European Journal of Cardiovascular Medicine

In her lifetime, women go through different reproductive phases like menarche, childbirth, lactation and menopause. The menopause is defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. It is preceded by a period of transition, which is the perimenopause. This period is ill-defined and usually starts in late 30’s upto 1 year after menopause. This period is marked by decreasing ovarian follicular reserve and drop in estrogen and progesterone levels. Along with the hormonal changes, women are more susceptible to micronutrient deficiency like anaemia and non-communicable diseases like osteoporosis, arthritis, hypertension, obesity, diabetes, cancer and mental health problems during the perimenopausal period.1,2

Tea is one the most consumed beverages globally and India is the 2nd largest producer and 4th largest exporter of tea in the world.3 Assam contributes to about 53% of the tea production in India. The backbone of the tea industry, the “tea tribe” is a culturally rich integral part of the Assamese community and constitutes about 20% of the total population.4 The tea tribe, despite being the most vital force behind the tea industry, are one of the most socioeconomically marginalized ethnic groups with poor health outcomes especially for women and children.5,6

The present study has been conducted in Sonitpur district, Assam. Among the tea growing districts in Assam, Sonitpur is one of the major tea producer in the north bank of the river Brahmaputra. It is the sixth among the districts in terms of area of tea cultivation and third in terms of tea production annually. It also offers a geographical and commercial hub for diverse ethnic and cultural population groups like Tea-garden tribe, Nepali, Assamese, Adivasi, Bengali, Bodo etc.

This is a community based cross sectional study with a comparative design. This study tries to compare the lives of women from tea garden with that of the women from non tea garden village areas who share similar geographical and environmental conditions with the tea garden community. Here, the researcher attempts to evaluate the variables pertaining to sociocultural background, health seeking behavior, and nutritional status influencing the health status and morbidity profile of women in their perimenopausal age group.7

This is a community based cross sectional comparative study. The study universe is comprised of the women in the age group 35-55 years. The comparison groups are the women from tea gardens and the other group of women representing the non tea garden villages. By considering 95% confidence interval, 10% acceptable margin of error, type-1 error (α) of 0.05, power 80% and anticipated proportion of perimenopausal morbidity among tea garden women as 45% and 35% among non tea-arden women,8,9,10,11 the sample size is calculated using the formula

Sample size=𝒛(𝟏−𝒑)

𝑳𝟐

Where z=1.96, p=prevalence, L= acceptable margin of error.

By considering a non-response rate of 5%, the sample size calculated to be 400. In the present study, 400 participants each from tea-garden and non-tea garden rural community were included respectively. The sampling technique used for obtaining the given sample size was cluster sampling. The sampling units for data collection were the tea gardens or villages. The list of the revenue villages and the tea gardens (including “lines” in each tea garden) under each block was obtained from the respective Block PHC. A multistage sampling method is used to select the clusters. The participants of the tea garden community were selected from two blocks having majority of the tea garden population and the participants of the non tea-garden community were selected from the other two blocks. Data was collected after explaining the purpose of the study in local language in the presence of family members or spouse and after obtaining informed consent. All the women eligible for the study were included from a selected cluster.

Data was collected using a pre-tested, pre-designed semi-structured interview schedule. Other tools used for the data collected were weighing machine, portable stadiometer, digital sphygmomanometer, Sahli’s hemoglobinometer. BG Prasad classification for socioeconomic status (2024 update) was used for assessing socioeconomic status, Parameters of physical activity, substance use were based on WHO-STEPS questionnaire, and secondary data of medical records were used to assess morbidity. Data were compiled using Microsoft excel and analyzed using SPSS.

The given study attempts to compare the sociodemographic, environmental and nutritional correlates pertaining to the morbidity pattern of women from tea garden community with that of the women from non tea-garden community. Total number of participants in both the groups were 400 each.

