European Journal of Cardiovascular Medicine

Hypertension is a leading public health challenge globally, contributing significantly to the burden of cardiovascular and renal diseases. According to the World Health Organization (WHO), the number of adults aged 30–79 years living with hypertension has surged to about 1.28 billion worldwide; nearly doubling since 1990; with almost half of these individuals unaware of their condition.[1] This condition markedly elevates the risk of heart attacks, strokes, and kidney failure and remains one of the top causes of mortality and morbidity worldwide. Notably, the majority of the global hypertensive population resides in low- and middle-income countries, including India, reflecting the epidemiological shift of chronic diseases to developing regions.  [2]

According to NFHS 5, nationally, 21% of women and 24% of men age 15 and over have hypertension, and 39% of women and 49% of men age 15 and over are pre-hypertensive, respectively. In response to this growing crisis, India became the first country to adopt the global non-communicable disease action plan in 2014, setting a national target of 25% relative reduction in hypertension prevalence by 2025. This underscores a high level of policy commitment, recognizing hypertension as a pressing health priority.[2]

Urban and rural differences in hypertension epidemiology form an important dimension of the problem, which is especially relevant for a district-level study in India. Traditionally, urban populations have shown higher hypertension prevalence than rural populations, attributed to more sedentary lifestyles, processed diets, and greater stress in cities. However, recent evidence indicates that this urban–rural gap is narrowing. As rural communities undergo lifestyle transitions (e.g. increased intake of oily/salty foods and reduced physical activity due to mechanization), hypertension rates in many rural areas have escalated. A recent meta-analysis of low- and middle-income countries found only a modest difference in hypertension prevalence between urban (about 30.5%) and rural (27.9%) populations, and noted that rural rates have been rising faster in recent decades. In India too, rural hypertension prevalence is rapidly catching up with urban level. This convergence means that both urban and rural populations warrant equal attention in hypertension surveillance. Therefore, focusing on both urban and rural areas within the same region (District Jalaun) provides a more comprehensive understanding of the hypertension burden and enables the assessment of how locality influences prevalence and risk factors in association with socio-demographic profile. [3-5]

STUDY DESIGN:

The study performedwas a descriptive cross-sectional study after taking Institutional Ethical consideration.

STUDY AREA:

The study was carried out at the urban and rural regions of Jalaun district, with the population of 1,689,974, comprising of 906,092 males and 783,882 females, having sex ratio of 865. The area covers 4,565 Km², with 75.21% of the population living in rural areas. [6]

STUDY POPULATION:

This research was conducted among the 800 rural and 800 urban residents of district Jalaun.

STUDY DURATION:

The study conducted for the duration 18 months, from November 2022 to April 2024, which was extended up to July 2024 (due to 3-month DRP posting). Pilot study has also been done from November 2022 to December 2022 to observe feasibility of study and validation of study questionnaire.

SAMPLE POPULATION

The people included in the study were all 30-60 years residents who were present during the duration of the study at Rahiya, Sarsoki and Patel Nagar, Jalun.

INCLUSION CRITERIA

Individuals who were of 30 years (not after 1^stNovember 2022) and not above 59 years 11 months 364 days during the time of the data collection.

EXCLUSION CRITERIA

• Individuals who were gravely sick and confined to bed and were unable to give the response.
• Individuals <30 years
• Individuals >60 years

SAMPLE SIZE CALCULATION

This study was carried out among 30-60 years population in rural and urban area of district Jalaun. We used to determine the sample size by 4 PQ /L² where;

• P is the prevalence of hypertension and it is taken as 21.7% according to NFHS-5 Uttar Pradesh data. [6]
• Q is 100-P that is 78.3%
• L is the Relative error it is taken as 10% of P (21.7)
• Error thus obtained is2.17, thus sample size calculated using the above formula,
• n=1446, adding correction of 10% factor the sample size obtained was 1600.
• Sample size was equally distributed in both areas, i.e. 800 participants were taken each from urban and rural areas.

SAMPLING TECHNIQUE

District Jalaun comprised of 11 Urban local bodies and 9 Rural blocks from which; Orai and Dakore block were selected using Simple random sampling technique through lottery method. Again, ward 9-Patel nagar of Orai and Rahiya, Sarsoki villages of Dakore block were randomly selected using lottery method from 32-wards and 161 villages through lottery method and house to house survey was conducted till the desired sample size achieved in that ward and block.

DATA TOOL

• Pretested questionnaire
• Weighing machine
• Manual Sphygmomanometer
• Stethoscope
• The questionnaire was filled accordingly to the inclusion criteria, and finally two measurements of the blood pressure were made within 2 minutes of interval.

