hypertension

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Aust. J. Rural Health (2012) 20, 219–225

Original Article
Prevalence of hypertension and pre-hypertension in rural women: A report from the villages of West Bengal, a state in the eastern part of India ajr_1287 219..225

Anindita Dutta, PhD,1,2 and Manas Ranjan Ray, PhD2
1

College of Environmental Sciences and Engineering, Peking University, Beijing, China; and
Department of Experimental Hematology, Chittaranjan National Cancer Institute, Kolkata, India

2

Abstract
Objective: To find out the prevalence of hypertension, pre-hypertension and tachycardia among the women in rural areas of West Bengal, identify co-factors associated with the prevalence and contribute to the body of evidence for future health programs to identify at-risk groups. Design: A population-based cross-sectional study was conducted. Setting: The study was conducted in remote villages.
Participants: 1186 women participants, aged 18 years or more were included.
Main outcome measures: They were interviewed using standard structured questionnaire. Blood pressure and tachycardia was monitored using digital sphygmomanometer. For each participant, we made two blood pressure measurements with an interval of 48 hours. Data was analysed statistically using SPSS software.
Results: Overall prevalence of hypertension in the study subjects was 24.7% and that of pre-hypertension and tachycardia was 40.8% and 6.4%, respectively. Both hypertension and pre-hypertension were seen to increase with age. Other identified significant factors were use of biomass fuel for cooking, absence of separate kitchen, higher body mass index (BMI), education and average family income.
Conclusion: This study suggests quite high prevalence of hypertension as well as pre-hypertension among the women of rural areas. The findings are significant from the women health perspectives. Early detection of prehypertensive and hypertensive subjects will help to
Correspondence: Dr Anindita Dutta, International Senior
Research Scholar/Postdoctoral Fellow, Zhu Tong Group,
College of Environmental Sciences and Engineering, Room #
217, Peking University, Beijing 100871, China. Email: [e-mail] Both authors contributed equally to the research and manuscript preparation.
Accepted for publication 7 May 2012.

formulate intervention strategies to allay the spread of cardiovascular diseases.
KEY WORDS: female, hypertensive, pre-hypertensive, tachycardia, village area.

Introduction
Hypertension and pre-hypertension are important public health issues in India. There are very few studies detailing the prevalence of hypertension as well as prehypertension in the eastern part of the country. Two recent studies have documented high rate of arterial hypertension in some parts of rural India.1,2 But there is a paucity of study concentrating on both hypertension as well as pre-hypertension from the eastern part of
India. Hence, it is important to run a similar study in the rural parts of West Bengal, which is a state located in the eastern part of India. This study was, thus, undertaken with a view to determine the prevalence of hypertension, pre-hypertension and tachycardia among women of rural West Bengal.
Hypertension is considered as a primary risk factor for cardiovascular diseases (CVD).3,4 It is a multifactorial trait that results from the net effect of environmental and genetic factors. Elevated systolic blood pressure is a major risk factor for atherosclerosis, cerebrovascular and coronary artery diseases, congestive heart failure, renal failure, peripheral vascular disease and premature death.5,6 A relatively small but sustained increase in diastolic blood pressure also increases the risk for coronary events and strokes by approximately
30% and 40%, respectively.7,8
Similarly, tachycardia (pulse rate > 100 beats per minute) is a potential health hazard. Higher resting heart rate is a simple and useful indicator of autonomic balance and metabolic rate. It has emerged as an independent predictor for arterial stiffness and atherosclerotic cardiovascular disease.9 It increases the risk of morbidity and mortality from CVDs. An increase in heart rate by 10 beats per minute (bpm) has been shown

© 2012 The Authors
Australian Journal of Rural Health © National Rural Health Alliance Inc.

doi: 10.1111/j.1440-1584.2012.01287.x

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A. DUTTA AND M. R. RAY

What is already known on this subject:
• Hypertension and pre-hypertension are important public health issues in India.
• Two recent studies have documented high rate of arterial hypertension in some parts of rural India.
• There are very few studies detailing the prevalence of hypertension as well as prehypertension in the eastern part of the country. What this study adds:
• This study suggests quite high prevalence of hypertension as well as pre-hypertension among the women of rural areas.
• The findings are significant from the women health perspectives.
• Early detection of pre-hypertensive and hypertensive subjects will help to formulate intervention strategies to allay the spread of cardiovascular diseases.

