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Professional MBBS Examination

July 2013

Roll No:

Registration No:

Batch:AFMC-12

Session No:2009-2010

Signature of the guide

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2nd
BANGLADESH UNIVERSITY OF PROFESSIONALS
FACULTY OF MEDICINE

This research project Study of Status of Blood Pressure & Treatment


Compliance among selected rural peoples of Dhamrai Upazilla, Dhaka is
submitted to the Faculty of Medicine, Bangladesh University of
Professionals in partial fulfillment of the requirements of the course of
Community Medicine, 2 nd Professional MBBS Examination for the session
2009-2010.

Students of AFMC 12 Armed Forces Medical College

Roll No: Dhaka Cantonment

Board of examiners:

1.

2.

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Acknowledgement

We are grateful to Almighty Allah- the most merciful for enlighten our spectrum of
knowledge and giving us the opportunity to accomplish this work with proper strength,
skill, resources and patience.

Our research would never have been possible to complete without the support and the
guidance of our respected teachers and staffs of Armed Forces Medical College (AFMC).
We would like to thanks them all.

At first we would like to express our gratitude to Brigadier General Mohammad Ali,
MBBS, DPH, M Phil, Head of the Department of Community medicine, Armed
Forces Medical College, for his approval and support to conduct our research. His
fatherly approach and knowledge guided us all the way to proper research work. It is a
privilege for us to work under such a dedicated teacher. He stood up as a role model of
enthusiasm and inspiration to us.

We would like to thank, Lt Col Maksumul Hakim,MBBS,and M Phil, Armed Forces


Medical College, for his kind patience and endless effort for the perfection of this
research. He spent his valuable time and energy for teaching us about the project. He
gave full effort to make our stay homely for the research work.

It is our pleasure to thank Lt Col Maksumul Hakim, MBBS, and M Phil for spending his
valuable time on us and guide us the right way. His tireless dedication to help in every
possible way in completing this research topic is undeniable.

We would like to thank Major Latifa, MBBS, MPH, M Phil, Assistant Professor, Armed
Forces Medical College for her guidance and encouragement.

The person whose afford and encouragement cannot be expressed through words is
Entomologist Mehedi Hasan Jewel. He guided us in every step, providing us all endless

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mental support behind the screen. We would like to express our gratitude and humble
gratefulness and thanks to him from core of our heart.

We would like to thank all the staffs of the Department of Community Medicine for their
cooperation with the process and also those who were with us from different branches.

This research project would not have been possible without the co-operation of
populations of the study area Dhamrai. They helped us all the way of our project by
providing necessary information, friendly cooperation, enthusiastic participation and
spontaneous assistance. It is only because of their support and their warm hospitality
that we were able to collect data accordingly. We also acknowledge the help provided
by Dhamrai Upazilla Health Complex. We hope that our study would play an important
role for their benefit.

Our acknowledgement would be incomplete without thanking our classmates, who took
individual responsibilities and went through lots of hardship to make our research
fruitful showing the best example of a perfect teamwork.

Last but not the least I thank all those who have helped us directly or indirectly in our
research work.

Name of the student

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Content
Contents

List of tables 6
List of figures 7-8
Abstract 9

Chapter1: Introduction

Introduction 11-15
Justification of the study
Objectives 20
Key variables 21-22
Operational definitions
Limitations of the study

Chapter 2::Review of Literature 28-31

Chapter 3: Methodology

Chapter4: Results 36-57

Results
Tables & figures

Chapter 5: Discussion

Chapter 6: Conclusion & Recommendations

Conclusion 63
Recommendation

Reference/Bibliography

Annexure

Questionnaire

Map of Dhamrai Upazilla

Photographs

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Table Title Page no


1 Distribution of respondents according to age group
2 Distribution of the religion of respondents
3 Distribution of respondents according to their marital status
4 Distribution of respondents according to their occupation
5 Distribution of respondents according to their family income
6 Distribution of respondents in relation to type of protein intake
7 Distribution of respondents according to blood pressure status
LIST OF TABLE
List of Figures

Page no
Figure Title
1 Pie diagram showing distribution of the respondents according to sex
2 Bar diagram showing educational status of the respondents
3 Pie diagram showing distribution of respondents in relation to physical
work
4 Pie diagram showing distribution of respondents in relation to fatty
food intake
5 Pie diagram showing distribution of respondents in relation to walking
at least 30 minutes a day
6 Pie diagram showing distribution of respondents according to smoking
habits among male
7 Pie diagram showing user of Contraceptive Pill among female
respondents
8 Pie diagram showing extra salt intake among the respondents
9 Pie diagram showing percentage of known hypertensive
among respondents
10 Pie diagram showing distribution of respondents according
to family history of hypertension
11 Pie diagram showing distribution of hypertention respondents in
relation to compliance to hypertensive drug

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49

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Abstract

Elevated blood pressure often remains asymptomatic presenting with


complications. Most of the people of our country are not conscious about
hypertension & its treatment, let alone the rural population. The study was
undertaken to assess the status of blood pressure & treatment compliance among
the adult population in Dhamrai Upazilla.

We selected two villages of Dhamrai Upazilla namely-Khatra,Dighol


, a cross sectional type of descriptive study was conducted from 10 th

November to 14 November 2012 among people of both sexes aged from 20 years &
above. Cluster sampling technique was adopted. A pretested questionnaire was
used to collect data.

