Prevalence and risk correlates of hypertension among adult rural population in Bihar


Background: Cardiovascular diseases will be prime cause of morbidity by 2020 in India. Objective: To determine prevalence and correlates of hypertension in an adult rural community. Materials and Methods: A cross-sectional study was carried out in the field practice area of the Department of Community Medicine of tertiary care teaching institute of Bihar among adult population to find out the prevalence of hypertension with the sociodemographic correlates from October 2009 to September 2010. A pretested predesigned questionnaire was used to collect sociodemographics data by interview technique from 997 study participants. The blood pressure was assessed and classified using recent JNC 7 and WHO criteria to grade hypertension. Results: Majority of the study participants were Muslims (89%) and in 40-49 age group (21.26%). In males and females, the overweight and obese combined were, respectively, 13%. In the dietary habit, 85.36% were non-vegetarian; 8.83% consumed salt more than 10 grams per day; 26.78% reported themselves as alcoholics; tobacco smokers were 58.28%, highest in 40-49 age group (23.58%). Overall, 11.43% were hypertensive and 16% were prehypertensive. Among hypertensive, majority were male (61%); and in 60-69 age group (27.27%), overweight and obese (56.14%), smokers (75.44%), non-vegetarian (67.54%). There was a significant linear trend between age and salt intake with prevalence of hypertension (P<0.0001). Conclusions: Hypertension in the rural population of Bihar was lower than previous estimates.

Keywords: Bihar, hypertension, obese, rural, salt intake, smokers

How to cite this article:
Ghosh A, Sarkar D, Mukherji B, Pal R. Prevalence and risk correlates of hypertension among adult rural population in Bihar. Ann Trop Med Public Health 2013;6:71-5
How to cite this URL:
Ghosh A, Sarkar D, Mukherji B, Pal R. Prevalence and risk correlates of hypertension among adult rural population in Bihar. Ann Trop Med Public Health [serial online] 2013 [cited 2017 Nov 14];6:71-5. Available from:

In India, lifestyle diseases were considered in the urban setting; so the medical fraternity has concentrated more on the urban people. With epidemiological transition, a dramatic reduction in physical exercise has been observed in the rural areas with an increase in the stresses of life. According to World Health Report 2002, cardiovascular diseases will be the largest cause of death and disability by 2020 in India; the contributing factors are increasing hypertension, dyslipidemia, diabetes, overweight or obesity, physical inactivity, and using tobacco. [1] Today, hypertension is the significant global public health problem and commonest cardiovascular health crisis. Recently, the prevalence of the hypertension has been incessantly increasing in India and other developing countries but understanding and efforts to intervene remains miserably poor. [2] High blood pressure per se is a quiet disorder to be typically asymptomatic till the end organ damages show the symptoms and signs-WHO has named it the “Silent Killer.” [3] Studies have reported hypertension as a significant public health problem in India with an estimated load of 10-15% in rural and 25-30% in urban population. [4],[5],[6] Hypertension is directly responsible for 57% of all strokes deaths and 24% of coronary heart disease (CHD) deaths in India and also remains to be the leading cause of blindness, renal failure, and congestive heart failure. [7],[8]

The rural population in India has difficulty to access quality healthcare. Further, they are not conscious enough to seek healthcare until they are critically ill. Community-based studies are required to highlight the problem of hypertension with the correlates for comprehensive approach. Therefore, this population-based study was undertaken to find out the prevalence and correlates of hypertension in an adult rural community in rural Bihar.

Materials and Methods

This community-based study was carried out in the field practice area of the Department of Community Medicine, Katihar Medical College, Bihar to find out the prevalence of hypertension in the population 20 years and above and to study the sociodemographic correlates affecting hypertension from October 2009 to September 2010.

Study instrument

The data collection tool used for the study was an interview schedule that was developed at the Institute with the assistance from the faculty members and other experts in relation to hypertension with the sociodemographic situation prevailing in India. This predesigned and pretested questionnaire contained questions relating to the information on family characteristics such as residence, type of family, family history of diabetes mellitus, and family history of chronic disease; income and personal characteristics such as age, sex, education, occupation, and dietary habit including salt intake and addiction. By initial translation, back-translation, re-translation followed by pilot study, the questionnaire was custom-made for the study. The pilot study was carried out at the institute among general subjects following which some of the questions from the interview schedule were modified.

Data collection procedure

Study was approved by Institutional ethics committee and informed verbal consent was obtained from all participants. The health workers informed and motivated the families to participate in the study along with the scope of future intervention, if necessary. All the participants were explained about the purpose of the study and were ensured strict confidentiality, and then informed consent was taken from each of them before the total procedure. The participants were given the options not to participate in the study if they wanted. Data regarding family and personal characteristics were recorded by personal interview.