to be associated with an increase in the risk of cardiac death by at least 20%, and this increase in the risk is similar to the one observed with an increase in systolic blood pressure by 10 mm Hg.10 Tachycardia may originate from the sinus node, heart’s natural pacemaker, and the change can be appropriate or inappropriate. Women are more predisposed to developing CVD compared to their male counterparts.11 That hypertension can be treated underscores the necessity of early detection and adequate treatment of hypertension. Also, the information regarding prevalence, identified potential risk factors will be helpful in developing health policies for prevention and control of this condition.
It will help to contribute to the body of evidence for future health programs to identify the at-risk groups.
Given to this background, the present was undertaken accordingly. five years prior to the date of study were eligible for inclusion into the study. The conduct of this study was approved by the Institutional Ethics Committee of Chittaranjan National Cancer Institute, Kolkata.

Materials and methods
Study areas, participants and study period
Health camps were organised for this cross-sectional study in 18 villages of Hooghly, Nadia, Burdwan,
Birbhum, Medinipore, 24 Parganas (South and North) and Howrah districts of West Bengal. The villages from different districts were selected randomly. Health camps were organised with the help of local governing bodies or panchayats, as they are called in West Bengal. This cross-sectional study included 1186 women aged
18 years or more. The study was carried out during the period of January 2007 to July 2011.
Prior informed consent was taken from the participants. We were able to interact with nearly 1260 eligible participants from different villages through the local panchayats. Participation rate was nearly 94.1% (1186 women) on an average at all villages. Nearly 5.9% (74 women) were unwilling to take part in this study. Only subjects who had resided within the district for at least

Questionnaire survey
Information regarding age, education, habits, occupation, cooking hours per day, cooking years, kitchen and fuel type, number of family members, occupation of the husband and exposure to environmental tobacco smoke
(ETS) for smoking habit of a member of the family, previous history of hypertension and complaints of cardiovascular disease and current use of medication for hypertension was obtained through personal interview using structured questionnaire. Each question was clearly explained to the participants in Bengali (mother tongue) so that they could figure them out and reply suitably. Socio-economic status (SES) was ascertained following the procedure of Srivastava12 and Tiwari et al.13 To report the actual prevalence, women currently under medication for hypertension were also included in the study.

Measurement of blood pressure and pulse rate
Systolic and diastolic blood pressures (SBP and DBP, respectively) were measured while the participants were at rest in a sitting position by digital sphygmomanometer (Omron, India). Guidelines of the British Hypertension Society were followed for blood pressure measurement.14 Systolic (the force that blood exerts on the artery walls as the heart contracts to pump out the blood) and diastolic (force as the heart relaxes to allow the blood to flow into the heart) blood pressures were expressed in millimeters of mercury (mm Hg). The pulse of the brachial artery was measured by the digital sphygmomanometer simultaneously with blood pressure.

© 2012 The Authors
Australian Journal of Rural Health © National Rural Health Alliance Inc.

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Diagnosis of pre-hypertension and hypertension
Hypertension was diagnosed following the Seventh
Report of the Joint Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure15 and 2003 recommendation of the World Health
Organization/International Society of Hypertension.16
The hypertensive condition was confirmed when SBP rose to 140 mm Hg or more, or DBP elevated to
90 mm Hg or more on two separate occasions with an interval of 48 hours, or being on regular antihypertensive therapy. Hypertension was subdivided into two stages based on severity of the problem: Stage 1
(mild to moderate) when SBP was 140–159 mm Hg or
DBP was 90–99 mm Hg or both; Stage 2 (severe hypertension) when SBP and DBP cross the 159 and
99 mm Hg marks, respectively in either case or both.
However, a diagnosis of pre-hypertension was established when either SBP was between 120 and
139 mm Hg, or DBP was between 80 and 89 mm Hg, or both.