A total of 360 adult people were studied. Among them 39.72% were male & 60.78%
were female. Among the male, 27.77% were smoker & 72.23% were nonsmoker. Among
360 adult people 323 (89.74) measured blood pressure before & 37 (10.26)
did not measure. On the basis of blood pressure measurement, we found
314(87.26%) normal, 12(3.35%) grade-i, 22(6.19%) grade-
ii, & 12(3.20%) grade-iii hypertensive cases. So, among the total population, the
occurrence of hypertensive was found in 12.74% cases, while the rest were
normotensive. Among the diagnosed hypertensive 41 (91.30%) take
antihypertensive medication & rest 4(8.70 %) dont take

The scenario from the above point of view is that very few people had
hypertension but treatment compliance was poor among them. If the observed
situation as found during survey period is not changed & modified, it would
create complications among the respondents suffering from hypertension.

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Chapter 1

Introduction

10 | P a g e
Blood is the most commonly tested part of the body, and it is truly the river of life. Every cell
in the body gets its nutrients from blood. Understanding blood will help us as our doctor
explains the results of our blood tests. In addition, we will learn amazing things about this
incredible fluid and the cells in it.

Blood is a mixture of two components: cells and plasma. The heart pumps blood through the
arteries, capillaries and veins to provide oxygen and nutrients to every cell of the body. The
blood also carries away waste products.

The adult human body contains approximately 5 liters (5.3 quarts) of blood; it makes up 7 to
8 percent of a person's body weight. Approximately 2.75 to 3 liters of blood is plasma and
the rest is the cellular portion.

Plasma is the liquid portion of the blood. Blood cells like red blood cells float in the plasma.
Also dissolved in plasma are electrolytes, nutrients and vitamins (absorbed from the intestines
or produced by the body), hormones, clotting factors, and proteins such as albumin and
immunoglobulin (antibodies to fight infection). Plasma distributes the substances it contains
as it circulates throughout the body.

The cellular portion of blood contains red blood cells (RBCs), white blood cells (WBCs) and
platelets. The RBCs carry oxygen from the lungs; the WBCs help to fight infection; and
platelets are one of the constitutional parts of blood clotting mechanism. All blood cells are
produced in the bone marrow.

What does "Blood Pressure" Mean?

The average hearts beats almost 90,000 times per day. With each beat, the heart expels
blood into the arteries strong, muscular tubes that carry blood to all parts of body,
branching into smaller and smaller tubes along the way. When the heart beats, it generates
force, which is transferred to the blood. As blood leaves the heart, it carries this force with it
into the arteries. This force pushes on the walls of the arteries and the arteries push back,
helping to propel the blood forward into the body. This force also causes pressure within the
arteries, which is called blood pressure. Blood pressure measurements consist of two
numbers. The systolic pressure is measured while the heart is contracting, and is the larger of
the two numbers. The diastolic pressure is measured while the heart is relaxing, and is smaller
than the systolic pressure. These two pressures are written together, like this: 120/80, and
11 | P a g e Chapter 1

A good head and a good heart always a formidable condition.The heart is the bodys engine room,responsible for pumping life-sustaining
Blood via a 60,000 miles long network of vessels.The organ works by beating 100000 times a day,40 million times a year in total
Clocking up three billion heart beat over an average life time.
pronounced "120 over 80." Both the systolic and diastolic blood pressure are important
determinants of cardiovascular risk, so both are used in evaluating overall blood pressure
status.

High blood pressure, also called hypertension, is elevated pressure of the blood in the
arteries. Hypertension results from two major factors, which can be present independently or
together:

The heart pumps blood with excessive force.


The body's smaller blood vessels (known as the arterioles) narrow, so that blood flow
exerts more pressure against the vessels' walls.

Although the body can tolerate increased blood pressure for months and even years,
eventually the heart may enlarge (a condition called hypertrophy), which is a major factor in
heart failure.
Some studies suggest that in people over 45 years old, every 10 mm Hg increase in pulse
pressure increases the risk for stroke rises by 11%, cardiovascular disease by 10%, and overall
mortality by 16%. (In younger adults the risks are even higher.)

Blood pressure (BP) is the pressure exerted by circulating blood upon the walls of blood
vessels, and is one of the principal vital signs. When used without further specification, "blood
pressure" usually refers to the arterial pressure of the systemic circulation. During each
heartbeat, BP varies between a maximum (systolic) and a minimum (diastolic) pressure. The
mean BP, due to pumping by the heart and resistance to flow in blood vessels, decreases as
the circulating blood moves away from the heart through arteries. The measurement blood
pressure without further specification usually refers to the systemic arterial pressure measured
at a person's upper arm. It is measured on the inside of an elbow at the brachial artery, which
is the upper arm's major blood vessel that carries blood away from the heart. A person's BP
is usually expressed in terms of the systolic pressure over diastolic pressure (mmHg), for
example 140/90. Along with body temperature, respiratory rate, and pulse rate, BP is one of
the four main vital signs routinely monitored by medical professionals and healthcare
providers.

12 | P a g e Chapter 1

Hypertention can be classified into:


(1)Esssial(primary)
(2)Secondary
Types of blood pressure:
Depending on the nature of blood vessels-
(1) Arterial blood pressure.
(2)Venous blood pressure.
(3)Capillary blood pressure.
Classification of blood pressure in adults:

Categor y Systolic ( mm Hg) Diastolic (mm Hg)


Optimal <120 <80

Normal 120- <130 80-<85

High normal 130-139 85-89

Grade 1 Hypertension/ Mild 140159 9099

Grade 2 Hypertension /Moderate 160179 100109

Grade 3 Hypertension/ severe = 180 = 110

For many patients control of blood pressure means consistent monitoring and modifying of
previous behaviors and lifestyle habits associated with high blood pressure. Overweight, high
cholesterol, tobacco and alcohol use, salt, heavy diet and low exercise have been found to
contribute to high blood pressure. To control hypertension, patients must be vigilant
regarding these aspects of behavior and lifestyle for the remainder of their lives.

