements as per the standard protocol. The definition of hypertension at baseline survey was systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg as per the WHO criteria or history of the previously diagnosed disease.[5] We stratified the patients with hypertension before the baseline survey as self-reported and newly detected if they had hypertension based on the BP measurements during the baseline survey.

We computed the proportion of patients on drug treatment; lifestyle modification and BP control overall and stratified by old and newly diagnosed patients during baseline survey. Chi-square tests were employed for comparing the old and newly diagnosed hypertensive patients for various attributes. All analyses were two-tailed, and P < 0.05 was considered statistically significant. We analyzed data using SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc. The study was approved by the Institutional Ethics Committee. We obtained informed consent from all participants.

We had surveyed 6026 patients aged 25–64 years at baseline and identified 1384 patients with hypertension. We were able to contact 1284 (92.8%) patients who had hypertension at baseline among 1384 eligible patients. The median duration of follow-up was 27 months. The illiterate patients were 359 (28.0%) and 602 (46.9%) were male [Table 1]. Among 1284 with hypertension, 339 (26.4%) had self-reported hypertension (old) at the baseline, and the remaining (new) were diagnosed with hypertension during the baseline survey.
Table 1: Sociodemographic characteristics of the patients with hypertension in a rural cohort at follow-up in Tamil Nadu, India (n=1284)

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Overall, 256 (19.9%) were on drug treatment at follow-up and 582 (45.3%) had BP under control. Among them, 179 (69.9%) were on a single drug, 71 (27.7%) were on two drugs, and 6 (2.3%) patients were on three drugs. The drugs prescribed were as follows: beta blockers 129 (50.4%), long-acting calcium channel blocker (CCB) 94 (36.7%), angiotensin-converting-enzyme inhibitor (ACEI) 47 (18.4%), diuretics 30 (11.7%), short-acting CCB 22 (8.6%), and angiotensin receptor blocker (ARB) 17 (6.6%). Among 38 patients with cardiovascular disease, 18 (47%) were on treatment since baseline, 15 (39%) were on treatment at baseline but dropped treatment at follow-up, and 5 (13%) never took any treatment. The treatment coverage among patients with cardiovascular disease (n = 38) for secondary prevention was as follows: Aspirin 9 (23.7%), beta blockers 5 (13.2%), ACEI/ARB 4 (10.5%), and statins 1 (2.6%). Overall, 74.1% (951) of the patients were aware of the need for change in the dietary and physical activity behaviors. Only 771 (60.0%) reported that they made one or more changes in the diet or physical activity. The most commonly reported lifestyle changes were reduced consumption of salt (49.7%), oil (38.2%), and staple food rice (25.2%).

Among 945 newly detected patients during baseline survey, only 95 (10.1%) were on treatment at follow-up. Among 339 patients with self-reported hypertension, 298 (87.9%) were on treatment at baseline, and only 151 (50.7%) continued to be on treatment at follow-up. In addition, only ten patients who did not take treatment at the baseline were on treatment at follow-up. The proportion of patients with BP control was 38% at baseline and 43% at follow-up among self-reported hypertensive. There was a significant increase in the proportion of old patients with BP under control at follow-up as compared to the baseline (McNemar test P < 0.05).

We compared the treatment status of newly diagnosed and self-reported hypertensives at the baseline and the follow-up. There was no significant difference in the hypertension control among self-reported and newly diagnosed patients irrespective of the treatment status. Change of dietary behaviors was reported by significantly higher proportion of patients with self-reported hypertension [Table 2].
Table 2: Treatment, blood pressure control, and lifestyle modifications among patients with hypertension in a rural cohort at follow-up in Tamil Nadu, India (n=1284)

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We observed poor coverage of hypertension treatment and also decline in the proportion of patients who took treatment that reflected poor health-seeking behavior of the population for an asymptomatic disease. Patients with newly detected hypertension during the screening had even lower treatment rates. The lack of drug treatment in this group might be due to either low-risk perception by the patient or lack of initiation of drug treatment by the doctors for lower grades of hypertension that are more likely to be detected due to the screening.

Overall hypertension control was low even among treated patients. This was consistent with observations from other developing countries. Hypertension control was 36.5% in a patient cohort in rural Cambodia and 40% in a primary care setting in South Africa.[6],[7] However, the control was higher as compared to a systematic review from India that estimated 10% control in the rural populations.[2] Higher control as compared to other populations could be due to high proportion of low grades of hypertension detected during the baseline survey. The effect of regression to mean with clear shift toward lower levels of BP is well documented in the hypertension cohorts.[8]

Hypertension control was not achieved in nearly half of the patients due to a combination of patient factors or provider issues such as prescription practices and therapeutic inertia. Therapeutic inertia was evident from the fact that majority of patients were treated with a single drug despite lack of control. There was a lack of dose titration consistent with observations from other non-Western countries.[9] The prescription practices were not aligned to the recent guidelines on hypertension treatment. Contrary to the guidelines, beta blockers were the most prescribed drugs in our study. Poor coverage of treatment for secondary prevention among patients with cardiovascular disease was also observed consistent with a multicentric study from developing countries including India.[10] The acceptance of lifestyle changes was poor despite having received counseling. One of the limitations of the study was lifestyle changes that were self-reported and could not be validated.

Hypertension treatment and control was inadequate in a rural setting in South India. There is a need for structured educational programs for the patients to improve the uptake of treatment and lifestyle changes and provider sensitization to improve the compliance with treatment guidelines.

Financial support and sponsorship

This study was supported by the National Institute of Epidemiology, Chennai.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet 2012;380:611-9.  Back to cited text no. 1
    
2.
Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, et al. Hypertension in India: A systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens 2014;32:1170-7.  Back to cited text no. 2
    
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Kaur P, Rao SR, Radhakrishnan E, Rajasekar D, Gupte MD. Prevalence, awareness, treatment, control and risk factors for hypertension in a rural population in South India. Int J Public Health 2012;57:87-94.  Back to cited text no. 3
    
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Kaur P, Rao SR, Radhakrishnan E, Ramachandran R, Venkatachalam R, Gupte MD. High prevalence of tobacco use, alcohol use and overweight in a rural population in Tamil Nadu, India. J Postgrad Med 2011;57:9-15.  Back to cited text no. 4
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Whitworth JA; World Health Organization, International Society of Hypertension Writing Group. 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens 2003;21:1983-92.  Back to cited text no. 5
    
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Isaakidis P, Raguenaud ME, Say C, De Clerck H, Khim C, Pottier R, et al. Treatment of hypertension in rural Cambodia: Results from a 6-year programme. J Hum Hypertens 2011;25:241-9.  Back to cited text no. 6
    
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Rayner B, Blockman M, Baines D, Trinder Y. A survey of hypertensive practices at two community health centres in Cape Town. S Afr Med J 2007;97:280-4.  Back to cited text no. 7
    
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Ambrosio GB, Dowd JE, Strasser T, Tuomilehto J. The dynamics of blood pressure in populations and hypertensive cohorts. Bull World Health Organ 1986;64:93-9.  Back to cited text no. 8
    
9.
Ferrari P; National Coordinators for the Reasons for not Intensifying Antihypertensive Treatment (RIAT) Trial. Reasons for therapeutic inertia when managing hypertension in clinical practice in non-Western countries. J Hum Hypertens 2009;23:151-9.  Back to cited text no. 9
    
10.
Yusuf S, Islam S, Chow CK, Rangarajan S, Dagenais G, Diaz R, et al. Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): A prospective epidemiological survey. Lancet 2011;378:1231-43.  Back to cited text no. 10
    



 
 
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