Diagnosis of tachycardia
Pulse rate of more than 100 bpm was considered as tachycardia following an international practice guideline developed by the American College of Cardiology, the American Heart Association Task Force on Practice
Guidelines and the European Society of Cardiology
Committee for Practice Guidelines.17 Tachycardia was not classified because it requires advanced medical facilities that were absent in the study areas.

Data analysis
The collected data were entered into computer programs for statistical analysis and interpretation. The results were analysed using SPSS statistical software
(Statistical Package for Social Sciences for windows, release 10.0, SPSS Inc., Chicago, IL, USA). Prevalence rates (age-standardised) of pre-hypertension, hypertension and tachycardia were estimated.18 Logistic regression analysis was used to identify potential risk factors associated with hypertension. A P-value < 0.05 was considered to be significant.

Results
Socio-demographic characteristics
The median age of the participants was 43 years (range:
18–65). Other socio-demographic factors are presented in Table 1. Though we had interacted with 1260 eligible participants initially through the local panchayats, 74

TABLE 1: Socio-demographic characteristics of the rural participants Attributes
Age, years
18–29
30–39
40–49
50–59
60+
BMI, kg m-2
30.0
Kitchen location
Separate
Adjacent
Fuel type
LPG
Biomass
Number of family members, median (range)
Smokers in family (ETS exposed)
Monthly family income, Rupees
10 000
Average years of schooling
0–5
6–10
>10
Food habit
Vegetarian
Non-vegetarian
Alcohol drinking habit

Participants
(n = 1186)

351
262
291
155
127

(29.6)
(22.1)
(24.5)
(13.1)
(10.7)

416
570
141
59

(35.1)
(48.1)
(11.9)
(4.9)

476 (40.1)
710 (59.9)
452
734
4
853

(38.1)
(61.9)
(3–9)
(71.9)

511
367
173
135

(43.1)
(30.9)
(14.6)
(11.4)

448 (37.8)
407 (34.3)
331 (27.9)
136 (11.5)
1050 (88.5)
0 (0)

Results are expressed as number of individuals
(percentage), unless otherwise mentioned. BMI, body mass index; ETS, environmental tobacco smoke; LPG, liquefied petroleum gas.

(5.9%) were unwilling to undergo the survey. Only
1186 (94.1%) women gave their consent to participate and hence, the results obtained from them have been analysed in the following sections.

Prevalence of pre-hypertension, hypertension and tachycardia
Pre-hypertension was prevalent among 40.8% women, while hypertension was present in 24.7% (Table 2).

© 2012 The Authors
Australian Journal of Rural Health © National Rural Health Alliance Inc.

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A. DUTTA AND M. R. RAY

TABLE 2: Prevalence of hypertension, pre-hypertension and tachycardia

Variables

Participants
(n = 1186)

Normal blood pressure
Pre-hypertension
Systolic
Diastolic
Both
Hypertension
Systolic
Stage 1
Stage 2
Diastolic
Stage 1
Stage 2
Systolic + Diastolic
Anti-hypertensive therapy
Tachycardia

409
484
193
53
238
293
115
94
21
66
60
6
87
25
79

(34.5)
(40.8)
(16.3)
(4.4)
(20.1)
(24.7)
(9.7)
(7.9)
(1.8)
(5.6)
(5.1)
(0.5)
(7.3)
(2.1)
(6.7)

Results are expressed as number of individuals
(percentage). Age standardised data have been presented according to World Health Organization age distribution18.

Tachycardia was observed among 6.7% of the population (Table 2). Among the hypertensive, only 25 persons
(2.1%) were aware that they had hypertension and hence, were under medication. Among those on antihypertensive therapy, 15 used to cook using liquefied petroleum gas (LPG), and the rest 10 women used biomass fuel for cooking. They were quite uniformly distributed in terms of the socio-demographic attributes.
Prevalence of pre-hypertension and hypertension increased with age, use of biomass fuel for cooking, absence of separate kitchen, body mass index (BMI) and education (Table 3). Pre-hypertension also varied with average family income.
Though tachycardia did not show any variablespecific variation, yet it was more prevalent among those who were aged more than 39 years, those who belonged to families with an average income of more than Rupees 10 000 and those who had BMI higher than 24.9 kg m-2. Table 3 represents the odds of having pre-hypertension, hypertension and tachycardia after adjusting for all other effects.