For many patients lifestyle modification alone will not reduce blood pressure to normal
ranges. These patients must take medication to regulate their blood pressure. A number of
medications are available, but patients must continue to take these drugs for the rest of their
lives or face the consequences of untreated high blood pressure. As with any long term
disease process, patient compliance is essential for long term positive outcomes.

However, high blood pressure is called the silent killer, because nearly one-third of those
people with hypertension don't know they have it. Many adults develop high blood pressure
after the age of 50. Uncontrolled high blood pressure can lead to stroke, heart attack or
kidney failure. It is a major risk factor for coronary heart disease, stroke, diabetes mellitus and
renal disease. Hypertension refers to arterial pressure being abnormally high, as opposed
to hypotension, when it is abnormally low. Blood pressure that is too low is known

13 | P a g e Chapter 1

Measurement of blood pressure:


(1) Direct method
(2)Indirect method-a.Palpatory method. b.Auscultatory method.
as hypotension. Hypotension is a medical concern only if it causes signs or symptoms, such
as dizziness, fainting, or in extreme cases, shock.

Many epidemiological hypertension studies have been conducted to identify the risk factors
for hypertension in various populations around the world. However, because each population
has its unique genetic makeup, lifestyle and dietary habits, the risk factors for hypertension
may be different from population to population, and therefore each population must
conduct studies to assess their specific risk factors. Traditionally, hypertension studies involve
clinical measurements of subjects blood pressures, with their associated costs.

High blood pressure, termed "hypertension," is a condition that affects almost 1 billion people
worldwide and is a leading cause of morbidity and mortality. More than 20% of Americans
are hypertensive, and one-third of these Americans are not even aware they are
hypertensive. Therefore, this disease is sometimes called the "silent killer." This disease is
usually asymptomatic until the damaging effects of hypertension (such as stroke, myocardial
infarction, renal dysfunction, visual problems, etc.) are observed. Hypertension is a major risk
factor for coronary artery disease and "heart attacks," which may require coronary artery
bypass surgery.

Hypertension is a major cardiovascular risk factor with a global prevalence of 26.4% in 2000,
projected to increase to 29.2% by 2025, and is the leading contributor to global mortality.
The data of the previous studies suggest the existence of more undiscovered blood pressure
related common variants. Cross-sectional studies of the general population have required
extremely large sample sizes to detect such small effect sizes.

In Bangladesh most of the people live in villages and most of them are of low socio economic
condition. They are busy to earn their bread and butter and are not aware of health. Health
care facilities are not also easily accessible to them. There ar e many remote villages, where
the health care services do not reach. So the health status of the people of these areas is
almost unknown. In case of any emergency condition such as stroke or heart failure they do
not get service near to hand, which lead to death in most of the cases. So, an elevated blood
pressure may be the cause of high mortality among them. The current topic of study may
contribute to lend a hand in gathering the knowledge and information about the blood
pressure status of the elderly people in rural areas of Bangladesh and also the treatment
status of the hypertensive people. Hence the study is justifiable and need based.

14 | P a g e Chapter 1
There are two reasons for studying the blood pressure measurements along with related test
results in rural community. First, it gives a rough idea of the health scenario of general
population of a country. And this information helps to allocate resources between projects
and other measures which are designed to improve health. Health impact data inform the
discussion on the external efficiency of investments of budget on the chronic non-
communicable diseases. Second, knowledge of this study assists with designing projects so
that they optimize their impact on health at a given cause which reflects the internal
efficiency. Findings from this study may help to inform needs for public health
interventions/recommendations, to identify potential risk factors and guide prevention
strategies, and to set a baseline for monitoring the changing pattern of disease in an area
that is hopefully experiencing a socioeconomic transition associated with poverty alleviation.

15 | P a g e Chapter 1
Justification of the study

According to recent estimates, nearly one in three U.S. adults has high blood pressure
(hypertension). High blood pressure killed 49,707 Americans in 2002. It was listed as a
primary or contributing cause of death in about 261,000 U.S. deaths in 2002. High blood
pressure was listed as a primary or contributing cause of death for 326,000 Americans in
2006.Although its underlying causes are mostly unknown, high blood pressure is easily
detected. However, once diagnosed, it cannot be cured; it can only be controlled.

All societies are confronted with the problem of defining a strategy to control high blood
pressure. Large, prospective epidemiologic studies unequivocally show a strong, direct
relation between high blood pressure and mortality due to cardiovascular disease (CVD).
Although the relative contribution of CVD deaths to total mortality in developing countries is
smaller than that in developed countries, developing countries, because of their large
populations, contribute nearly twice as much as do developed countries to the global CVD
burden. Because hypertension is the most common cardiovascular condition in the world, its
prevention and treatment are important public health issues.

By the year 2020, non-communicable diseases such as cardiovascular diseases (CVD) will be
the major causes of morbidity and mortality in developing countries, accounting for almost
four times as many deaths as from communicable diseases. This shift potentially coincides
with socio-economic changes and the =nutrition transition associated with poverty alleviation.
Further, risk factors for HTN, such as dietary habits, are not clearly defined in these
populations. This is especially important because of the global effort to improve the socio-
economic status of this region and associated changes, which could potentially have both
beneficial and adverse consequences.

