Oduru Suresh

Cluster randomised feasibility trial to improve the Control of Hypertension In Rural India (CHIRI): a study protocol

Introduction Hypertension is emerging in rural populations of India. Barriers to diagnosis and treatment of hypertension may differ regionally according to economic development. Our main objectives are to estimate the prevalence, awareness, treatment and control of hypertension in 3 diverse regions of rural India; identify barriers to diagnosis and treatment in each setting and evaluate the feasibility of a community-based intervention to improve control of hypertension. Methods and analysis This study includes 4 main activities: (1) assessment of risk factors, quality of life, socioeconomic position and barriers to changes in lifestyle behaviours in ∼14 500 participants; (2) focus group discussions with individuals with hypertension and indepth interviews with healthcare providers, to identify barriers to control of hypertension; (3) use of a medicines-availability survey to determine the availability, affordability and accessibility of medicines and (4) trial of an intervention provided by Accredited Social Health Activists (ASHAs), comprising group-based education and support for individuals with hypertension to self-manage blood pressure. Wards/villages/hamlets of a larger Mandal are identified as the primary sampling unit (PSU). PSUs are then randomly selected for inclusion in the cross-sectional survey, with further randomisation to intervention or control. Changes in knowledge of hypertension and risk factors, and clinical and anthropometric measures, are assessed. Evaluation of the intervention by participants provides insight into perceptions of education and support of self-management delivered by the ASHAs. Ethics and dissemination Approval for the overall study was obtained from the Health Ministrys Screening Committee, Ministry of Health and Family Welfare (India), institutional review boards at each site and Monash University. In addition to publication in peer-reviewed articles, results will be shared with federal, state and local government health officers, local healthcare providers and communities. Trial registration number CTRI/2016/02/006678; Pre-results.

Factors associated with awareness, treatment and control of hypertension in a disadvantaged rural Indian population

The aim of this study was to identify factors associated with awareness, treatment and control of hypertension in a rural setting in India. Following screening of the population, all individuals with hypertension (blood pressure (BP) ⩾140/90 mm Hg or taking antihypertensive medications) were invited to participate in this study. We measured BP, height, weight, skinfolds, waist and hip circumference, and administered a questionnaire to obtain information regarding socioeconomic and behavioural characteristics. Multivariable logistic regression was used to determine factors associated with awareness, treatment and control of hypertension. We recruited 277 individuals with hypertension. Awareness (43%), treatment (33%) and control (27%) of hypertension were poor. Greater distance to health services (odds ratio (OR) 0.56 (95% confidence interval (CI)) 0.32–0.98) was associated with poor awareness of hypertension while having had BP measured within the previous year (OR 4.72, 95% CI 2.71–8.22), older age and greater per cent body fat were associated with better awareness. Factors associated with treatment of hypertension were having had BP measured within the previous year (OR 6.18, 95% CI 3.23–11.82), age ⩾65 years, physical inactivity and greater per cent body fat. The only factor associated with control of hypertension was greater per cent body fat (OR 1.05, 95% CI 1.01–1.11). Improving geographic access and utilisation of health services should improve awareness and treatment of hypertension in this rural population. Further research is necessary to determine drivers of control.

PS 06-06 ASSOCIATION BETWEEN INFLAMMATION AND HYPERTENSION IN A RURAL, DISADVANTAGED INDIAN POPULATION IS DIFFERENT FOR MEN AND WOMEN

