European Journal of Cardiovascular Medicine

As India moves into the epidemiological and demographic transition, we are faced with an increasing burden of non-communicable diseases. One of the goals of the newly developed Sustainable Development Goals is the reduction of premature mortality. ⁽¹⁾ Non-Communicable Diseases (NCDs) like Cardiovascular diseases, Diabetes, Cancer and Chronic Obstructive Pulmonary Diseases have become major public health challenges, which contribute to high morbidity and mortality in India. People of all age groups, regions and countries are affected by NCDs. These conditions are often associated with older age groups, but evidence shows that 17 million NCD deaths occur before the age of 70 years. Of these premature deaths, 86% are estimated to occur in low- and middle-income countries. Children, adults and the elderly are all vulnerable to the risk factors contributing to NCDs, whether from unhealthy diets, physical inactivity, exposure to tobacco smoke or the harmful use of alcohol or air pollution. ⁽²⁾  The four common NCDs (Cardiovascular diseases, Cancer, Diabetes and Chronic respiratory diseases) are estimated to account for over 57% of the total mortality in the age group of 30-59 years, thereby adversely impacting social and economic    development. ⁽³⁾

These diseases are driven by forces that include rapid unplanned urbanization, globalization of unhealthy lifestyles and population ageing. Unhealthy diets and a lack of physical activity may show up in people as raised blood pressure, increased blood glucose, elevated blood lipids and obesity. These are called metabolic risk factors and can lead to cardiovascular disease, the leading NCD in terms of premature deaths. ⁽²⁾

As a signatory to the Global Action Plan for the Prevention and Control of Noncommunicable Diseases (NCD), India is now mandated to halt the rise of diabetes by 2025 and reduce the prevalence of hypertension by 25% between 2010 and 2025. To achieve these targets, the Government of India has launched a National Multisectoral Action Plan for the Prevention and Control of NCDs and a dedicated program for the National Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS).⁽⁴⁾ Series of measures have taken by MoHFW (Ministry of Health and Family Welfare) beginning from NTCP (National Tobacco Control Programme) in 2007 and launch of NPCDCS (National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and stroke) in 2010 to population-based screening in 2016 for effective control of these diseases.

In our country due to low levels of health awareness and significant information asymmetry that exists, screening for diseases where there are no obvious symptoms is perceived to be an unnecessary process, particularly so, amongst the poor, for whom a day’s visit to the secondary or tertiary facility for screening, might mean the loss of a day’s wages. ⁽⁵⁾ Management of NCDs includes detecting, screening and treating these diseases, and providing access to palliative care for people in need. High impact essential NCD interventions can be delivered through a primary health care approach to strengthen early detection and timely treatment. ⁽²⁾

Population based screening will also serve the purpose of increasing awareness in the community about NCDs/ risk factors and the need for periodic screening. It also enables an understanding of better health and avoidance of risk factors in the general community. ⁽²⁾ Community Based Assessment checklist (CBAC) is a simple and effective method for assessing non communicable diseases and assigning risk score to individual. India being vast and diverse country, CBAC is the cost-effective approach as it can be used with minimum training by health worker.

There is paucity of studies and further exploration on usage of CBAC as screening tool needs to be undertaken. There is a need for intensive population based screening and early detection of individuals with NCD risk factors. Hence, this study is an attempt to know the load in the community and further strength population-based screening which are currently undertaken at primary health care level. The objectives of study are to estimate NCD risk using Community Based Assessment Checklist (CBAC) among adult population.

A descriptive, community based, cross sectional study was conducted at Manikeshwari, which is urban filed practice area of department of community medicine, Gulbarga Institute of Medical Sciences, Kalaburagi (GIMS), Karnataka. Study was conducted for a period of 3 months among adult population with more than 30 years of age and those individuals who are known case of hypertension, diabetes mellitus, stroke, or cardiovascular disease and pregnant women were excluded from study. According to NFHS 5, the prevalence of overall hypertension in Karnataka is 25%, and using formula n=z²pq/d², sample size was found to be 300. ⁽¹²⁾

Data collection method: There are 7 wards in UHTC Manikeshwari with 66353 with 17561 houses. Required sample size was divided among 7 wards according population proportion to size. From each ward, houses were selected by systematic random sampling and eligible subjects were included in the study. Participants were interviewed and examined after obtaining verbal consent. Data was collected by semi structured questionnaire which contained socio-demographic details, Community Based Assessment Checklist. Anthropometric Measurements and blood pressure was recorded as a part of routine general physical examination.

Study Tool: Community Based Assessment Checklist (CBAC) is used by health workers in PHC for screening of NCDs like Hypertension, Diabetes and Cardiovascular diseases. It is simple questionnaire which is intended to capture details related to age, family history for any of the NCDs, waist circumference, and risky behaviours such as physical inactivity, use of/or exposure to tobacco and alcohol use. Each question has allotted score and if total score of individual subjects is 4 and above indicates high risk for developing NCDs and need for further evaluation and follow up.