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DATA COLLECTION PROCEDURE:

• The data was collected through house-to-house survey A brief introduction was given to the participants regarding the study and importance of study in the present scenario.
• After attaining Consent from the participants, a semi‑structured questionnaire was used for data collection.
• The questionnaire was created using information from similar studies including socio-demographic, dietary pattern.[7-8]
• The questionnaire was pretested before administering to the study clients. A pilot study comprising of 20 participants from the study areas was done prior to data collection to find out whether the questionnaire is feasible or not.

The average of two readings was used. Then according to the Blood Pressure, the participants were categorized based on JNC 8 criteria:

DATA ANALYSIS PLAN

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS). The data was initially processed and coded on MS Excel. When presenting data, normally distributed data was typically shown using means and standard deviation. Categorical data was presented as a frequencies and percentages (%) and their association was determined utilizing either χ2 or Fisher’s exact probability tests. A p-value < 0.05 was considered to be statistically significant at 95% confidence interval.

Table 1: Age wise distribution of study participants

This table shows both urban and rural convergence, where majority of study population were between 40-49 years followed by 30-39 years and least contributed to 50-60 years in both areas.

TABLE 2: Gender distribution of study participants

Table 2 shown the gender wise distribution of study participants, out of which dominance indicated to males in urban while females in rural.

Table 3: Prevalence and association of the hypertension in respective of the residential area.

Prevalence of hypertension in urban area was on a higher extent (18%), compared to the rural area (14.6%), but found to be statistically non-significant (p-value: 0.0677)

Table 4: Prevalence and association of Grading of hypertension in in respective of the residential area.

The single most common category in the study population is pre-hypertension (45.3 %), followed by normal BP (38.3 %), and manifest hypertension (stage 1 + stage 2) accounts for 16.3 % of all subjects.

Normal BP is markedly more frequent in the rural cohort (42.5 %) than in the urban cohort (34.1 %). However, Pre-hypertension is the predominant category in both settings but is higher in urban residents (47.8 % vs 42.8 %).Stage 1 hypertension also shows a higher prevalence in urban participants (16.8 %) than in rural (14.1 %).Stage 2 hypertension, although rare overall (0.9 %), is more than twice as prevalent in urban (1.25 %) than rural (0.5 %) areas. With statistical association, indicating a significant association (p-value:0.03) between area of residence and BP category.Thus, urban residency is linked to a shift toward higher BP classifications when compared with rural residency.

Table 5: Dietary pattern of subjects and association with hypertension

This table shows majority of rural area constituted by vegetarians and majority of urban area constituted by non veg diet. Hypertensive prevalence was more among non veg diet in both study area. The Prevalence of pre hypertension was more among non veg diet in both areas. Normal hypertension in both areas was constituted by vegetarians. Among vegetarians only 10% were hypertensive in the rural and only 14% were hypertensive in urban area respectively. Significant association was seen in the distribution of blood pressure categories between rural and urban populations across different diets(p-value-0.001).         

Table 6: Salt intake per person and use of extra salt other than used for cooking and association with hypertension

The above tables show hypertensive prevalence was more among those who intake salt more than 5 gm teaspoon in both rural and urban. Majority of the study population intake salt ≤5 gm tea spoon in the both the study area. Those residing in the urban study population consumes >5 gm teaspoon salt more with respect to the rural counterpart. Hypertensive prevalence was more among those who use extra salt other than those used in cooking in both rural and urban According to salt intake per person the factor is significant. Significant difference (p-value:0.001) was present in salt intake levels between study areas and the use of extra salt other than used for cooking and the hypertension.

This study was conducted to compare the hypertensive prevalence and its associated risk factors of hypertension among 30-60 years population in both the study areas of district Jalaun and to identify the socio-demographic and the lifestyle risk factors connected to hypertension in study population of district Jalaun.

A total of 1600 subjects were selected, which included 800 each from the rural and urban areas of Jalaun respectively. Majority of the study population pertained to age group of 40–49 yrs followed by 30–39 yrs and 50-60 years. 58% of the study population were constituted by males rest 42% by females. Hypertensive prevalence in rural and urban area according to this study was 14.6% and 18 % respectively. This was slightly lower than the NFHS 5 data of Uttar Pradesh which is 19% and 23% respectively. [6]

In this study the hypertension was found to be more among 50 to 60 years in both the study population with respect to 30-39 and 40-49 years, and hypertension was least among 30-39 years in both the study area. In all age groups, hypertension was more in urban when compared to rural. The trend of prevalence increases when age progresses in both the study area. In this study the there was a statistically significant difference in the distribution of hypertension status across different age groups between the rural and urban populations.