Discussion
This study showed that prevalence of pre-hypertension
(40.8%) and hypertension (24.7%) was noticeable in the rural areas of West Bengal. Tachycardia (6.7%) was also perceptibly present among the village women. In

spite of the gravity of the problem, there has nearly been no study in rural West Bengal to identify the at-risk group. Hypertension is a growing menace not only in the developed countries but also in the developing countries like India. Even then, less attention has been given to this aspect. Though some studies have been carried out in the cities and other urban places of India,19–21 only few such studies have been done in the villages.22–24 The status of West Bengal in this regard is poor. A few studies on urban community25,26 have been done but we have found none such studies on rural communities.
Our findings are comparable to the prevalence found in the other studies carried out in India.19–26
In our study, pre-hypertension was more prevalent compared to hypertension. Identification of prehypertensive group at an early stage would help to take prevention and therapeutic steps to stop development of hypertension. This study is, hence, very significant from this point of view.
Our study showed that both pre-hypertension and hypertension were more prevalent among the older groups, though tachycardia did not show any such trend. Also, biomass-using women had higher prevalence of pre-hypertension and hypertension compared to their LPG-using counterparts. Similar observations regarding biomass use and prevalence of hypertension has been found in a Guatemalan study.27 Other factors associated with higher prevalence of pre-hypertension and hypertension was absence of separate kitchen, less education and lower family income.
The group with less education and lower family income were more at risk. This might be due to the reason that they are under maximum stress. Women from a poorer economic background flock less to school and are more involved in doing household chores in the village areas of West Bengal. They are involved in cooking, getting married, having children and taking the responsibilities of the family at a very early age. Hence, they are prone to be under more stress compared with the other groups.
Previously, we had reported28 that hypertension and pre-hypertension was present among 29.5% and 39.3% biomass-using women, respectively. In LPG users, the prevalence was 11% for hypertension and 19.1% for pre-hypertension. When the two populations were combined, we got a prevalence of 20.4% and 29.4%, respectively. In the current study, the respective rates are 24.7 and 40.8, respectively. These differences may be due to the different age group composition in the previous
(median age: 34 years (range: 22–41) for biomass users; three years (23–40) for LPG users) and the current studies (median: 43, range: 18–65). This study also includes subjects from higher age group (23.8% were aged more than 50 years).

© 2012 The Authors
Australian Journal of Rural Health © National Rural Health Alliance Inc.

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HYPERTENSION PREVALENCE IN RURAL INDIA

TABLE 3:

Multivariate relationship between independent variables and pre-hypertension, hypertension and tachycardia
Odds ratio (95% confidence interval)

Variable

Pre-hypertension

(a) Together with women on anti-hypertensive therapy
Age in years
18–29†
1.00
30–39
2.69‡ (1.90–3.79)
40–49
3.20‡ (2.29–4.47)
50–59
3.25‡ (2.18–4.85)
60+
2.17‡ (1.41–3.34)
Fuel type
LPG†
1.00
Biomass
4.08‡ (3.13–5.33)
Kitchen location
Separate†
1.00
Adjacent
4.51‡ (3.46–5.89)
Education
0–5 years
1.11 (0.84–1.47)
6–10 years†
1.00
>10
2.25‡ (1.67–3.02)
Family income
10 000
4.08‡ (2.48–6.70)
BMI, kg m-2
30.0
0.77 (0.44–1.37)
Food habit
Vegetarian†
1.00
Non-vegetarian
1.26 (0.87–1.82)
(b) Excluding the women on anti-hypertensive therapy
Age in years
18–29†
1.00
30–39
2.69‡ (1.90–3.79)
40–49
3.20‡ (2.29–4.47)
50–59
3.25‡ (2.18–4.85)
60+
2.17‡ (1.41–3.34)
Fuel type
LPG†
1.00
Biomass
4.08‡ (3.13–5.33)
Kitchen location
Separate†
1.00
Adjacent
4.51‡ (3.46–5.89)
Education
0–5 years
1.11 (0.84–1.47)
6–10 years†
1.00
>10
2.25‡ (1.67–3.02)
Family income
10 000
4.08‡ (2.48–6.70)
BMI, kg m-2
30.0
0.77 (0.44–1.37)
Food habit
Vegetarian†
1.00
Non-vegetarian
1.26 (0.87–1.82)
†Reference group. ‡Significant. BMI, body mass index; LPG, liquefied petroleum gas.