Objective: There is some evidence that low grade inflammation is associated with an increased risk of hypertension, but whether this is the case in disadvantaged populations in India has not been established. We aimed to assess the risk of hypertension associated with high sensitivity C-reactive protein (CRP), a marker of inflammation, in a rural population of Indians living in poverty. Design and Method: In a case-control study in 58 villages in southwestern Andhra Pradesh, we age- and sex-matched 300 cases with hypertension to 300 controls without hypertension. Blood pressure (BP) was measured according to a strict protocol. CRP (Immulite 2000xpi) was categorized into three groups: < 1 mg/L (reference category), 1 to <3 mg/L, and ≥ 3 mg/L. Conditional logistic regression was used to determine associations between CRP and hypertension (BP ≥ 140/90 mmHg), adjusted for income, smoking, central obesity, and residual effects of age. Results: In this population, 34% of participants had CRP levels below 1 mg/L and 31% ≥ 3 mg/L. We were unable to detect an association between hypertension and CRP levels of 1 to < 3 mg/L (Odds Ratio (OR) 1.29, 95% Confidence Interval (95%CI) 0.83 to 2.00) or CRP ≥ 3 mg/L (OR 1.33, 95%CI 0.84 to 2.10). When investigating these associations by sex, there was an association between CRP and hypertension in men (levels of 1 to < 3 mg/L [OR 1.80, 95%CI 1.00 to 3.24] and ≥ 3 mg/L [OR 1.99, 95%CI 1.04 to 3.82]). No similar association was found in women (levels of 1 to < 3 mg/L [OR 0.79, 95%CI 0.39 to 1.60] and ≥ 3 mg/L [OR 0.80, 95%CI 0.41 to 1.56]). Conclusions: We provide evidence of a cross-sectional association between CRP and hypertension in men, but not in women, in this rural disadvantaged population. CRP could add to the prediction of future CVD in rural communities, particularly in men, but this requires further testing.

PS 15-17 KNOWLEDGE ABOUT RISK FACTORS FOR HYPERTENSION IN RURAL INDIA IS EVEN POOR IN PEOPLE AWARE OF THEIR HYPERTENSIVE STATUS

Objective: The prevalence of hypertension in rural populations in India is increasing, but little is known about awareness of hypertensive status or knowledge of risk factors for hypertension. We aimed to determine knowledge about risk factors for hypertension in individuals with and without hypertension, and to identify factors associated with better knowledge. Design and Method: Residents of randomised rural villages (n = 58) were invited to participate in a study of hypertension. We measured blood pressure (BP), height, weight, waist and hip circumference and administered a questionnaire to obtain information on sociodemographic and behavioural characteristics, and knowledge of hypertension. Multivariable logistic regression analyses were conducted to determine factors associated with knowledge of more than one risk factor (median) for hypertension. Results: The study included 626 individuals. Knowledge about risk factors for hypertension was poor in both those with hypertension who were aware (74/117; 63%) and unaware of the condition (169/209; 81%); as well as those without hypertension (247/300; 82%). Only 13% of women and 29% of men were aware of more than one risk factor for hypertension. Factors associated with knowledge about risk factors for hypertension were younger age (Odds Ratio (OR) 0.98, 95% Confidence Interval (95% CI) 0.96–0.97), being male (OR 2.32, 95% CI 1.36–3.98), higher educational attainment (OR 1.86, 95% CI 1.11–3.14), being overweight or obese (OR 2.91, 95% CI 1.75–4.84), and being aware of ones hypertensive status (OR 2.72, 95% CI 1.61–4.60). Conclusions: Our findings highlight poor knowledge about risk factors for hypertension in a disadvantaged Indian population. Targeting educational interventions to the identified high risk groups should be a priority, as this may improve knowledge of hypertension as well as promote healthy lifestyle behavioural changes in this rural population.

MPS 08-06 Socio-economic position and diet play important roles in the development of hypertension in a setting of disadvantage

Objective: Poor diet quality and low socio-economic position (SEP) have been associated with hypertension in high income and urban populations. However, limited evidence exists for the relationship between diet, SEP and blood pressure in disadvantaged rural populations. We aimed to assess the impact of SEP and diet on hypertension in a disadvantaged rural South Indian population. Design and Method: In a case-control study of hypertension, conducted in 58 villages in rural Andhra Pradesh, 300 cases were matched 1:1 by age and sex. Blood pressure and anthropometry were measured using a strict protocol. Sodium and potassium were measured from 24-hour urine samples. Participants were interviewed to obtain socio-demographic, lifestyle and dietary information. Conditional logistic regression was used to determine factors associated with hypertension (blood pressure ≥ 140/90 mmHg). Results: The median age was 60 years (interquartile range 20); 56% were men. Median salt intake did not differ significantly between cases and controls (7.2 vs. 7.3 grams/day, P = 0.9). The median sodium-to-potassium ratio was greater in cases than controls (8.4 vs. 8.1, P = 0.007). In multivariable analyses, high SEP (odds ratio (OR) 3.2, 95% confidence interval (CI) 1.4–7.7, P = 0.008) and physical inactivity (OR 3.0, 95% CI 2.0 − 4.6 P < 0.001) were associated with a greater odds of hypertension. Polygamy (OR 2.9, 95% CI 1.2–7.2, P = 0.02) and consuming alcohol (OR 2.1, 95% CI 1.2–3.8, P = 0.008) were associated with a greater odds of hypertension in men, whereas obesity (OR 2.6, P = 0.05) was associated with hypertension in women. Conclusions: The main drivers of hypertension in this population are poor diet, SEP and lifestyle factors such as physical inactivity and consuming alcohol. Therefore strategies to improve diet quality and lifestyle behaviors may help reduce the burden of hypertension in this disadvantaged Indian population.