16 | P a g e Chapter 1
Countless epidemiological surveys have shown that there are striking inter individual and
inter population differences in blood pressure. In mostbut not allpopulations, blood
pressure generally rises (more or less) with age from youth into older age. The exceptions are
isolated preliterate groups in remote locations, where average systolic and diastolic blood
pressures are optimal at all adult ages, manifesting little or no upward slope with ageand
where lifestyles differ markedly compared to those of other populations worldwide. Data
from migration studiesfor example, the Luo Migrant Study in Kenya and the Ye Migrant
Study in Chinastrongly indicate that changes in lifestyle and nutrition explain increases in
blood pressure and vascular disease following migration and adoption of diets broadly
similar to those of host populations. Furthermore, an inverse relation between socioeconomic
status (SES) and blood pressure has also been recorded repeatedly in many population
studies of specific ethnic groups.

Although Bangladesh was classified as being in the earliest stage of this transition, a recent
review of prevalence surveys conducted in Bangladesh indicated that the prevalence of
hypertension has increased from 3% to 9% since 1976. Parallel to this increase, the
prevalence of chronic energy deficiency [body mass index (BMI; in kg/m 2 ) 18.5 on the basis of
international criteria] in adults decreased by 14% from 1981 to 1996. Nutritional epidemiology
in Bangladesh and other low income countries with widely varying dietary practices faces the
challenge of identifying prudent, affordable, and culturally acceptable diets. Recently, dietary
pattern analysis has emerged as an alternative approach to studies of diet and chronic
diseases. Instead of evaluating the influences of individual nutrients or foods, pattern analysis
examines the effects of the overall diet. Major dietary patterns have been related to CVD risk
in studies conducted in Western countries. Recent intervention trials such as the Dietary
Approaches to Stop Hypertension (DASH) trial in the United States found short-term
beneficial effects of the DASH diet (fruit, vegetables, low-fat dairy products, and reduced fat)
on blood pressure in hypertensive and borderline hypertensive patients. However, no large
epidemiologic studies have systematically evaluated associations of dietary factors or patterns
with blood pressure in a low-income population. The nutritional determinants of
hypertension in Bangladesh and other low-income countries are largely unknown.

Hypertension is now regarded as a disease of modern civilization. According to WHO it is one of the
most important preventable causes of premature morbidity and mortality in developed and
developing countries. Bangladesh is a developing country; it is one of the commonest cardiovascular
disorders, posing a major public health challenge to population socio-economic and epidemiological
transition.

Chapter 1
17 | P a g e
The public-private initiatives have been taken in the health sector since independence of Bangladesh
is treated positive, but the health services didnt reach to the most of the peoples yet. The
epidemiological studies in Bangladesh are largely confined to the primary health care facilities, basic
sanitation, maternal and child health. But recent health scenario shows increasing occurrence of
cardiovascular diseases, diabetes mellitus, and renal diseases among affluent populations of the
country as well as in rural community. High blood pressure imposes potential threat on occurrence of
these diseases by 80%. So, high blood pressure (hypertension) has become a major concern in recent
years.

Nearly one- third on the people generally are not aware of having hypertension which makes it an
Iceberg disease and makes it more difficult to address the whole scenario of the country. It follows the
rules of halves:

1
3

5 7
2
4 6 8

50% of the hypertensive patients are aware of hypertension.

50% of aware patients are treated.

50% of treated patients are adequately treated.

The epidemiological studies and surveys on blood pressure can be beneficial in understanding the risk
factors that are involved in progressive rise of blood pressure in our country. Also the study can help
in uncovering a portion of in apparent, submerged populations at risk of developing hypertension
and its sequels.

18 | P a g e Chapter 1
As the nutritional determinants of hypertension in Bangladesh and other low-income
countries are largely unknown, blood pressure survey can address the determinants which
are directly or indirectly imposing threat on mass health.

Hypertension is a non-curable disease. Due to its chronicity, the duration of treatment is


prolonged and requires life-style modification. This study would help to understand the
peoples knowledge about this disease, awareness and treatment compliance in our country.

An elevated blood pressure or hypertension is now regarded as a disease of modern


civilization. According to WHO it is one of the most important preventable causes of
premature morbidity and mortality in developed and developing country. As Bangladesh is a
developing country; it is one of the commonest cardiovascular disorders, posing a major
public health challenge to population socio economic and epidemiological transition.

The complications due to hypertension are highly fatal such as stroke, left ventricular failure,
congestive cardiac failure, aortic dissection etc. It also causes nephropathy, retinopathy and
peripheral vascular disease. The higher the pressure, the greater the risk and lower the
expectation of life. So, in case of most of the undiagnosed case people are aware of
hypertension after reaching to the door of death. But hypertension is a preventable disease.
It has its own risk factors and most of them are modifiable. Modification of life style such as
weight reduction, physical activity, reducing salt intake, intake of dietary fiber etc. are effective
in preventing and also controlling blood pressure. But the key reason for poor blood
pressure control in people with treated hypertension is the use of mono therapy that is only
the antihypertensive drugs.

In Bangladesh most of the people live in villages and most of them are of low socio
economic condition. They are busy to earn their bread and butter and are not aware of
health. Health care facilities are not also easily accessible to them. There are many r emote
villages, where the health care services do not reach. So the health status of the people of
these areas is almost unknown. In case of any emergency condition such as stroke or heart
failure they do not get service near to hand, which lead to death in most of the cases. So, an
elevated blood pressure may be the cause of high mortality among them. The current topic
of study may contribute to lend a hand in gathering the knowledge and information about
the blood pressure status of the elderly people in rural areas of Bangladesh and also the
treatment status of the hypertensive people. Hence the study is justifiable and need based.

19 | P a g e Chapter 1
Objectives

General objectives:

To assess blood pressure status of


people in selective villages of
Dhamrai Upazilla.

