Awareness, Treatment and Control of Hypertension among Adults Aged 30 Years and Above in a Rural Field-Practice Area

Raised blood pressure in 21.3 per cent of women and 24.0 per cent of men aged 15 and over was measured by NFHS-5 (2019–21), and many adults first learn of theirs only at a complication. The care pathway is best described as a cascade — awareness (ever told by a health professional), treatment (currently on medication) and control (on treatment with blood pressure below 140/90 mmHg) — and each step loses people. The India Hypertension Control Initiative (IHCI) of MoHFW, ICMR and WHO India has shown that protocol-based care in government facilities improves control, but primary detection still depends on opportunistic facility screening rather than community data.

This ICMR Short-Term Studentship (STS)-style study measures the full cascade among adults aged 30 years and above in the rural field-practice area of a medical college's Department of Community Medicine. It is a community-based cross-sectional survey of about 300 adults selected by two-stage sampling from the PHC's family registers, using a WHO STEPS-adapted questionnaire (Step 1) together with standardised blood-pressure measurement and anthropometry (Step 2) at the participant's home. Each participant's position in the cascade is classified, and factors associated with raised and uncontrolled blood pressure — age, sex, education, occupation, socioeconomic status (modified BG Prasad scale), tobacco and alcohol use, salt intake, body mass index, waist circumference and family history — are analysed with chi-square tests and binary logistic regression. Every participant receives health education, and anyone with very high readings is referred to the PHC the same day.

The rural field-practice area served by the college's PHC runs opportunistic blood-pressure screening under NP-NCD, but the programme has no local estimate of how many adults aged 30 and above actually have raised blood pressure, how many know it, how many are treated, and how many are controlled. Facility registers count only people who attend; adults who never visit the PHC — often the majority in rural areas — are invisible to the system, and health staff cannot say at which step of the care cascade the losses occur.

Without cascade data, the PHC cannot target its work: screening drives may repeatedly detect the same diagnosed-but-uncontrolled patients while missing undiagnosed ones, counselling may be generic rather than directed at adherence or salt intake, and referral of severely raised readings is left to chance. This study measures awareness, treatment and control of hypertension among adults aged 30 years and above in the rural field-practice area, identifies the sociodemographic and behavioural factors associated with raised and uncontrolled blood pressure, and gives the PHC an evidence base for organising screening, follow-up and referral.

Abstract

A community-based cross-sectional study will be conducted among 300 adults aged 30 years and above in the rural field-practice area of a medical college to estimate the proportion of adults with raised blood pressure and to measure the hypertension care cascade: awareness, treatment and control. Data will be collected at home visits using a WHO STEPS-adapted questionnaire, standardised blood-pressure measurement and anthropometry, and analysed with descriptive statistics, chi-square tests and binary logistic regression.

Introduction

Raised blood pressure is the leading modifiable risk factor for death worldwide, and India's response runs through the National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD), which mandates opportunistic screening of all adults above 30 years at health facilities. NFHS-5, the first round to measure blood pressure across all adults aged 15 and above, found raised blood pressure in 21.3 per cent of women and 24.0 per cent of men. Population-level control, however, requires that people with raised readings move through detection, treatment and sustained control — the cascade that WHO STEPS-style surveys are designed to measure.

Review and gap

Indian community studies consistently report that a large share of hypertensive adults are undiagnosed, and that among those treated, many do not reach control. Rural areas fare worse than urban ones on every step of the cascade. Most available estimates are facility-based, which miss adults who never attend clinics; population-based rural studies in the recent literature, with standardised measurement and cascade reporting, remain uncommon for individual field-practice areas.

Proposed work

• Two-stage sampling: villages selected from the PHC's list by simple random sampling, then households from family registers by systematic random sampling; one eligible adult per household chosen by the Kish method.
• Standardised home measurement: validated digital device, correct cuff, seated after five minutes' rest, two readings three minutes apart with a third if they differ by more than 10 mmHg; weight, height and waist measured with standard technique.
• Cascade classification for every participant and analysis of associated factors.
• Health education for every household and same-day referral for dangerously high readings.

Feasibility

• Setting: the rural health training centre maintains family folders and community health workers who introduce the student to households.
• Time: 300 home visits at 12–15 per day fit into four weeks of field work within the two-month STS window, alongside approvals and analysis.
• Cost: device and consumables, printing and travel only; analysis uses free software (OpenEpi, Jamovi, Epi Info).
• Ethics: Institutional Ethics Committee approval, written informed consent, anonymised data and a referral pathway are built into the protocol.

In scope

• Adults aged ≥ 30 years resident for at least six months in the rural field-practice area; one eligible adult per sampled household.
• Questionnaire (sociodemographics, behaviour, treatment history), blood-pressure measurement, weight, height and waist circumference.
• Descriptive cascade analysis with 95% confidence intervals, chi-square tests and binary logistic regression; same-day referral and health education.

Out of scope

• Biochemical measures (blood glucose, lipids, creatinine) — WHO STEPS Step 3 requires laboratory support beyond the STS budget.
• Electrocardiography or assessment of target-organ damage.
• Follow-up of control over time (a cross-sectional study measures one point in time).
• Urban comparison area (suggested as future scope).

