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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 7
| Issue : 4 | Page : 183-191 |
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Patient compliance, comorbidities, and challenges in the management of hypertension in India
Prateek Singh1, TR Dilip2
1 Institute of Economic Growth, New Delhi, India
2 International Institute for Population Sciences, Mumbai, Maharashtra, India
| Date of Submission | 19-Oct-2022 |
| Date of Decision | 19-Oct-2022 |
| Date of Acceptance | 26-Nov-2022 |
| Date of Web Publication | 07-Jan-2023 |
Correspondence Address:
Prateek Singh
Village- Mahagaon (kot), Post-Garathaman, Varanasi - 221 208, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jncd.jncd_72_22
Background and Objectives: As of now, only one-third of those with hypertension in India are unaware of the existence of this condition, and only a negligible share of those diagnosed can control it through medication. There is a need to understand the characteristics and behaviors of patients treated for hypertension for generating evidence for better management of this condition. In this context, the study examines the key factors associated with uncontrolled blood pressure (BP) levels in patients under medication for hypertension.
Subject and Methods: Data from the nationally representative Longitudinal Ageing Study of India survey, 2017–18, are used for the analysis. This study is restricted to 12,353 respondents aged 45 years and above who were already diagnosed with hypertension before the survey and are under medication. BP level at the point of the survey was used to classify the respondents as hypertension under control (systolic <140 mm and diastolic <90 mm), Grade-1 Hypertension (systolic 14–159 mm or diastolic 90–99 mm), Grade-2 Hypertension (systolic160–179 mm or diastolic 100–109 mm), and Grade-3 Hypertension (systolic 180 or above mm or diastolic 110 or above mm). Bivariate and multivariate logistic regression analysis is performed to study the association between hypertension control in these patients and their demographic, socioeconomic, and behavioural characteristics.
Results: A critical proportion of respondents have uncontrolled hypertension of Grade 1 (31%), Grade 2 (15%), and Grade 3 (2%), despite taking medication for the same. As compared to their remaining counterparts, the risk of uncontrolled hypertension is high in rural areas (odds ratio [OR] = 1.37, 95% confidence interval [CI], P < 0.01), old-adults living alone (OR = 1.63, 95% CI, P < 0.05), patients having no schooling (OR = 1.18, 95% CI, P < 0.05), patients with obesity (OR = 1.2, 95% CI, P < 0.05), moderate alcohol drinkers (OR = 2.1, 95%CI, P < 0.01), abusive alcohol drinkers (OR = 1.6, 95% CI, P < 0.01).
Interpretation and Conclusions: Poor control over BP levels among patients from rural areas, the poorest and most vulnerable sections, supports the governmental efforts initiated since 2018 to expand community-level screening and provisioning of noncommunicable diseases, including that for hypertension. In addition, concrete efforts for health promotion within patients under medication for hypertension too are essential for better management of this condition.
Keywords: Aging, hypertension, India, medication, noncommunicable diseases
How to cite this article:
Singh P, Dilip T R. Patient compliance, comorbidities, and challenges in the management of hypertension in India. Int J Non-Commun Dis 2022;7:183-91 |
How to cite this URL:
Singh P, Dilip T R. Patient compliance, comorbidities, and challenges in the management of hypertension in India. Int J Non-Commun Dis [serial online] 2022 [cited 2023 Mar 31];7:183-91. Available from: https://www.ijncd.org/text.asp?2022/7/4/183/367307 |
| Introduction | |  |
Noncommunicable diseases (NCD), mainly high blood pressure (BP) (hypertension) among adults are increasing globally and remaining at high levels in low- and middle-income countries. Hypertension accounted for 44% of the 42 million deaths related to NCDs globally in 2019.[1] Hypertensive patients are estimated to have doubled from 650 million to 1.28 billion between 1990 and 2019, mainly due to population growth and aging.[2],[3] It is becoming the measure cause of premature deaths.[3] Hypertension is the leading cause of cardiovascular diseases (CVD).[4] Hence, the goal of hypertension treatment is to lower high BP and protect important organs, such as the brain, heart, and kidneys, from damage.