By simple random sampling technique, 997 study participants were selected. Body weight was measured (to the nearest .5 kg) in the standing motionless on the Bath room scale with feet 15 cm apart, and weight equally distributed on each leg. Height was measured (to the nearest .5 cm) by Stadeometer in standing position with closed feet, holding their breath in full inspiration, and Frankfurt line of vision. Blood pressure was measured by auscultation, using the standardized sphygmomanometer. All the participants were requested to take rest for 10 minutes. Blood pressure was measured in sitting position with an appropriate sized cuff encircling the arm. Two separate readings were taken at an interval of minimum 3 minutes. The average of two readings was taken. Recent JNC 7 and WHO classifications were used for classifying the hypertension. [9],[10],[11] On an average, five to six interviews were conducted in a day. Details of the questionnaire can be provided, if required. Information on hypertension was disseminated to the patients and their caregivers in health education sessions to complement the findings of study.

Statistical analysis

The data collected were thoroughly cleaned and entered into MS Excel spreadsheets and analysis was carried out. The statistical analyses were done using Graph Pad In Stat “version 3” software. Proportion of adult person with hypertension was presented as percentage and Chi square tests were used in this study to analyze epidemiological variables. P<0.05 was used as the definition of statistical significance.


Among 997 study participants in the population 20 years and above, majority were Muslims (89%) and in 40-49 age group (21.26%). Of the hypertensive, majority were male 69 (60.53%); and in 60-69 age group (31.58%). Two-third of the hypertensive was noted in the age group 50 and above (65.79%) [Table 1].

Table 1: Age-sex distribution of hypertension among the study participants
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Our study participants had a literacy of 52.76%. By the way, 26.78% of the study reported themselves as alcoholics; tobacco smokers were 58.28%, highest in 40-49 age group (23.58%). In the dietary habit, 85.36% were non-vegetarian; 8.83% consumed salt more than 10 grams per day. In overall prevalence of hypertension and risk factors, 114 (11.43%) were hypertensive and prehypertensive. Among hypertensive participants, overweight and obese were (56.14%), smokers (75.44%), and non-vegetarian (67.54%). In male and female participants, the overweight and obese combined were, respectively, 13% [Table 2].

Table 2: Distribution of correlates of hypertension among study population
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Overall, 11.43% were hypertensive and 16% prehypertensive. Among hypertensive, majority were male (61%); and in 60-69 age group (27.27%), overweight and obese (56.14%), smokers (75.44%), and non-vegetarian (67.54%). Among 114 hypertensive and prehypertensive participants, 101 (88.60%) had waist-hip ratio above normal. There was a significant linear trend between age and salt intake with prevalence of hypertension (P<0.0001).


For the changing life patterns in the rural India, there is a shifting in the overall pattern cardiovascular diseases due to stress and tension intrinsic within the epidemiological transition. Among our study participants, 11.43% were hypertensive and 16% were prehypertensive. Among hypertensive, majority were male (61%); and in 60-69 age group (27.27%), overweight and obese (56.14%), smokers (75.44%), and non-vegetarian (67.54%) with a significant linear trend between age and salt intake with prevalence of hypertension.

In rural community of Varanasi district, the prevalence of hypertension was found 7.19% and study conducted in rural area of J and K state, the overall prevalence of hypertension was observed 8.31%. [1] Researchers from south India reported 37% prevalence of hypertension in 30-64 age group. [12]

Gupta from Jaipur, through three serial epidemiological studies (Criteria: ≥140/90 mm of Hg) carried out during 1994, 2001, and 2003 demonstrated rising prevalence of hypertension (30%, 36%, and 51%, respectively, among males and 34%, 38%, and 51% among females). [4] In 2002, Hazarika et al. reported 61% prevalence (criteria:=JNC VI) of hypertension among aged 30 and above of both sexes in Assam. [13] A study on hypertension in a rural south Indian community by Gilberts et al. showed that prevalence of hypertension was 12-5%. [14] Another study by Yuvaraj et al. in rural area of Davanagere shows the prevalence of hypertension is 18.3%. [15]

In this study, prevalence of hypertension among male (13.09%) is more than female (9.57%). Jajoo et al. reported higher prevalence in women (40.60 per thousand versus 28.92 per thousand), Malhotra et al. (5.8% versus 3.0%), Goel et al. (8.82% versus 5.57%) reported the same. [16],[17],[18] But Gupta et al. and Agarwal et al. reported higher prevalence in males than females. [19],[20] Whelton reported relative male preponderance below the age of 50. [21]

In this study, the risk of hypertension increased significantly with increase in age. Malhotra et al., Singh et al., Gupta et al., Gilberts et al. also reported that there is increase in prevalence of hypertension with the advancement of age. [14],[17],[19],[22]

Jajoo et al., Malhotra et al., Singh et al., Goel et al., and Joshi et al. also reported that there is increase in risk of hypertension with increase in BMI. Similar finding was noted when nutritional status was decided by using waist-hip ratio. [16],[17],[18],[22],[23] In this study, only 13.2% of the population was overweight and obese (BMI>25.0), 24.0% of the population had waist-hip ratio equal to or more than cut-off (0.9 for males and 0.8 for females). This implies the importance of waist-hip ratio in thin built individuals as central obesity indicated by increased waist-hip ratio has been positively correlated with high blood pressure in several populations.

