|BRIEF RESEARCH ARTICLE
|Year : 2021 | Volume
| Issue : 2 | Page : 190-193
Multi-morbidity and blood pressure control: Results of a cross-sectional study among school teachers in Kerala, India
GK Mini1, Malu Mohan2, PS Sarma3, KR Thankappan4
1 Principal Investigator, AchuthaMenon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology; Associate Professor, Global Institute of Public Health, Ananthapuri Hospitals and Research Institute; Founding Director, Women's Institute for Social and Health Studies, Women's Social and Health Studies Foundation, Trivandrum, Kerala, India
2 Senior Research Consultant, Women's Institute for Social and Health Studies, Women's Social and Health Studies Foundation, Trivandrum, Kerala, India
3 Professor and Head, Achutha Menon Centre for Health Science Studies, Sree ChitraTirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
4 Professor, Department of Public Health and Community Medicine, Central University of Kerala, Kasaragod, Kerala, India
|Date of Submission||16-Dec-2020|
|Date of Decision||18-Feb-2021|
|Date of Acceptance||07-Apr-2021|
|Date of Web Publication||14-Jun-2021|
K R Thankappan
Department of Public Health and Community Medicine, Central University of Kerala, Kasaragod, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The patterns of concordant and discordant comorbidities of hypertension and their association with hypertension control were ascertained in this cross-sectional study. A total of 402 adults with hypertension were identified from the baseline survey of a randomized controlled trial for hypertension control among school teachers in Kerala. Chronic conditions were captured and categorized into concordant and discordant comorbidities. Nearly 57% of teachers with hypertension reported multimorbidity. Concordant morbidity was reported by 44% and discordant by 21% of participants. The odds of hypertension control was higher among those who reported at least one discordant morbidity (odds ratio [OR]: 2.76, 95% confidence interval [CI]:1.69–4.49) and those who reported at least one concordant morbidity (OR: 2.08, CI: 1.37–3.16), compared to their counterparts. Hypertension control was higher for those who reported any comorbidity (OR: 2.37, CI: 1.51–3.71) compared to those who did not report any. Well-designed large-scale mixed methods studies are required to thoroughly explore multimorbidity and its relationship with hypertension control in India.
Keywords: Comorbidity, concordant, discordant, hypertension, India, multimorbidity
|How to cite this article:|
Mini G K, Mohan M, Sarma P S, Thankappan K R. Multi-morbidity and blood pressure control: Results of a cross-sectional study among school teachers in Kerala, India. Indian J Public Health 2021;65:190-3
|How to cite this URL:|
Mini G K, Mohan M, Sarma P S, Thankappan K R. Multi-morbidity and blood pressure control: Results of a cross-sectional study among school teachers in Kerala, India. Indian J Public Health [serial online] 2021 [cited 2021 Oct 17];65:190-3. Available from: https://www.ijph.in/text.asp?2021/65/2/190/318352
According to the Global Burden of Disease Study, in 2017, high systolic blood pressure (SBP) was the leading global risk factor for early death and disability for all ages combined, when ranked by risk-attributable disability-adjusted life years. Hypertension is associated with a high level of multimorbidity, and studies have reported that the majority of hypertensive patients suffer from at least one other chronic condition. It was reported that the strongest predictor of high SBP was the number of comorbidities and SBP got lowered by 2.03 mmHg for each additional comorbidity and was lower among patients with multimorbidity regardless of the type of morbidity. However, these studies did not explore the relationship between the type of comorbidities and the control of hypertension.
The conceptualization and categorization of comorbidities, as concordant and discordant, was originally conceived by Piette and Kerr in association with diabetes care. Comorbidities concordant with hypertension have been conceptualized as those having a similar pathophysiologic profile, while the discordant comorbidities have no direct relationship or similarity with hypertension in the overall pathophysiologic profile. Such a categorization of co-morbidities could facilitate an examination of the relationship between the type of comorbidities and hypertension control. A study that examined the impact of co-morbid conditions on the quality of hypertension care found that the odds of receiving overall good quality care was highest for concordant-only co-morbidities, followed by discordant-only co-morbidities compared to no comorbidity.
School teachers are a risk group for hypertension owing to their sedentary lifestyle and occupational stress. However, the association between the presence of comorbidities and hypertension control was not well explored. In this study, we examined the pattern of concordant and discordant comorbidities of hypertension and their association with control of hypertension among school teachers in Kerala, India.