Statistical Analysis: Data was entered in MS Excel 2019 version and presented in percentages and proportions; Chi square test was applied wherever required to find association between subjects with high risk CBAC score and various other variables.

Out of total 300 subjects, highest number of subjects belonged to age group 31-40 years, 65% were females and around 40% had illiterate. Majority (46%) of subjects reported housewife as their occupation and 70.3% were belonging to nuclear families. [Table 1]

NCD risk score of 4 and above was significantly high in male subjects.NCD risk increased with increase in age and was more common in illiterate group. No statistically significant association was found between high NCD risk score and occupation, socio-economic status and type of family. Based on their blood pressure, study participants were divided into three categories, normal, high normal and hypertension, among 300 participants, 73 (24.3%) were detected to have hypertension, 106 (35.3%) were high normal blood pressure and 121 (40.4%) having normal blood pressure. Study participants with “hypertension” category were having high NCD risk score of 50.7%, followed by those in 33% in “high normal” category and least was in “normal” category with 24.8%. High NCD risk score was increasing with increase in blood pressure. This association was statistically highly significant. Based on Body Mass Index, study participants were divided into different categories. NCD Risk score was highest in obese category (58.8%) followed by those in overweight category (35.1%), normal (27%) and least in underweight (17.2%). NCD risk score was increasing with increase in body mass index. This association was statistically highly significantly. [Table 2]

This study is conducted in urban slum area of Kalaburagi district, which is situated in northern part Karnataka, with aim to estimate non-communicable disease risk using CBAC (community-based assessment checklist).

Most of the participants (65%) in this study are females and among them 70.7% identified housewife as their occupation. Almost all the participants were belonging to Hindu religion. 41.3% of study sample consisted of younger population in the age group of 30 to 40 years and non-formal education constituted 40% of population.

Validity of CBAC as the screening tool has been tested by Vinoth Kumar Kalidoss et al in Kerala and reported sensitivity and specificity to be 85.7% and 53.7% respectively. Score of 4 and above increased sensitivity to 98%. However, Gupta et al found sensitivity and specificity to be 65.4% and 52.4% and reported lesser predictive value for diabetes and hypertension as compared to IDRS score.

Among the 300 randomly selected study participants in this study,102 had risk score of 4 and above, which is 34% of sample.  These study subjects are at high risk of developing non-communicable diseases like hypertension, diabetes mellitus, cardiovascular diseases and cancer, hence have to be screened more frequently and referred to higher center. Kaur et al reported much higher risk score 57.7% as compared to our study, in rural Haryana. Choudhry N et al also reported very high-risk score. (24% at CBAC >4 ,48% at CBAC =4). However, Jaacks et al conducted study with higher sample of 11,322 in rural Punjab reported CBAC score >4 to be 14.4%. Preet at al conducting similar study in medical camp in Delhi noted 24% of study sample were having risk score 4 and above. Gupta et al in hospital-based study found 29.3% of sample to have high risk score. Variation in different numbers in scoring can be due to rural-urban variation, hospital-field variation, gender composition variation and self-reporting nature of screening tool. There are six parameters in CBAC scoring regarding age, smoking, alcohol consumption, waist circumference, physical activity and family history of NCDs. Among these, five are self-reporting parameters and one parameter waist circumference can be verified. Hence investigator has to rely on the answers given by subjects to be correct.

CBAC risk score was significantly higher in males (41.9%) compared to females (29.7%) in this study. Kaur et al also reported similar finding. High CBAC risk score increased consistently with increase in age group of subjects. Jaacks et al also reported similar finding in their study. In our study, literacy status of subjects was significantly associated with high CBAC risk score. Illiterate, schooling and pre-university and above subjects had 45.8%, 27.1% and 13.6% respectively. Hence with increase in literacy level consistent decrease in risk scores. This may be attributed to subjects becoming more aware of their health with increase in literacy status. Jaacks et al reported similar finding, 50.2%, 29.4% and 20.4% of subjects in high risk with non-formal education, primary and middle schooling and high school and above education respectively.

In present study, occupation, socio-economic status and type of family did not have significant association with high risk. However, Jaacks et al reported employment and income to have significant association with high-risk score.

On measurement of blood pressure, hypertension, high normal and normal subjects had 50.7%, 33% and 24.8% respectively. 46% of hypertensive subjects were in high-risk group as compared to 26% in low-risk group as noted by Jaacks et al.

With increase in BMI of subjects, CBAC risk score also increased consistently. Similar findings were found by Komal Preet et al, BMI of 25 and above had more risk of high scores.

In our study, with CBAC as screening tool, 34% of study subjects have risk score of 4 and above. Increased age and male gender have significantly higher score. Higher literacy status is associated with significantly lower CBAC score. Occupation and socio-economic status did not show any association with CBAC score. Higher blood pressure and increased BMI are significantly associated with higher CBAC score.

Acknowledgments: We would like to express our gratitude to all the study population who participated in this study and interns who has supported in the study.

Funding:  ICMR STS Project Funding.

Conflict of interest: None declared.

Ethical approval: The study was approved by the Institutional Ethics Committee

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