© 2012 The Authors
Australian Journal of Rural Health © National Rural Health Alliance Inc.

Hypertension

Tachycardia

1.00
3.04‡ (1.86–4.99)
5.73‡ (3.60–9.10)
7.18‡ (4.31–11.95)
11.09‡ (6.56–18.74)

1.00
2.15 (0.91–5.04)
2.65‡ (1.18–5.96)
4.374‡ (1.89–10.13)
7.53‡ (3.35–16.94)

1.00
1.51‡ (1.14–1.20)

1.00
0.80 (0.51–1.27)

1.00
1.65‡ (1.25–2.18)

1.00
1.04 (0.65–1.66)

1.67‡ (1.20–2.31)
1.00
1.89‡ (1.34–2.67)

1.26 (0.74–2.14)
1.00
0.98 (0.54–1.80)

0.48 (0.33–0.70)
0.61 (0.41–0.91)
1.00
0.97 (0.60–1.56)

0.34 (0.18–0.65)
0.35 (0.18–0.69)
1.00
1.41‡ (0.73–2.72)

1.56‡ (1.14–2.14)
1.00
3.94‡ (2.65–5.86)
5.78‡ (3.31–10.09)

1.53 (0.84–2.80)
1.00
4.58‡ (2.42–8.64)
8.13‡ (3.88–17.07)

1.00
0.43 (0.30–0.63)

1.00
0.48 (0.27–0.86)

1.00
3.04‡ (1.86–4.99)
5.71‡ (3.58–9.10)
7.19‡ (4.31–11.89)
11.07‡ (6.51–18.73)

1.00
2.15 (0.91–5.04)
2.65‡ (1.18–5.96)
4.374‡ (1.89–10.13)
7.53‡ (3.35–16.94)

1.00
1.49‡ (1.12–1.23)

1.00
0.80 (0.51–1.27)

1.00
1.66‡ (1.23–2.19)

1.00
1.04 (0.65–1.66)

1.67‡ (1.20–2.31)
1.00
1.86‡ (1.33–2.68)

1.26 (0.74–2.14)
1.00
0.98 (0.54–1.80)

0.48 (0.33–0.70)
0.63 (0.41–0.91)
1.00
0.95 (0.61–1.57)

0.34 (0.18–0.65)
0.35 (0.18–0.69)
1.00
1.41‡ (0.73–2.72)

1.56‡ (1.14–2.14)
1.00
3.94‡ (2.65–5.86)
5.78‡ (3.31–10.09)

1.53 (0.84–2.80)
1.00
4.58‡ (2.42–8.64)
8.13‡ (3.88–17.07)

1.00
0.43 (0.30–0.63)

1.00
0.48 (0.27–0.86)

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A. DUTTA AND M. R. RAY

Our study has one limitation. No evidence-based data were available regarding the dietary intake of the participants. Dietary salt intake might have played a significant role in the prevalence data. Hence, we suggest using standardised tools29 to evaluate their role in the prevalence of hypertension. This was beyond our scope to carry out a similar study, given to the fund constraints. But given to the fact that this study is the first of its kind from West Bengal to have reported prevalence of pre-hypertension, hypertension and tachycardia combined together among the rural population, this study is highly significant. We believe that this study will serve a pilot to more such studies in the near future.
In a nutshell, this study is very important from the health perspectives. It will serve as an eye-opener to the health officials and policymakers. It will also encourage researchers to undertake studies on this aspect in other areas of West Bengal, which we could not cover. This study may serve as a pillar to contribute to the body of evidence on health and help the health department to easily identify people at risk of developing cardiovascular disease and give them proper treatment.

Acknowledgement
The study was funded by Council of Scientific and
Industrial Research, India.

Conflict of interest
The authors declare that there is no conflict of interest.

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