Hypertension in urban slums of southern India: Burden, awareness, health seeking, control and risk factor profile.

INTRODUCTION: Hypertension is the leading risk factor for global disease burden. Inequalities in health among urban poor and non-poor is a matter of concern. The current study was done to estimate the prevalence of hypertension and to describe the health seeking and risk factor profile of people with hypertension in the urban slums of Kochi, Kerala, India. METHODS: Blood pressure of 5980 adults from 20 randomly selected slums were measured by door to door survey by trained nurses as a part of baseline assessment for a cluster randomised controlled trial. RESULTS: Prevalence of hypertension was found to be 34.8% (95% CI 33.5-34.9). Among those with hypertension, 66.9% were aware of their hypertensive status, of which 75.8% were initiated on treatment for hypertension. Proportion of hypertensive in the population who had their blood pressure under control was 24.5%. Among hypertensive, 53% were obese, 25.1% had diabetes mellitus, 14% had history of hospitalisation for high blood pressure. Of them, 60.3% had a per capita salt consumption above 8 g/day and 47.5% of them reported sitting for more than 8 h on a usual day. Mean monthly out of pocket expenditure for treatment of hypertension was $9(Median $8, IQR $16). CONCLUSION: One in three adults in urban slums of Kochi had hypertension. High rates of obesity, salt intake, physical inactivity prevails among the people with hypertension. Awareness, treatment initiation and control rate of hypertension are lower in urban slums as compared to non-slum urban areas. Slums require additional attention to ensure equitable and universal access to hypertension control.

Effectiveness of a community-based education and peer support led by women's self-help groups in improving the control of hypertension in urban slums of Kerala, India: a cluster randomised controlled pragmatic trial.

BACKGROUND: With less than 20% of people with hypertension achieving their target blood pressure (BP) goals, uncontrolled hypertension remains a major public health problem in India. We conducted a study to assess the effectiveness of a community-based education and peer support programme led by women's self-help group (SHG) members in reducing the mean systolic BP among people with hypertension in urban slums of Kochi city, Kerala, India. METHODS: A cluster randomised controlled pragmatic trial was conducted where 20 slums were randomised to either the intervention or the control arms. In each slum, participants who had elevated BP (>140/90) or were on antihypertensive medications were recruited. The intervention was delivered through women's SHG members (1 per 20-30 households) who provided (1) assistance in daily hypertension management, (2) social and emotional support to encourage healthy behaviours and (3) referral to the primary healthcare system. Those in the control arm received standard of care. The primary outcome was change in mean systolic BP (SBP) after 6 months. RESULTS: A total of 1952 participants were recruited-968 in the intervention arm and 984 in the control arm. Mean SBP was reduced by 6.26 mm Hg (SE 0.69) in the intervention arm compared with 2.16 mm Hg (SE 0.70) in the control arm; the net difference being 4.09 (95% CI 2.15 to 4.09), p<0.001. CONCLUSION: This women's SHG members led community intervention was effective in reducing SBP among people with hypertension compared with those who received usual care, over 6 months in urban slums of Kerala, India. TRIAL REGISTRATION NUMBER: CTRI/2019/12/022252.

Uncontrolled Blood Pressure and Associated Factors Among Persons With Diabetes: A Community Based Study From Kerala, India.

The coexistence of raised blood pressure (BP) in people with type 2 diabetes mellitus (T2DM) is a major contributor to the development and progression of both macrovascular and microvascular complications. The aim of our study was to determine the prevalence of uncontrolled BP and its associated factors in persons with T2DM in a district in Kerala. METHODS: The study was conducted in Ernakulam district in Kerala, and a total of 3,092 individuals with T2DM were enrolled after obtaining consent. Those with a BP "above or equal to 140 mmHg" and/or "above or equal to 90 mmHg" were thus considered to have uncontrolled BP. If the BP was equal or >140 and/or 90 mmHg, a repeat reading was taken after 30 min and the average of the two was considered. Basic demographic details were enquired along with electronic measurement of BP, HbA1c estimation and screening for diabetic retinopathy, peripheral arterial disease (PAD), and peripheral neuropathy. Quantitative and qualitative variables were expressed as mean (SD) and proportions, respectively. The model for determinants of uncontrolled BP was developed adjusting for age, gender, education, duration of diabetes, occupation, body mass index (BMI) and clustering effect. RESULTS: The mean age of the study population was 59.51 ± 9.84 years. The mean duration of T2DM was found to be 11.3 ± 6.64 years. The proportion of uncontrolled HTN adjusted for clustering was 60% (95% CI 58 and 62%). Among them, only one in two persons (53.3%) had a history of hypertension. Age >60 years [adjusted odds ratio (aOR) 1.48, 95% CI 1.24, 1.76; p < 0.001], unemployment (aOR 1.33, 95% CI 1.01, 1.75; p < 0.01), duration of diabetes > 11 years (aOR 1.42, 95% CI 1.19, 1.68; p < 0.001), and BMI ≥23 (aOR 1.33, 95% CI 1.10, 1.59; p < 0.002) were found to be independent determinants of high BP levels when adjusted for the aforementioned variables, gender, education, and cluster effect. The association between complications, such as peripheral neuropathy, PAD, and retinopathy showed a higher risk among those with uncontrolled BP. Retinopathy was 1.35 times more (95% CI 1.02, 1.7, p < 0.03), PAD was 1.6 times more (95% CI 1.2, 2.07, p < 0.001), and peripheral neuropathy was 1.5 (95% CI 1.14, 1.9, p < 0.003) times more compared to their counterparts. CONCLUSION: Target BP levels were far from being achieved in a good majority of the persons with T2DM. To reduce further macrovascular and microvascular events among people with T2DM, effective awareness and more stringent screening measures need to be employed in this population.