Hypertension is also called a “silent killer” without major symptoms, due to which there is a delay in diagnosis and detection of the disease. Evidence from India shows 46% of all persons with hypertension are unaware of their condition and are not receiving treatment, and 42% are aware of it but are not receiving treatment, leaving only (1 out of 5) 21% in whom hypertension is controlled.[5] Therefore, they are unaware, untreated, and even after treatment not able to control, and it shows a triple burden.[6]
A study conducted on South Asian adults aged 35–70 shows that the prevalence of hypertension is 30.7% in India, 33.5% in Pakistan, and 39.3% in Bangladesh. Of those with hypertension in India (40.4%) are aware,(31.9%) are treated, and (13.0%) are able to control it.[7] The overall prevalence of age-sex-adjusted self-reported hypertension was 25.8% in India, with significant variation across Indian states. Elderly individuals 4 out of 10 adults over 45 years of age in India, are unaware of their hypertensive condition.[8] Of those acquainted, 73% are currently taking medication, and only 10% have their hypertension under control.[9] In India, 57% of deaths related to stroke and 24% of deaths related to coronary heart disease are conjoined to hypertension.[10] Similarly, In accordance with global evidence, hypertension is the overriding risk factor for CVD in India.[11]
Hypertension detection, awareness, and control are very low in India,[8], [9,[11],[12] and the hypertensive patients are expected to increase exponentially in the future.[13] There are several studies that are concentrated on prevalence and awareness.[7],[8],[14] However in this study, the focus is on identifying the subgroups of populations in India that are unable to exercise hypertension control despite medication for the same. This is important as the patients under medication are also expected to make related behavioral changes in their diet and lifestyle to improve hypertension treatment outcomes.
| Subject and Methods | | |
The data from the wave-I (2017–18) of the longitudinal aging study of India (LASI) undertaken by the Ministry of Health and Family Welfare, Government of India. LASI was designed in line with the Health and Retirement Studies carried out across many countries. This full-scale national survey provides comprehensive and internationally comparable data for all Indian states on the health, economic, and social determinants and consequences of population aging. The LASI covered a panel sample of 72,250 individuals aged 45 and above and their spouses from 35 states and union territories of India (excluding Sikkim).[15]
Only 12,353 respondents aged 45 years in the LASI sample, who were reported to be diagnosed with hypertension and is under medication for it, were considered for this analysis [Figure 1]. The following two questions in the survey were used to identify such respondents under medication for hypertension in the survey; (1) has any health professional ever told you that you have hypertension? and (2) To control your BP or hypertension, are you currently taking any medication? The BP readings recorded for respondents in the LASI survey were used as a measure of hypertension control status among those under medication for hypertension. | Figure 1: Flow diagram showing exclusions and final sample sizes of the study population, longitudinal ageing study of India 2017–18
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Here, the Omron HEM 7121 BP monitor was used in LASI to screen respondents for hypertension, adopting internationally comparable protocols.[16] Consenting participants were encouraged not to consume any caffeinated beverages and restrict alcohol and smoking for at least 30 min before measuring BP. It noted first, second, and third systolic and diastolic readings at equated time intervals. The mean of the last two readings was taken as the final reading for our study. In accordance with the national guidelines,[17] the respondent under medication for hypertension were categorized as below:
- Hypertension under control: systolic <140 mm and diastolic <90 mm
- Grade 1 Hypertension: systolic 140–159 mm or diastolic 90–99 mm
- Grade 2 Hypertension: systolic160–179 mm or diastolic 100–109 mm
- Grade 3 Hypertension: systolic 180 or above mm or diastolic 110 or above mm.
For this analytical exercise targeted on patients on medication for hypertension, those with hypertension under control and with grade 1 hypertension were treated as having better treatment outcomes when compared to their counterparts with grade 2 and Grade 3 hypertension. Association between hypertension control and demographic, social, economic, lifestyle, and health-related risk factors was performed.
Demographic, social, and economic factors
Demographic factors include the current age of the patients and their sex. Socioeconomic factors include the place of residence (rural/urban), marital status (married/widowed/divorced), living arrangement (living alone/living with spouse and others/living with spouse and children/living with children and others/living with others only), religion (Hindu/Muslim/Christian/Others), social groups (scheduled caste/scheduled tribe/other backward class/others), education status based on completed years of school education (no schooling/<5 years of schooling/5–9 years of schooling/ten or more years of schooling), work status (never worked/currently working/former worker) and Economic status based on monthly per-capita consumer expenditure (MPCE) of the respondent's household (poorest/poorer/middle/richer/richest).