The age distribution of the tea-garden women was 15.75% in 35-40 years, 32.25% in 40-45 years, 29.5% in 45-50 years and 22.5% in 50-55 years; while the age distribution of the non tea-garden women was 11.25% in 35-40 years, 27.75% in 40-45 years, 31.75% in 45-50 years and 29.5% in 50-55 years (p=0.03 chi square value=8.449). The mean age among tea-garden women was 45±5.7 years and among non-tea-garden women was 47±6.3 years (p=0.023, t-test=4.708). [Table 1]

The educational qualification of the tea-garden women was 53.75% no formal education, 26.75% upto primary school, 14.75% up to high school and 4.75% up to higher secondary class or above; in case of the non tea-garden women educational qualification was 3.75% no formal education, 44% upto primary school, 40.25% up to high school and 12% up to higher secondary class or above. (p<0.0001) [Table 1] It was observed that 64.5% of the tea garden women were employed in public/private job (mostly as tea garden worker), whereas 71.5% of the non tea garden women were not employed. Majority of the tea garden women were financially independent (72.5%) but majority of the non tea garden women were financially dependent on their spouse or other family members (69.75%) [P<0.0001, 95%CI= 2.105-2.958]. Regarding the socioeconomic status according to BG Prasad classification (2024), among the tea garden women majority belonged to middle class 36% and lower middle class 31.5%; whereas among the non tea garden women majority belonged to upper middle class 38.75% and middle class 30%. (p<0.0001, Chi square = 46.042). In the housing and environment, it was observed that among the tea garden women, 35.75% of were living in overcrowded condition, 18.25% did not have proper ventilation in house and 38.5% were using water for daily use from insanitary sources. However, among the non tea garden women, 22% (p<0.0001) had overcrowding, 19.25% did not have proper ventilation in house and 29.25% (p=0.007) were using water for daily use from insanitary sources. [Table 1 & 3]

The mean age at marriage among tea-garden women was 19±2.1 years and among non tea-garden women was 21±1.7 years (p<0.0001, t-test=14.8, 95%CI= 1.7-2.2). The mean age at the first child among tea-garden women was 21±1.4 years and among non tea-garden women was 23±2.2 years (p<0.0001, t-test=15.3, 95%CI= 1.7-2.2). Among the tea-garden women 46.75% had two or less than two living children and 53.25% had more than two children, whereas, among the non tea- garden women 60.25% had two or less than two living children and 39.75% had more than two children. During their childbirth the tea-garden women reported higher proportion of home delivery (67.25%) and the non tea-garden women reported higher proportion of institutional delivery (70.75%) [Fisher’s exact test, p<0.0001, 95%CI= 0.3884-0.5308]. [Table 2] In lifestyle and behavioral risk factors, chewing betel nut was most common substance used (84.75% among tea garden women and 79.5% among non tea garden women). Diet survey was done using 24-hour recall method and it was observed that among the tea-garden women 39.75% consumed approximately 1500-1800 kcal per day, 31.25% consumed 1800-2200 kcal, followed by 21.75% consumed less than 1500 kcal; whereas among the non tea-garden women 42.5% consumed approximately 1800-2200 kcal per day, 35.5% consumed 1500-1800 kcal, followed by 13.25% consumed more than 2200 kcal (P<0.0001, chi square= 37.013). [Table 4]

During physical examination, Body Mass Index (BMI) among the tea-garden women was low in 32.75%, normal in 62% and overweight in 5.25% of participants; whereas among the non tea- garden women BMI was low in 24%, normal in 63.25% and overweight in 12.75% of participants (P=0.0001, chi square= 17.946). Blood pressure among the tea-garden women was normal in 28.25%, pre-hypertensive in 37.5% and hypertensive in 34.25% of participants, whereas among the non tea-garden women blood pressure was normal in 42%, pre-hypertensive in 32.25% and hypertensive in 25.75% of participants (P=0.0002, chi square= 17.162). As per the hemoglobin level observed during this study, 47% of the tea garden women had mild to moderate anaemia and 14% had severe anaemia, whereas 42.75% of the non tea garden women had mild to moderate anaemia and 3.25% had severe anaemia (P<0.0001, chi square= 37.280). [Table 4]