Specific objectives:

20 | P a g e Chapter 1

To identify the prevalence and cause of primary and secondary hypertension in different age group.
To evaluate the prevention and treatment of hypertension.
To evaluate the awareness of hypertension.
Key Variables

Socio-economic variables:

Age and sex


Religion
Educational qualification of the respondent
Marital status
Occupation of the person
Physical activity
Monthly family income
Types of family
Number of family members

Variables related to diet & food habit:

Daily dietary fat


Dietary protein
Extra salt intake
Smoking
Alcohol consumption
Physical activity
Oral contraceptives

21 | P a g e Chapter 1
Variables related to blood pressure status:

Measurement of blood pressure


Medication
Complication related to hypertension
Familial hypertension
Other diseases

22 | P a g e
Chapter 1
Operational Definitions

Blood pressure:

Blood pressure may be defined as a lateral pressure exerted by the flowing blood on
the wall of the arteries.It decreases as the blood moves through the arteries,the capillaries and the vein .

Hypertension:

Persistent systolic blood pressure more than 139 mmHg and diastolic blood pressure more
than 89 mmHg in average two readings on different dates using the left arm with the subject
in sitting position.

Normotensive:

A person is said to be normotensive when his systolic blood pressure is below 140 mmHg
and the diastolic pressure is below 90 mmHg.

Cerebrovascular accident (CVA):

The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain
is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as
a stroke.

23 | P a g e Chapter 1
Myocardial infarction:

It is a condition when the heart can no longer pump blood adequately to supply the brain
and other organs of the body due to sudden blockage of the coronary arter y leading to
ischemic necrosis of heart. Almost all heart attacks occur in people who have coronary artery
disease (coronary atherosclerosis).

Smoker:

Smokers ar e those persons who smoke cigarettes, cigar, biri, hukkah or pipe regularly for at
least one year and usually more than once a day on an average.

Non- smoker:

Those persons who have never smoked cigarettes, biri, cigar, hukkah or pipe.

Physical exercise:

It refers to physical movements in addition to the normal day to day routine activities so as to
burn the extra energy or calorie intake and hence preventing the unnecessary accumulation
of fat in the body.

24 | P a g e Chapter 1
Sedentary job:

It implies the desk job without any physical labor and is performed by the staff in their day to
day activities in the office.

Extra salt intake:

It refers to the intake of salt other than that used in the food during cooking accounting to a
total of 7-8 gm/day.

25 | P a g e Chapter 1
Limitations of the study

In spite of our best efforts, there were many limitations in our study which are as follows:

As the information regarding blood pressure status and treatment compliance collected from
a selected rural area of Dhamrai Upazilla, the result does not represent the real picture of the
hypertensive populations and also their treatment compliance of Bangladesh throughout. So,
universal acceptable conclusion cannot be depicted.

The study was conducted in a very short period of time. The time allocated for data collection
was not sufficient enough due to tight study schedule.

Money allocated for the study was not sufficient enough for such kind of study.

During the period of data collection, some respondents were unable to understand the
questions due to socio-cultural barrier. Most of time they interpreted their savings. In those
cases, monthly family income has been estimated from monthly or daily expenditure and
monthly savings.

Many respondents failed to give the exact figure of their monthly family income.

We collected the data from 9:00 am to 2:00 pm. During that time male members of the family
were outside of their houses for working purposes. For this reason we faced difficulties to find
the male respondents.

Confounding factors may not be equally distributed between the groups being compared
and this unequal distribution may lead to bias and subsequent misinterpretation.

Regarding the dietary survey, it may measure current diet in a group of people with a disease.
This current diet may be altered by the presence of disease. So it is hard to find out if the
previous dietary habit responsible for the disease process.

Many other variables contributing to high blood pressure were not included in the study due
to limited time and inadequate resources.

Diurnal variations of blood pressure of the respondents could not be measured due to
obvious reasons.

26 | P a g e
Chapter 1
Maximum number of respondents belongs to almost similar socio-economic group of people.

Investigations related to blood pressure level could not be done for resource constraints.

At the beginning as the study area was selected purposively, the result may suffer from
selection bias.

The allocated time for study was not enough to carry on comprehensively.

27 | P a g e Chapter 1
Chapter 2
Review of literature

28 | P a g e
Coronary heart disease (CHD) is estimated to be the most common cause of death globally
by 2020 and hypertension is one of the most important modifiable risk factors for CHD and
in Western and Asian population. Studies from India and Bangladesh have shown an
increasing in the prevalence of hypertension. So all societies are confronted with the problem
of defining a strategy to control high blood pressure. There is an increasing emphasis in the
major general and specialized scientific journals on the burden of cardiovascular disease in
terms of mortality and morbidity and of hypertension is a leading risk factor in low income
countries like ours. The instruments and strategies prepared to deal with this problem
however derived mostly from experimental and observational studies. Observational studies
in low income countries aiming to assure not only the causal side of the risk but the critical
question of transferability of measures recommended to identify patients at risk and to
influence their clinical outcomes. Different literatures such as books, journals and magazines
were reviewed in order to gain through knowledge on the status of the blood pressure and
treatment compliance among rural people. Some contributory studies have been found in
our country as well as in international sphere. A few have been reviewed having special
significance with our present study.

Hypertension & Cardiovascular Risk:

29 | P a g e Chapter 2
Most population based studies confirm that hypertension increases on individual's risk of
various cardiovascular consequences approximately two to three times. Large population
based cohort studies consistently show continuous, strong, graded relation between blood
pressure and cardio-vascular system but no clear threshold value separates hypertensive
patients who will experience future cardiovascular events from those who will not multiple
high quality long term cohort studies and randomized clinical trials have shown that the risk
from raised blood pressure can be partially reversed. Hypertension is implicated in 35% of all
atherosclerotic cardiovascular events including 49% of all cases of heart failure.