PS 06-09 SEX DIFFERENCES IN THE ASSOCIATION BETWEEN ADIPOSITY AND HYPERTENSION IN A DISADVANTAGED RURAL INDIAN POPULATION

Objective: Obesity is associated with hypertension in high income countries, but less is known about this association in rural regions of low- to middle-income countries. We aimed to assess the risk of hypertension associated with obesity in a disadvantaged region of rural South India. Design and Method: We undertook a case-control study in 58 villages in southwestern Andhra Pradesh. Three hundred cases with hypertension were age- and sex-matched to 300 controls without hypertension. Blood pressure (BP), waist circumference, waist-hip ratio (WHR), and body mass index (BMI) were measured according to strict protocols. Percent body fat was estimated using skinfold thickness measured at the biceps, triceps, subscapular and supra-iliac regions. Conditional logistic regression was used to determine associations between each measurement of body fat and hypertension (BP ≥ 140/90 mmHg), adjusted for age and disadvantage. Linear regression was used to determine the relationship between continuous measurements of adiposity and systolic and diastolic BP. Results: Overall, mean BMI was 20.5 kg/m2, 29% of people were underweight, 9% were overweight and 14% were obese. Hypertension was positively associated with obesity, as defined by a BMI ≥ 23 kg/m2 (Odds Ratio (OR) 1.8, 95% Confidence Interval (CI) 1.1–3.0), waist circumference (OR 2.2, 95% CI 1.3–3.8) and WHR (OR 2.1, 95% CI 1.4–3.0), but not percent body fat. WHR was a better predictor of hypertension in women (OR 3.3, 95% CI 1.8–6.0) than men (OR 1.5, 95% CI 0.92–2.4, p for difference 0.04). All measures of adiposity were associated with diastolic BP (p < 0.05), but not systolic BP. Similar patterns were observed in men and women. Conclusions: Our findings confirm that even in this relatively thin rural sample in India, BMI, waist circumference and WHR are strongly associated with hypertension. Central adiposity may play a greater role in the pathogenesis of hypertension in women in these populations. Those with high waist circumference, particularly women, should be screened for hypertension.

Novel dietary intake assessment in populations with poor literacy.

BACKGROUND AND OBJECTIVES Cultural and/or environmental barriers make the assessment of dietary intake in rural populations challenging. We aimed to assess the accuracy of a meal recall questionnaire, adapted for use with impoverished South Indian populations living in rural areas. METHODS AND STUDY DESIGN Dietary data collected by recall versus weighed meals were compared. Data were obtained from 45 adults aged 19-85 years, living in rural Andhra Pradesh, who were recruited by convenience sampling. Weighed meal records (WMRs) were conducted in the household by a researcher aided by a trained field worker. The following day, field workers conducted a recall interview with the same participant. Eight life size photographs of portions of South Indian foods were created to aid each participants recall and a database of nutrients was developed to calculate nutrient intake. Pearson correlations were used to assess the strength of associations between intake of energy and nutrients calculated from meal recalls versus WMRs. Least products regression was conducted to examine fixed and proportional bias. Bland-Altman plots were constructed to measure systematic or differential bias. RESULTS Significant correlations were observed between estimates for energy and nutrients obtained by the two methods (r2=0.19-0.67, p<0.001). No systematic bias was detected by Bland-Altman plots. Recall method underestimated the intake of protein and fat in a manner proportional to the level of intake. CONCLUSIONS Our culturally adapted meal recall questionnaire provides an accurate measure for assessment of the intake of energy, macronutrients and some micronutrients in rural Indian populations.