We analyzed the baseline cross-sectional survey data collected as part of a randomized controlled trial on control of hypertension among teachers in schools in Kerala (CHATS-K). The study was conducted in the district of Thiruvananthapuram from January to July 2018. Data were collected from 2216 school teachers of 92 schools in the district. Among them, 402 were found to have hypertension, and the present study analyzed data of these hypertensives. Both government and government-aided private schools were included in the study. Detailed methodology is published elsewhere.
The participants were asked about the presence of chronic diseases diagnosed by a physician/health care provider, and those who reported positively were asked about the specific diseases they were suffering from. A maximum of five diseases was reported. We also gathered information on sociodemographic and behavioral characteristics.
All the measurements were taken according to the World Health Organization STEPS protocol. Anthropometric measurements such as height and weight were measured using Stadiometer (Model 206, Seca, Hamburg Germany) and portable electronic weighing scale (Model HN 283, Omron Corporation, Shimogyo-ku, Kyoto, Japan), respectively. Blood pressure was measured three times using automatic Omron BP apparatus (OMRON-4, Omron Corporation, Kyoto, Japan) with at least 5 min gap. The mean of the last two readings was taken as the final blood pressure.
The concordant comorbidities included diabetes, hyperlipidemia, stroke, kidney disease, and heart problems. Discordant comorbidities included arthritis, osteoporosis, musculoskeletal, asthma, thyroid, and gynecological diseases.
Overweight was defined as body mass index ≥25 kg/m2. Hypertension was defined as SBP ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 or on medication for hypertension. Control of hypertension was defined as SBP <140 mm Hg and DBP <90 mm Hg.
The study was approved by the host Institute Ethics Committee. Written informed consent was obtained from all the participants. Analysis was performed in SPSS version 21.0 (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp) and STATA version 14.1. In all cases, P ≤ 0.05 (after correction for the sampling design based on cluster sampling) was considered statistically significant.
A total of 402 school teachers with hypertension were included in this study, of which 71% were women. The average age was 47 years. Eighty-one percent of the participants were overweight and this was significantly higher for women than men (women: 85.6%, men: 70.3%). A family history of hypertension was reported by 74% of participants. The majority of the participants were postgraduates (58%), 30% graduates and 12% had high school or any other technical education. The mean SBP of the study population was 135 mm Hg, and the mean DBP was 87 mm Hg. Among the hypertensives, 34% achieved adequate control.
Nearly 57% of teachers with hypertension reported multi-morbidity. Concordant morbidity was reported by 44% and discordant by 21% of participants. Around 10% were having both concordant and discordant comorbidities. [Table 1] gives the baseline characteristics by type of comorbidity. The proportion of those with any comorbidity was significantly higher in older age groups. Overweight teachers reported a higher proportion of comorbidity than their normal-weight counterparts.
|Table 1: Baseline characteristics of hypertensive study subjects by pattern of comorbidity (n=402)|
Click here to view
Mean SBP was lower by 3.66 mm Hg and DBP was lower by 2.93 mm Hg for those who reported any comorbidity compared to those with no comorbidity. The mean value of SBP was lower by 2.20 mm Hg and DBP by 3.46 mm Hg for those who reported diabetes. A similar difference for dyslipidemia was SBP: 1.99 mm Hg and DBP: 2.45 mm Hg.
The most prevalent comorbidity was dyslipidemia (31%), followed by diabetes (20%) and thyroid disease (14%). The prevalence of all other comorbidities reported was below 10%. Diabetes and dyslipidemia together were present in eight percent of the study participants. Control of hypertension was significantly higher for those with diabetes, dyslipidemia and for those who had gynecological problems.
Hypertension control was significantly higher for women than men (39.1% vs. 22.0%), and for older teachers aged 45–55 years than younger teachers aged 30–44 years (26% vs. 37%). [Table 2] presents the type of comorbidity with control of hypertension. Control of hypertension was significantly higher among those who reported at least one discordant morbidity (odds ratio [OR]: 2.76, confidence interval [CI]: 1.69–4.49), those who reported any comorbidity (OR: 2.37, CI: 1.51–3.71) and those who reported at least one concordant morbidity (OR: 2.08, CI: 1.37–3.16) compared to their counterparts. The hypertension control increased with the higher number of comorbidities. The control rate was 2.4 times higher for those who reported any comorbidity compared to those with no comorbidity.