As hypertension is only one of the many risk factors for CVS, a patients progress depends
more on the sum of their risk factor than on their pressure. Numerous factors definitely CVS
risk including age, male sex, family raised cholesterol, smoking, diabetes mellitus, obesity,
sedentary life style and left ventricular hypertrophy guidelines for the management of the
both the hypertension and cardiovascular disease generally now recommended the use of
simplified version of several risk prediction model such as- Framingham, disease life
expectancy model, coronary risk disk, PROCAM risk function, British regional heart study
function.

Cholesterol:

A strong graded r elation raised serum cholesterol and coronary artery in run total values
above 220mg/dL. The protective effect of high density lipoprotein cholesterol runs to be at
least as strong as the effect of the low density fraction particularly in woman.

Smoking:

The risk of cardiovascular disease in smokers is proportional to the number of cigarette


smoked & how deeply the smoker inhales, and it is approximately greater for woman than
man. The risks of pipes & cigar smokers sum to fall between those of non-smokers and
cigarette smokers relative risk 1.3, 95% confidence interval 1.1 to 1.5 for heart disease, with a
dose response relation.

Diabetes Mellitus:

30 | P a g e Chapter 2
It is one of the strongest modifiable risk factors for cardiovascular disease and its effect in
woman is relatively greater than in man for all cardiovascular events except congestive heart
failure. Diabetes often co-exist with obesity, hypertension and (syndrome x); these patients
are particularly predisposed to atherosclerotic diseases.

Sedentary life style:

A high quality cohort study in middle aged man followed for 16 years showed that physical
fitness is graded and independent predictor of cardiovascular mortality; after adjustment for
baseline risk factors, the relative risks were 0.41(0.20-0.84) in the fittest group, 0.45 (0.22 to
0.92) in the second fittest group; and 0.59 (0.28 to 1.22) in next fourth compared with the
group with the lowest fitness ranges.

Left Ventricular hypertrophy:

Left Ventricular hypertrophy is a common effect of hypertension and a strong independent


predictor of future cardiovascular events. Left Ventricular hypertrophy with repolarization
changes on the electrocardiogram carries a higher risk than hypertrophy diagnosed solely on
voltage criteria.

31 | P a g e
Chapter 2
Chapter 3

Materials & Methods

32 | P a g e
Type of study:

It was descriptive type of cross sectional study.

Sites of study:

The study was done in the following villages, named- Khatra ,Dighol - of
Dhamrai Upazilla of Dhaka district.

Duration of study:

The study was conducted for a period of 4 days starting from 10th November to 14th November,
2012.

Study population:

The study population was adult household members of the above mentioned villages.

Selection criteria of study population:

Inclusion criteria:

The study population was permanent resident of Dhamrai Upazilla.

Those who will be present during the time of data collection.

Those who will take part in interview willfully.

33 | P a g e Chapter 3
Exclusion criteria:

Travelers or temporary resident of Dhamrai Upazilla.

Individuals within unsound mental state/psychologically abnormal.

Individuals who disagreed to provide necessaryinformation.

Sample size:

The sample size was 360 persons of above mentioned villages.

Sampling technique:

Purposive sampling was followed for this study.

Data collection tools/instruments:

Data was collected on a semi-structured questionnaire

Methods of data collection:

Before data collection, the purpose of the study was explained to each respondent.
.Data was collected for 3 consecutive days from 9:00 am to 1:30
pm. At first day the data was collected from Khatra, next day from Dhigol and on third
Data was collected through face to face interview based on semi
structured questionnaire.

Chapter 3
34 | P a g e
Procedures of blood pressure measurement:

The person should sit for several minutes in a quiet room. He should not engage in
physical activity, tobacco taking or eaten within 30 minutes.

The arm should be supported and at level with the heart.

The cuff should be placed on bare arm, about 2cm above from the elbow crease and
the cuff should cover the two- third the circumference of the elbow.

The bell of the stethoscope should be placed over the brachial artery, using sufficient
pressure to provide good sound transmission without over compressing the artery.

Once pulse obliteration pressure is determined, initiate the auscultatory blood


pressure measurement by rapidly inflating the cuff to a level of 20 to 30 mmHg above
the pulse obliteration pressure. Then deflate the cuff at a rate of 2 mmHg per second
while listening to the korotkoff sound.

Phase 1 (first tapering sound) and phase 2 (disappearance) is used to determine


korotkoff sound to identify systolic and diastolic blood pressure values respectively.

Obtain minimum of two blood pressure measurements at intervals at least 1 minute.


Then the average blood pressure is measured.

Data processing and analysis:

Data was checked daily after collection for missing values and inconsistency and was
corrected and then a master sheet was prepared from collected and corrected data in
Microsoft Office application. Data was analyzed by a calculator. Results were presented on the
tables and figures.

35 | P a g e Chapter 3
Chapter 4
Result

36 | P a g e
Table 1: Distribution of respondents according
to age group

Age Frequency Percentage


range(yrs) (%)
20-29 62 17.33
30-39 84 23.18
40-49 106 29.45
50-59 51 14.14
60-69 36 9.89
70-79 13 3.70
80-89 8 2.31
Total 360 100

Most of the respondents were between the age group 40-49 years least respondents belonged
to 80-89 age group.

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Pie Chart 1: Distribution of the
respondents by sex

Pie chart showing distribution of respondents by sex. Most of the respondents were
female 60.78%.