Study design: community-based cross-sectional study.

Setting and duration: rural field-practice area of the Department of Community Medicine; ten weeks — weeks 1–2 protocol, IEC and pilot; weeks 3–6 data collection; weeks 7–8 analysis; weeks 9–10 report and feedback.

Sample size: taking the expected prevalence of raised blood pressure among adults ≥ 30 years as 40 per cent (p = 0.40, q = 0.60, from published Indian community studies), absolute precision d = 6 per cent and 95 per cent confidence: n = Z²pq/d² = (1.96² × 0.40 × 0.60)/0.06² ≈ 257. Adding 10 per cent for non-response gives ≈ 283; the study aims for 300 adults, which also allows subgroup analysis of the treated subset. The calculation is verified in OpenEpi (Proportions → Sample size). Precision of 6 rather than 5 per cent was chosen to keep field work within the two-month STS window.

Sampling: two-stage. Stage 1 — the PHC serves about a dozen villages; four are selected by simple random sampling from the sub-centre list. Stage 2 — households are drawn from the family registers of the selected villages by systematic random sampling (interval k = total households/300; random start from a random-number table); one eligible adult per household is selected by the Kish method when several qualify. A household is revisited once more if the selected adult is absent, then replaced by the next household in the register.

Inclusion: age ≥ 30 years; resident ≥ 6 months; written informed consent. Exclusion: pregnancy (blood-pressure interpretation changes); acute illness on the day of visit; inability to communicate due to severe illness.

Instruments: WHO STEPS-adapted instrument — Step 1: sociodemographic items, tobacco and alcohol use (current/former/never), added salt, fruit and vegetable servings, physical activity at work and travel, history of ever being told BP is high, current medication, family history, known diabetes; Step 2: blood pressure, weight, height, waist. Blood pressure is measured with a validated automatic oscillometric device after five minutes seated rest, no tobacco, food or caffeine for 30 minutes, arm supported at heart level, correct cuff for arm circumference; two readings three minutes apart, a third taken and the mean of the last two used when the first two differ by more than 10 mmHg. Modified BG Prasad socioeconomic scale with the latest CPI-IW updation classifies families. The tool is translated, back-translated, content-validated by three faculty members and pre-tested on 20 adults in a non-sampled village.

Definitions: raised BP — mean SBP ≥ 140 and/or DBP ≥ 90 mmHg or on antihypertensive medication; awareness — previously told by a health professional; treatment — currently on prescribed medication; control — treated and mean BP < 140/90 mmHg.

Ethics: Institutional Ethics Committee approval before data collection, per the ICMR National Ethical Guidelines (2017); written informed consent in the local language; household serial numbers only — no names, phone numbers or identity documents; participants with SBP ≥ 180 or DBP ≥ 110 mmHg, or symptoms, are referred to the PHC the same day with a referral slip; all participants receive salt-reduction and adherence counselling.

Statistical analysis: data entered daily in Epi Info/Google Forms and analysed in Jamovi. Prevalence and cascade proportions with 95% confidence intervals; chi-square tests for associations with raised BP and with uncontrolled BP among the treated; binary logistic regression for independent predictors (adjusted odds ratios, 95% CI); p < 0.05.

The study follows a two-stage household survey pipeline with a pilot gate and a same-day referral loop.

flowchart TD
  A["Guide allotted, protocol drafted"] --> B["IEC approval (ICMR National Ethical Guidelines 2017)"]
  B --> C["Tool validation, translation and pilot on 20 adults"]
  C -->|revise items| C
  C --> D["Stage 1: four villages by simple random sampling"]
  D --> E["Stage 2: households by systematic random sampling"]
  E --> F{"Eligible adult consents?"}
  F -->|No or absent twice| G["Replace with next household"]
  G --> F
  F -->|Yes| H["Step 1 questionnaire: behaviour and history"]
  H --> I["Step 2: BP (two readings), weight, height, waist"]
  I --> J{"SBP >= 180 or DBP >= 110 or symptoms?"}
  J -->|Yes| K["Same-day referral slip to PHC"]
  J -->|No| L["Health education: salt, adherence, follow-up"]
  K --> L
  L --> M["Daily data entry: Epi Info / Google Forms"]
  M --> N["Jamovi: cascade proportions, chi-square, logistic regression"]
  N --> O["STS report and cascade dashboard for the PHC"]

Variables

The cascade logic

Everyone screened → of those with raised BP, the aware → of the aware, the treated → of the treated, the controlled. Each ratio is reported with its denominator, and the biggest single drop identifies where the PHC should intervene first.

• Repeat survey after one year to measure movement through the cascade following PHC screening drives.
• Add Step 3 biochemistry (fasting glucose, lipids) with the college laboratory to build a combined cardiometabolic risk profile.
• Urban–rural comparison with the college's urban field-practice area using the same instrument.
• Adherence sub-study among treated participants using pill counts and a brief scale, to explain the treated-uncontrolled stage.
• Linkage with an IHCI-style register: help the PHC set up a simple follow-up register for detected cases, aligned with the India Hypertension Control Initiative protocol approach.