As people get older, they were more likely to have elevated blood pressure. This is because blood vessels become stiffer with age, which makes blood pressure rise. [9]In a similar study done by Cheng W et al, [10] Males' age-related rise in SBP is linear, but females' age-related rise is non-linear. Men saw a later but lengthy period of growth in high systolic Bp  when compared to  women did, although over the past ten years, a significant growing trend of high SBP risk among those who are  middle-aged  has been seen Similar to our study a study done by Singh Shikha et al, [11] The old age group and the age group before the eldest (45–54 years) in men had the greatest mean blood pressure, both diastolic and systolic, respectively, whereas the women in the 45-54 age group had the highest mean blood pressure levels, both.

In this research, contributed 57% of rural and 59% of urban while females contributed 43% and 41% respectively in rural area and urban area. With respect to female’s hypertension was more common among males in both rural and urban. Females contributed more to the normotensives in both rural as well as urban. The prevalence of pre hypertension was also more in males than females in both rural and urban areas. There was no statistically significant association in the blood pressure categories between study populations across gender.In a similar study conducted by EkwunifeOI,[13] et al in Nigerian population and found that males had a significantly higher blood pressure compared to females.

In this study Majority of study participants resides in pucca house and least in kucha house. Both in rural and urban hypertension was more prevailed in those residing in pucca house with respect to semi pucca. Kucha house is not seen anywhere in urban area. significant association was found between the area of residence and blood pressure categories when considering housing type.In a study by Sharma et al the risk of hypertension was significantly inversely correlated with local deprivatiWhen compared to highly disadvantaged areas, those from the least deprived areas had higher probability hypertension.[14]

In the current study majority of rural area were constituted by vegetarians and majority of urban area were constituted by non veg diet. Hypertensive prevalence was more among non veg diet in both the study areas. Prevalence of pre hypertension was more among non veg diet in both study areas. Normal hypertension in both study area was constituted by vegetarians. Among vegetarians in rural area only 10% were hypertensive and only 14% are hypertensive in the urban area respectively. Significant difference was present in the blood pressure categories between study populations across different diets.

Additionally, this dietary pattern was linked to higher energy intake, which raises the sodium level, and reduced potassium intake, both of which are important CVD risk factors.In a study conducted by Chandwani H et al,a comparatively higher prevalence was found among males, those with a nonvegetarian diet, high saturated fat intake, and a lack of physical exercise. [15]

In the current study hypertension was more among those who intake salt more than 5 gm teaspoon in both study area. Majority of the subject’s intake salt ≤5 gm tea spoon in both the areas. Those residing in the urban study population consumes >5 gm teaspoon salt more when compared to the rural counterpart. Hypertensive prevalence was more among those who use extra salt other than those used in cooking in both study area.

According to salt intake per person the factor is significant.Both the amount of salt consumed and the amount of extra salt used for purposes other than cooking varied significantly between study-areas, as did the hypertensive prevalence. [16-18]

The INTERSALT study, conducted in 32 countries, showed that a high dietary salt intake is a major contributor to hypertension. Similarly, Ghosh et al. found that 81.1 % of hypertensive patients in urban areas and 59.5 % in rural areas exceeded 6 g of salt per day, with the urban group being 2.54 times more likely to surpass this threshold. [5] However, the study did not clarify how much extra (discretionary) salt each group added at the table. Other investigators reported comparable trends: Chandwani H et al. observed a higher rate of hypertension among individuals consuming excess salt, while Bhadoria AS, Kasar PK, and Toppo NA et al. identified elevated per-capita salt intake as a key risk factor for hypertension in urban populations. [15,19]

Among the 1600 adults studied, only 38.3 % had normal blood pressure, while 45.3 % were pre-hypertensive and 16.3 % were overtly hypertensive (Stage 1 + Stage 2). These figures underscore that more than three in five mid-life adults in Jalaun already carry some degree of elevated cardiovascular risk. However, urban residents were significantly less likely to have normal BP (34.1 % vs 42.5 %) and more likely to be pre-hypertensive or hypertensive (χ² = 13.88, df = 3, p = 0.003). Stage 2 hypertension, though rare overall (0.9 %), was more than twice as common in urban areas (1.25 % vs 0.5 %).The study corroborated previous evidence that excess dietary salt, physical inactivity, overweight/obesity, tobacco/alcohol use and self-reported stress were significantly associated with higher BP categories, with salt intake emerging as the strongest modifiable determinant.

RECOMMENDATIONS

Promoting healthy lifestyles is important. This involves engaging in regular physical activity, eating a balanced diet low in calories and sodium, quitting smoking, and consuming no alcohol. The best method for bringing blood pressure down to a normal range is to alter one's lifestyle, as most study participants had pre-hypertension. Implementing the above multi-level actions could accelerate. Community health workers can bridge access gaps, and structured lifestyle support can reduce systolic BP by 4–7 mmHg on average.

FINANCIAL SUPPORT: NIL

CONFLICT OF INTEREST: NIL

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