35 | P a g e
Religion Frequency Percentage (%)
Islam 348 96.74
Hindu 12 3.26
Others 0 0
Total 360 100

Most of the respondents were Muslim whereas rests were Hindus. No other religion was found.

36 |P a g e
BAR DIAGRAM 1:EDUCATIONAL STATUS OF THE RESPONDENTS

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Most of the respondents 321 (89.13%) were married.

38| P a g e
Most of the respondents (47.11%) do household work.

39 | P a g e
Pie chart showing that most (81%) of the respondents do physical work.

PIE CHART 2:DISTRIBUTION OF RESPONDENTS IN RELATION


PHYSICAL LABOUR

40| P a g e
TABLE 5: DISTRIBUTION OF RESPONDENTS ACCORDING TO THEIR
FAMILY INCOME

Family income of most of the respondents belongs to 5000-10000 TK group.

41 | P a g e
PIE CHART 3:DISTRIBUTION OF RESPONDENTS IN RELATION TO FATTY
FOOD INTAKE

Pie chart showing that most of the respondents (78.33) do not take fatty food in their diet.

42 |P a g e
46 | P a g e
Chapter 4
Most of the respondents (63.66%) take fish as their protein.

TABLE6:DISTRIBUTION OF RESPONDENTS IN RELATION TO TYPE


PROTEIN INTAKE

43 | P a g e
PIE CHART 4: DISTRIBUTION OF RESPONDENTS IN RELATION TO
WALKING AT
LEAST 30 MINS A DAY

Pie chart shows that 67.78% respondents walk at least 30 minutes a day.

44 | P a g e
PIE CHART 5:DISTRIBUTION RESPONDENTS ACCORDING TO
SMOKING
HABITS AMONG MALE

Pie chart shows that most of the male respondents (72.23%) do not smoke.

45 |P a g e
PIE CHART 6: PIE CHART SHOWING USES OF CONTRACEPTIVE
PILL
AMONG FEMALE RESPONDENTS

29.93% of female respondents use contraceptive pill whereas other do not

46 |P a g e
PIE CHART 7:PIE DIAGRAM SHOWING EXTRA SALT INTAKE
AMONG THE RESPONDENTS

Pie chart shows that most of the respondents (91.54%) take extra salt in their food

47| P a g e
PIE CHART 8:PIE CHART SHOWING PERCENTAGE OF KNOWN
HYPERTENSIVE
AMONG RESPONDENTS

Among the respondents 89.74% were hypertensive whereas rest were normotensive

48| P a g e
PIE CHART 9:DISTRIBUTION OF RESPONDENTS ACCORDING TO
OF
FAMILY HISTRY OF HYPERTENSION

60.59% of the respondents had a history of hypertension in their family and 39.49% did not

4|9 P a g e
TABLE 7:DISTRIBUTION OF RESPONDENTS ACCORDING TO BLOOD
PRESSURE STATUS

87.26% of the respondents were normotensive and 3.20% had grade 3 (severe) hypertension

50|P a g e
55 | P a g e
Chapter 4
56 | P a g e
Chapter 4
PIE CHART10:DISTRIBUTION OF HYPERTENTION RESPONDENTS IN
RELATION TO
IN RELATION COMPLIANCE HYPERTENSIVE DRUG

Approximately 91.30% hypertensive respondents took anti- hypertensive medication regularly

51 | P a g e
Chapter 5

Discussion

58 | P a g e
The study entitled 'status of blood pressure and treatment compliance among adult
population in DHAMRAI Upazilla' was a descriptive cross sectional study. The study was
carried out from 14 November to 20 November 2012. The objective of this study was to assess
the blood pressure status and socio-demographic characteristics of the respondents. A total
of 360 respondents were included in this study aged 20 years or above. Information about
socio demographic characteristics, life style, risk factors were collected, compiled and
analyzed.

There was a distinct pattern in the distribution of the respondents in the age categories. The
distribution of the respondents was found to be diffuse among all the age groups above 20
years. The percentage of the respondents in age group 20-29 was found to be 17.33%, in 30-
39 age group it was found to be 23.18%, in age group 40-49 it was 29.45% and above 50
years of age the respondents were around 30.04%.It has been reported that increase in blood
pressure occurs progressively throughout the age and that about two third of the elderly can
9
be defined as hypertensive with stage 2 hypertension.

There is an evidence of variability in blood pressure according to the sex. In our study among
the respondents 60.78% were female and only 39.72% males. But this picture of reference is quite
contradictory to the overall sex ratio of the country which is 0.9males/female. The reason for
this discrepancy is that the study was conducted in time (from l0:00 am to 2:00pm) which

59 | P a g e
Chapter 5
suggests that most of the male person had been working outdoor at that time and which is
the reason for having less male respondent.

Education status is one of the main statuses with wide range of factors depending on it which
include the life style, habits, the beliefs and economic conditions. According to our study,
46.26% of total respondents received institutional education. This literacy rate is very close to the
national adult (15+) rate (47.5). 12 The relation of the hypertension according to our study was
very discrete.

Our study included Muslim respondent mostly. That means 96.74% respondents were
Muslim. This doesn't the true picture of the population distribution based on religion at the
local and national level. The national religion-wise distribution of population of Bangladesh
showed89.3s%Muslim &9.64%Hindus. 13

Monthly family income of the respondents was recorded and they were categorized in
different income groups. It was reflected that, out of all the respondents the highest number
259 were in the income group of Tk.5000-10000. Followed by 81 in the income group
<Tk.5000. A similar study conducted in April, 2007 at Sreepur, Gazipur district estimated that
the mean income of the respondents was TK 5857.52. 14 which is close to our study finding.
Respondents in our study were almost same socio economic status compared to the study of
Rahman KMM conducted in the rural areas of Naogaong. 15

Other than physical labor questions were also asked regarding regular walking for at least 30
minutes which we took as a form of exercise due to lack of facilities like a heal club in rural
areas. We found out that 67.78% of the respondents did walk for 30 minutes and 32.23% did not.