Among the diseases reported by the participants which were diagnosed earlier and taking medicines, hypertension (TG-18.75%, Non TG-20.5%), type-2 diabetes (TG-3%, Non TG- 7.25%), thyroid disorder (TG-2.5%, Non TG-7%), chronic obstructive pulmonary disease (TG- 2.75%, Non TG-3.5%), tuberculosis (TG-4%, Non TG-0.75%) were common. [Table 5] Current morbidity profile among the tea garden women as per the history and general examination, included Fatiguability (21.5%), Joint pain and stiffness (30.5%), Muscle cramp (28.75%), Peptic

ulcer and reflux (23.75%), Indigestion and bloating (26.75%), and Menstrual irregularity (16.5%); among the non tea garden women, morbidity profile included Fatiguability (22%), Joint pain and stiffness (41.5%), Muscle cramp (38%), Peptic ulcer and reflux (28.5%), Indigestion and bloating (30.75%), Menstrual irregularity (9.25%), Mood swing, disturbed sleep (18.25%) and vertigo (9%). While assessing the health seeking behavior of the participants, 51.75% of the tea garden women preferred allopathic system, 28.75% prefer traditional methods within their belief system; in case of non tea garden women 71% preferred allopathic system and 23.75% preferred ayurvedic / homeopathic system (P<0.0001). [Table 5]

Table 1. Sociodemographic variables.

Table 2. Reproductive history.

Table 3. Environment.

Table 4. Behaviour & Physical examination.

Table 5. Morbidity profile.

across three tea garden estates, showed that, 25.7% of the participants were illiterate, 76.3% belonged to middle class as per BG Prasad classification, 77% participants preferred allopathic physicians for treatment, 51% also reported consulting folk/traditional healers, and 63.3% had health insurance. Among the morbidity reported, 15.7% had communicable diseases and 47.3% had non-communicable diseases. Among the NCDs, diabetes was 7.8%, hypertension was 35.9%, musculoskeletal disorder 17.6%, gastrointestinal and neurological disorder 19%. In our study, it was observed that 53.75% tea garden women were illiterate, 72% tea garden and 53% non-tea garden participant were receiving social security schemes; and among the morbidities joint pain 30%, gastrointestinal problem 30%, fatiguability 21%, pre-hypertension 37%, hypertension 34% were observed.

A study done by Das BP,13 amongst the menopausal women living in the Char area around Fakhruddin Ali Ahmed Medical College, Barpeta, Assam showed that 100% of them had more than 2 children, 60% were illiterates, 36% of the women had the habit of taking tobacco in some form smoking/chewing. As per the reported morbidity, Joint pains (51%), backache (48%), fatigue (36%), urinary problems (28%), hot flushes (20%) and cold sweats (12%) were the most frequently complained symptom. Common co morbid conditions afflicting the women were arthritis (30%), hypertension (18%) and diabetes (4%). In our study, it was observed that 53% tea garden women and 39% non tea garden women had more than 2 children, tobacco consumption was 6% among tea garden women and 4% among non tea garden women. And among the morbidities, hypertension 34%, mild to moderate anaemia 47%, severe anaemia 14%, joint pain 30% were observed among tea garden women.

A study done by Rivam Sarkar,14 in a tea-estate situated at Naxalbari block, Siliguri subdivision, Darjeeling district, West Bengal, showed that 65.2% presented with Non-communicable disease and 34.8% had communicable disease. Among the NCDs 96% had hypertension, 79% had joint pain. In our study, it was observed that hypertension 3%, thyroid disorder 2.75%, COPD 2.75%, tuberculosis 4% and diabetes 3% were common pre-existing morbidities.

A study done by Vazirani A and Ravichandiran N,15 among the postmenopausal women attending the OPD at the Obstetrics and Gynecology Department at Sree Balaji Medical College and Hospital, Chennai showed that 70% of the females belong to the age group of 45–49 years, 61% of women belong to a joint family, 48% belonged to middle class according to BG Prasad scale. Among the morbidities, joint pain was the most frequently reported symptom (86%), followed by depression (51%), and hot flashes (49%). In our study, it was observed that The mean age among tea-garden women was 45±5.7 years and among non tea-garden women was 47±6.3 years. And among the morbidities, hypertension (tea garden 34%, non tea garden 25%), severe anaemia (tea garden 14%, non tea garden 3%) joint pain (tea garden 30%, non tea garden 41%) were observed among the perimenopausal women.