We also found that the risk of hypertension decreased with increased level of education. Though most of the studies documented that hypertension is more prevalent in people with high educational level, such finding is expected in communities where the epidemiological transition is in advanced stage.

The risk of hypertension was significantly associated with smoking tobacco. Among the hypertensive, 75.44% were smokers. The risk of hypertension did not differ significantly in non-vegetarian and alcohol users though daily drinkers were observed to have systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels higher than once-a-week drinkers, independent of total weekly quantity. Hazarika et al. reported alcohol use as significant risk factor. [13]

Against a backdrop of overall 63.84% literacy in Bihar, our study participants had a literacy of 53%. Coupled with lack of awareness and ignorance about the complications of hypertension, the situation is conducive to the perpetuation of the disease. [24]

In a review of cross-sectional CHD epidemiological studies in India performed over the past 50 years, researchers noted that hypertension had increased gradually in rural areas. [25] Cardiovascular diseases are foremost players in the untimely death in India. Facts from developed countries delineate that these can be considerably barred by means of population-based policy. A multifactorial comprehensive move toward prevention of cardiovascular disease in the global scale for the low- and middle-income countries has been recommended by the proponents of prevention. [26]

The strength of the study was that it was a population-based cross-sectional that highlighted the burden of hypertension among adult rural population in one of the poorer Bihar-Madhya Pradesh-Rajasthan-Uttar Pradesh (BIMARU) states in India. There is a growing evidence to develop various surveillance programs of increasing rural health burden of the non-communicable diseases. Bias was taken care of by random sampling. The lack of positive attitude could be an important barrier to early diagnosis of hypertension.

We had several limitations. First, as the sample was small and drawn from one limited geographic area within Katihar district, the results cannot properly be generalized to the national population. Second, because of the cross-sectional design, this study had limited extrapolative value. Third, researchers in this field are troubled with related illiteracy and other psychological barriers of rural Bihar. Fourthly, we could not include in the study of the prevalence of hypertension among adolescents. Lastly, the probability of missing data cannot be excluded as the collection of secondary data was difficult because of ignorance of the rural mass.

In the future directions of the study, holistic researches are needed on all the dimensions of hypertension in the rural population that includes the physical and psychosocial levels of perception of health as there is a professional indifference to rural health. Recent epidemiologic studies show increasing “epidemic” of cardiovascular diseases throughout the world among all the age groups. Yet, a large proportion of cases go undiagnosed. WHO key approach for control of cardiovascular diseases depends, for the most part, on the competence of healthcare delivery services and patient conformity. Previously thought as a disease of urban well off population, a rural encroachment is increasingly being reported. The probability of escalating cardiovascular diseases in areas of rural India represents a public health concern and not much research had been done about the risk factors in rural areas. In our participants with reported doing hard manual work, however, had hypertension in 25.26% need to be explored. Research on post-intervention knowledge and practice among patients and caregivers has to be repeatedly explored. We hope to find out that this study should have been repeated at regular interval in our country by multicentric study to find out national prevalence. The key factor to prevent hypertension is to generate awareness among our Peers, Public health experts, Health Services Researchers, Healthcare Providers and Planners to consider the higher prevalence, and associated risk factors of hypertension as a public health problem in the developing countries.

This study brings out the burden of hypertension and vulnerability of a population to the risk of developing life style diseases, hence the importance of integrating hypertension screening into primary healthcare as with increased age, hypercholesterolemia, and high salt intake they are likely to develop hypertension. These findings suggest that this could lay the foundation for the introduction of control of cardiovascular diseases at the primary healthcare. It is now desirable that screening programs for hypertension should be taken up in rural areas of Bihar because the majority do not have access healthcare facilities or do not avail them due to reasons better known to them. The JNC-VII criteria seek to identify adults at risk of developing hypertension to bring them into treatment or preventive regimens. Along with the presence of risk factors, the population most vulnerable to hypertension can be identified to minimize target organ damage, cardiovascular risk, and chronic disability all the more important in the rural perspective.


Any short-term solution may not help us to reach the goal of control of cardiovascular diseases in a multicultural multilingual and geographically uneven country like India. Further, health professionals alone are unable to deal with this mammoth task. Strategic interventions to obviate the cause for noncompliance to intervention need holistic responsibility of professionals, health services, governments, and teaching institutions. For a substantial impact on this burden, unique preventive healthcare strategies specific to the rural population need to be clearly formulated and tested. Behavior change communication supported by the screening is important for early detection and management to prevent complications for which a holistic approach is needed initiated by the political will of the nation. Incidentally, representative national level data on hypertension are lacking and even NFHS-1, NFHS-2, and NFHS-3 did not cover hypertension data. We hope that in the days to come, in the national level activities, the method of collection of baseline data on this important parameter for a baseline data by the Government of India will be formulated for better perception of the problem.

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Source of Support: None, Conflict of Interest: There are no potential, perceived, or real competing and/or conflicts of interest among authors regarding the article and therefore have nothing to declare.


DOI: 10.4103/1755-6783.115209


[Table 1], [Table 2]

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