Lifestyle and health-related risk-factors
The body mass index (BMI) information available was used to classify respondents as (1) normal or underweight (BMI <25), (2) overweight (BMI 25–30), and (3) obese (BMI >30). Respondent's current smoking status (Yes/No). Respondents were classified according to their levels and frequency of alcohol consumption (1) who never consume alcohol (never consumer) (2) once in 1 or 2 months (light drinkers), (3) 1 to 3 days per month (moderate drinkers) and (4) 4 or more days per week (abusive drinkers). Adherence to diet restrictions was captured based on the regulation that the patients observed in their salt intake in their diet (Yes/No). Respondents were considered to be having moderate physical activity if they performed at least 150 min of moderate-intensity physical activity throughout the week (Yes/No). The activity of daily living (ADL) is defined on the basis of the patient was ability to do normal daily self-care activities, such as movement in bed, changing position from sitting to standing, feeding, bathing, dressing, grooming, and personal hygiene as (Yes/No). Based on reported diabetes, the respondents were classified as (1) nondiabetic, (2) diabetic under medication, and (3) diabetic not under medication.
A Chi-square test was carried out in order to check the bivariate association between background characteristics with risk of grade 2 and grade 3 hypertension. Due to the high volume of missing data, the variable duration diagnosed with hypertension was not considered for multivariate analysis. In logistic regression, dependent variable was coded as 0 if “hypertension. Grade I hypertension” and 1 if “grade 2 or grade 3 hypertension.” The first logistic regression model examined the association with demographic, socioeconomic, and demographic factors. The second model accounted for behavioral and heath-related risk faction in addition to variables in the model I. StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC was used for data analysis.
| Results | | |
A total of 12,353 individuals aged 45 and above reported their BP. Among them, 53% have their BP under control after taking medication, 31% had grade 1 hypertension, 15% had grade 2 hypertension, and 2% had grade 3 hypertension.
Differential by demographic and socioeconomic factors
Results indicate [Table 1], [Figure 2] and [Supplementary Table 1] that patients 75 years and older (20%), residents of rural areas (18%), divorced/separated individuals (22%), those living alone (19%), and those with <5 years of education (15%) are more likely to suffer from grade 2 or grade 3 hypertension. As far as patients' sex, work status, and wealth status are concerned, there was no significant difference. | Figure 2: Distribution of adults aged 45 years and above medicated for hypertension by their blood pressure level and by their demographic and socioeconomic characteristics, India. Note: Hypertension under control (systolic <140 mmHg and diastolic <90mmHg), Grade 1 Hypertension (systolic 140–159 mmHg or diastolic 90–99 mmHg), Grade 2 hypertension (systolic 160–179 mmHg or diastolic 90–99 mmHg), Grade 3 Hypertension (systolic more than equal to 180 mmHg or diastolic more than or equal to 100 mmHg)
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 | Table 1: Risk of grade 2/grade 3 hypertension in adults aged 45 years and above under medication for hypertension by background characteristics, India 2017-2018
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Differential by lifestyle and health-related risk-factors
Patients currently consuming any type of tobacco (15%), patients consuming alcohol four or more days per week (38%), patients having difficulties in activities of daily living (19%), and patients' duration of diagnosed with hypertension of more than 10 years (18%) are having grade 2 or grade 3 hypertension even after medication [Table 1]. Variables like the presence of other noncommunicable c diseases, obesity, and involvement in yoga or meditation were not showing any association with hypertension treatment outcomes.