In our study, the mean age of participants from tea garden were relatively younger as compared with the non tea garden women (p=0.02), majority of them had low education (p<0.0001) and inadequate access to health education, economically backward (p<0.0001) and mostly engaged in tea garden jobs like plantation, leaf plucking or factory work. On the other hand, perimenopausal women in non tea garden areas had access to better housing and environment, were financially less

independent (p<0.0001), better access to institutional delivery and Cesarean section, more calorie intake (p<0.0001) and higher proportion of overweight (p=0.0001). Among the morbidities, higher prevalence of anaemia (p<0.0001) and hypertension (p=0.0002) was observed among the women in tea garden; whereas, joint pain, muscle cramp, Indigestion and bloating, Mood swing, disturbed sleep were more common among the women in non tea garden areas.

Perimenopausal symptoms are more of psychosocial issue rather than biological. The healthcare delivery system should develop a supportive environment for these women to have access to evidence based treatment, counselling for a healthier outcome. Social security schemes like Ayushman Bharat and Atal Amrit Abhiyaan have provided a much promising platform for women in underserved areas to secondary and tertiary level care at zero out-of-pocket expenditure.

1.       Nanette Santoro. Perimenopause: From Research to Practice. Journal of women’s health. Volume 25, Number 4, 2016. Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2015.5556

2.       Burger HG, Hale GE, Robertson DM, et al. A review of hormonal changes during the menopausal transition: Focus on findings from the Melbourne Women’s Midlife Health Project. Human Reprod Update. 2007;13(6):559–565.

3.       https://worldostats.com/country-stats/tea-production-by-country/

4.       https://ttwd.assam.gov.in/about- us/ourhistory#:~:text=There%20are%20more%20than%201000,speed%20implementatio n%20of%20welfare%20schemes

5.       Medhi G, Hazarika N, Shah B, Mahanta J. Study of Health problems and Nutritioal status pf Tea garden population of Assam. Indian J Med Sci. 2006; 60(12): 496-505

6.       Singh S N, Narain A and Kumar P (2006), Socio-Economic and Political Problems of Tea Garden Workers: A Study of Assam, Mittal Publication, New Delhi.

7.       Sahoo D, Konwar K, Sahoo BK. Health condition and health awareness among the tea garden laborers: a case study of a tea garden in Tinsukia district of Assam. IUP Journal of Agricultural Economics. 2010; 7(4):50.

8.       Sundararajan M, Srinivasan V. Prevalence of menopausal symptoms and healthseeking behavior of school teachers with menopausal symptoms in Kumbakonam, South India. Int J Community Med Public Health 2023;10:1224-31.

9.       Natarajan N, Nandi P, KA N, et al. (March 09, 2024) Investigating the Prevalence of Menopausal Symptoms and Medico-Social Dimensions of Menopause in Rural Puducherry, India: A Cross-Sectional Analytical Study. Cureus 16(3): e55841. DOI 10.7759/cureus.55841.

10.    Kairi TK, Dey S. Prevalence of work-related musculoskeletal symptoms among tea garden workers in Bangladesh: a crosssectional study. BMJ Open 2022;12:e061305. doi:10.1136/bmjopen-2022-061305.

11.    Bebina Vincia Anjala Mary, Padmapriya D, Dr. Suja Suresh, (2025) Exploring The Prevalence Of Menopausal Symptoms And Medico-Social Dimensions Of Menopause– A Cross Sectional Study. Journal of Neonatal Surgery, 14 (4), 225-231.

12.    Sonalee Rajput, Sibasis Hense and K.R. Thankappan. Healthcare utilisation: a mixedmethod study among tea garden workers in Indian context. Journal of Health Research. Vol. 36 No. 6, 2022. pp. 1007-1017.Emerald Publishing Limited. e-ISSN: 2586- 940X. p-ISSN: 0857-4421. DOI 10.1108/JHR-02-2021-0101.

13.    Das BP, Talukdar T, Ahmed AS. Common health issues of menopausal women living in Char area around Fakhruddin Ali Ahmed Medical College and Hospital, Barpeta in NorthEast India, Journal of Obstetrics & Gynaecology Barpeta, 1 (1):36-40.

14.    Sarkar R, Dasgupta P, Bhattacherjee S. Morbidity pattern of tea garden residents of Darjeeling, India. MRIMS J Health Sci 2024;12:215-8.

15.    Vazirani, A., Ravichandiran, N. Prevalence of Menopausal Symptoms and Their Health Seeking Behavior in Postmenopausal Women in a Tertiary Care Hospital. J Obstet Gynecol Cancer Res. 2024;9(4):385-94.