A significant proportion of our study participants reported the presence of at least one comorbidity. The proportion of participants with only concordant comorbidities far exceeded those with only discordant comorbidities. This is in agreement with a longitudinal study conducted among hypertensive war veterans of the United States of America.
Our findings of a higher prevalence of comorbidities among older teachers and women are similar to the study results that reported a better hypertension control rate for women as compared to men, especially if they are premenopausal and aged <60. A higher prevalence of concordant comorbidities among men and discordant comorbidities among women in our study was similar to an earlier study finding. In our study, the higher hypertension control among participants with discordant comorbidities could be due to the fact that a significantly higher proportion of participants with discordant comorbidities were women.
Studies have found low education to be independently associated with a high risk of multimorbidity, and this association is explained through its relationship with health-related knowledge, lifestyles, and socioeconomic status. However, school teachers are generally well educated, and hence the role of education may not be significant to our study participants.
The presence of comorbidities was found to be positively associated with hypertension control. This was well in alignment with other studies that explored this association, which found that the number of comorbidities was one of the strongest predictors of BP control among hypertensives., Our study findings are in concordance with an earlier study which reported that hypertensive patients with one or more comorbidities had better hypertension control.
Comorbidities are associated with their impact on patients' exposure to the health system's support and increase the monitoring of chronic conditions. The higher probability of hypertension control among patients with any comorbidity could be due to their greater exposure to the health system. When interpreted using the health belief model, the presence of associated comorbidities could have contributed to better hypertension control and reduced the risk of uncontrolled hypertension. Well-designed large-scale mixed methods studies are required to thoroughly explore multimorbidity and its relationship with hypertension control in India. Potential reduction of blood pressure by task shifting and task sharing interventions in low- and middle-income settings is a promising approach for better control of hypertension irrespective of their comorbidity status.
One of the limitations of the study was that we depended on self-reports for the comorbidities, although they were physician identified. Since the prevalence of comorbidities with hypertension is more among older ages, our findings from teachers aged 30–55 years (predominantly females) may not be generalizable to other population groups.
Financial support and sponsorship
Public Health Research Initiative research grants awarded by the Public Health Foundation of India with the financial support of the Department of Science and Technology, Government of India.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stanaway JD, Afshin A, Gakidou E, Lim SS, Abate D, Abate KH, et al
. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1923-94.
Sarkar C, Dodhia H, Crompton J, Schofield P, White P, Millett C, et al.
Hypertension: A cross-sectional study of the role of multimorbidity in blood pressure control. BMC Fam Pract 2015;16:98.
Piette JD, Kerr EA. The impact of comorbid chronic conditions on diabetes care. Diabetes Care 2006;29:725-31.
Petersen LA, Woodard LD, Henderson LM, Urech TH, Pietz K. Will hypertension performance measures used for pay-for-performance programs penalize those who care for medically complex patients? Circulation 2009;119:2978-85.
Chetia D, Gogoi G, Baruah R. Hypertension and occupational stress among high school teachers of Dibrugarh district. Int J Community Med Public Health 2017;5:206-9.
Mini GK, Sarma PS, Thankappan KR. Cluster randomised controlled trial of behavioural intervention program: A study protocol for control of hypertension among teachers in schools in Kerala (CHATS-K), India. BMC Public Health 2019;19:1718.
Choi HM, Kim HC, Kang DR. Sex differences in hypertension prevalence and control: Analysis of the 2010-2014 Korea National Health and Nutrition Examination Survey. PLoS One 2017;12:e0178334.
Paulsen MS, Andersen M, Thomsen JL, Schroll H, Larsen PV, Lykkegaard J, et al.
Multimorbidity and blood pressure control in 37 651 hypertensive patients from Danish general practice. J Am Heart Assoc 2012;2:e004531.
Winkleby MA, Jatulis DE, Frank E, Fortmann SP. Socioeconomic status and health: How education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health 1992;82:816-20.
Anand TN, Joseph LM, Geetha AV, Prabhakaran D, Jeemon P. Task sharing with non-physician health-care workers for management of blood pressure in low-income and middle-income countries: A systematic review and meta-analysis. Lancet Glob Health 2019;7:e761-71.
[Table 1], [Table 2]