Results from multivariate analysis
The odds ratio (OR) for the selected demographic, socioeconomic, behavioral, and health factors associated with poor treatment outcomes for hypertension are presented in [Table 2]. The risk of having grade or grade hypertension is 1.2 times higher (OR = 1.21, P < 0.05) for those aged 75 years and above compared to patients aged 45–54. Patients residing in rural area have almost 1.4 times (OR = 1.37, P < 0.01) more chance of getting hypertension than urban resident patients. As compared to the patients who live with their spouse and children, those who live alone (OR = 1.63, P < 0.05) or live with others (OR = 1.55, P = 0.08) are at a higher risk of hypertension. As compared Hindu, Christian (OR = 1.3, P < 0.01) and Sikh, Jain, Buddha, and others (OR = 1.2, P < 0.05) are at a higher risk of hypertension. Scheduled tribe (OR = 1.4, P < 0.01) are more vulnerable than patients belonging to the General or Other backward class. As compared to patients who completed 10 or more years of schooling, patients having no schooling (OR = 1.18, P < 0.05) and patients with 5–9 years of schooling (OR = 1.17, P < 0.05) are at higher risk. Compared to the richer people, the poorest (OR = 1.3, P = 0.007) people are at higher risk of hypertension. For patients' sex, marital status, and for their work status, we did not find any significant results. | Table 2: Results from logistic regression of demographic and socioeconomic factors affecting the grade 2/grade 3 of hypertension, India 2017-2018
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It shows that obese patients (OR = 1.2, P < 0.05) have a higher risk of hypertension than counterparts who are underweight. Moderate drinkers (OR = 2.1, P < 0.01) and abusive drinkers (OR = 1.6, P < 0.01) have a higher risk than those who never had alcohol [Figure 3]. Those who are not taking care of diet restrictions (OR = 1.2, P < 0.05) have a lower risk than those taking diet restrictions. Those who have difficulty with activity in daily living (ADL) (OR = 1.2, P < 0.05) are at higher risk than those who did not have any problem with ADL. As compared to nondiagnosed diabetes patients, patients taking medication for diabetes (OR = 1.12, P < 0.05) and thereafter riskier for those who are not taking medication for it (OR = 1.4, P < 0.05) [Figure 3]. For patients consuming tobacco and doing a moderate physical activity, we did not find any significant results. Detailed result is shown in [Table 3]. | Figure 3: Risk of getting hypertenison for pateints with overweight and obesity, diabetes and consumption of alcohol after taking medication for it, India 2017–18
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 | Table 3: Results from binary logistic regression of behavioral and comorbidities affecting the grade 2/grade 3 of hypertension, India 2017-2018
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| Discussion | | |
The study brings out the patient level challenges in managing the challenges. Firstly, only half of the elderly aged 45 and above were able to control their BP level after taking medication for it. Secondly, more than one out of every six hypertensive patients are at Grade 2 or Grade1 hypertension despite taking medication. Thirdly, patients who belong to a poor family, scheduled tribes, less educated, and resending in rural areas are more vulnerable to poor treatment outcomes. Hypertension control is poor in patients staying alone when compared to those staying with a spouse or other family members son/daughter, showing a contributory role in familial setting in controlling hypertension. As noted in other studies obesity[18] and excess use of alcohol[19] are barriers in hypertension management. This study clearly shows poor control of hypertension among those with diabetes, and the situation is worst in the case of diabetes patients not under medication for the same. There were studies that are trying to understand the effect of tobacco consumption and hypertension; out of them, few studies show positive[20],[21] and few shows negative relation.[22] No such relation was observed in this study.
The finding of this study is highly relevant in similar populations experiencing a shift from communicable to NCDs. Their health systems in future need to be geared to meet the infrastructure and workforce required for treating NCDs. According to the National Noncommunicable Disease Monitoring survey 2017–18, More than seven out of ten urban and rural public primary care facilities were providing daily NCD services to patients.[23] Moreover, nearly one in four and one in three facilities in urban and rural areas were providing inpatient care for diabetes and hypertension, respectively. This study suggests that patients residing in the rural areas are more vulnerable due to a lack of facilities, only 2.3% and 1.1% of public primary care facilities in urban and rural areas had all the necessary technologies and medicines as per WHO guidelines.[23] The private and public primary and secondary facilities in India are not adequately prepared for the prevention of NCDs.[24]
The comprehensive data set because of its cross-sectional nature, has some limitations, which could have contributed to the inverse or lack of association in the case of other selected behavioral variables. The share of frail persons in this survey of the old age population is higher, and these subgroups often tend to have activity restrictions leading to poor participation in ADL and physical activity. They also tend to have dietary restrictions due to medical reasons. Another limitation is that we have self-reported information on whether they are currently under medication. Additional information on treatment continuity, and frequency in BP check-ups and in seeking medical advice, could be collected in LASI follow-up survey for a better understanding of the management of hypertension.
| Conclusions | | |
The Government of India' flagship Ayushman Bharat-Health and Wellness Centre (AB-HWC), initiated in 2018, has NCD care as a key component within the comprehensive primary care package.[25] A major challenge for this scheme will in addressing the shortage of essential medicines and trained health workers[26],[27] for these illnesses requiring long-term care. Community-based screening for NCDs including hypertension, will certainly reduce undiagnosed hypertension and increase demand for medicines to control the same. The analysis is an illustration of the existing/potential demand for Ayushman Bharat Health and wellness centres (AB HWCs), in order to reach out to those requiring long-term medical attention including hypertension and other NCDs. The other major challenge of AB-HWCs is in creating awareness and interventions towards improving healthy lifestyles in patients, which is noted to be limited but is significantly associated with improved hypertension.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]
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