60 | P a g e
Chapter 5
In our study 27.77% of the male respondents were smoker and 72.23% were non-smokers. The risk
of CVD in smokers is proportional to the number of cigarettes smoked smoked per day and
16
how deeply the smokers inhales. This was in with a research by Ernest E et al.

In a similar study carried out in Dhaka cantonment around 10 years back, only little as l0%
had previously measured their BP. This reflects an increase in awar eness and cautiousness

Hypertension has been again linked to the intake of food rich in fats and oils which contribute
to the rise of serum cholesterol level. In our study, the respondents were asked about the
consumption of their food. It was found that a good 78.33% of the respondent did not take fatty
food much whereas only 21.67% took fatty food regularly. Amongst the regular fatty food
consumers most of them were hypertensive. Several others statistical units like BMI and blood
cholesterol level are used to identify dietary pattern in the society but due to lack of logistics
and equipment we could not do it.

61 | P a g e

Even in rural areas.So we have found that 89.74% are known hypertensive among the respondents and 91.20% respondents take antihypertensive drug.
Chapter 5

Chapter 6
Conclusion & Recommendation

62 | P a g e
According to the survey findings it could be stated that knowledge about blood pressure and
the low level of compliance to anti-hypertensive medication found in this study, which is
consistent with findings in other countries, emphasizes the need for population-wide primary
prevention of elevated BP and cardiovascular disease. Such measures include educational,
legislative, and fiscal actions to encourage the adoption of a healthy diet (particularly lower
salt intake) and to increase facilities and opportunities for physical activity in leisure. It has
been estimated in the Asia- Pacific region, for example, that reducing the population systolic
BP by as little as 3% would prevent 15% of all stroke deaths and 6% of all coronary deaths.

Nonetheless, anti-hypertensive medication is among the most cost-effective high-risk


interventions for non-communicable diseases. Detection and treatment of hypertension must
therefore be considered in both industrialized and developing countries, particularly for
patients with other risk factors. Less than optimal compliance in many hypertensive patients,
such as found in this study, stresses the need to improve adherence to medication. Poor
adherence to therapy is largely unrecognized in clinical practice and monitoring compliance
could be a useful way of detecting poor adherence to medication as the cause of poor BP
control, particularly in patients with high overall cardiovascular disease risk. These issues may
be particularly critical in developing countries where anti-hypertensive treatment can drain
health care resources.

More gener ally, the influence of knowledge, attitudes, and practices among patients and
health professionals (e.g. how chronic disease is perceived and treated, and the role of
traditional medicine) on compliance to medication should be examined and relevant
measures should be taken accordingly.

Patients non-adherence to therapy is increased by misunderstanding of the condition or


treatment, denial of illness because of lack of symptoms or perception of drugs as symbols of
ill health, lack of patient involvement in the care plan, or unexpected adverse effects of
medications. The patient should be made to feel comfortable in telling the clinician all
concerns and fears of unexpected or disturbing drug reactions. The cost of medications and
the complexity of care (i.e., transportation, patient difficulty with poly-pharmacy, difficulty in
scheduling appointments, and lifes competing demands) are additional barriers that must be
overcome to the problem of hypertention.

63 | P a g e

Chapter 6
Recommendations

Blood pressure control is of prime importance in treatment of hypertension. So that following measure
Should be taken:

Large scale community based study regarding blood pressure status should be carried
out.

Health education should be given by health workers regarding the self-maintenance


and monitoring of blood pressure.

Health education and mass awareness should be arranged to raise awareness among
people regarding hypertension and its consequences through mass media.

64 | P a g e Chapter 6
Governent should contribute by providing logistic and financial support.

Life style should be changed by following activities.

Life style changes:

1. Weight reduction and regular exercise (like, jogging)

2Reducing Sugar in diet.

3Reducing sodium (salt) in the diet decreases blood pressure in about 60% of people

4. Increasing daily calcium intake has been shown to be highly effective in reducing blood pressure.

5Tobacco smoking should be avoided.

6. Alcohol consumption should be avoided.


7. Should practice of eating vegetables & low fat diet.

8. Relaxation therapy should be taken to reduce environmental stress, like from

meditation,
reducing high sound levels and over-illumination.
Muscle Relaxation
paced breathing.

Life Style changes canreduce the blood pressure to a safe level, But Drug Therapy can still not be avoided

65 | P a g e Chapter 6
References:

1. Park K. Textbook of Preventive and Social Medicine, 20 th edition 2010.

2. Rashid KM, Rahman M & Hyder S. Textbook of Community Medicine and Public Health, 5 th

edition 2010.

3. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure.

4. Nutritional influence on risk of high blood pressure in Bangladesh: a population-based cross-


sectional study by Yu Chen, Pam Factor-Litvak, Geoffrey R Howe, Faruque Parvez, and Habibul
Ahsan.

5. Journal of Human Hypertension (2010): Prevalence and correlates of hypertension: a cross-


sectional study among rural populations.

6. www.nationmaster.com

7. www.MedicineNet.com

8. www.wikipedia.org

9. Amery, A. 1985.Mortality & morbidity results from the European working Party on High Blood
Pressure in the elderly. Lancet,1:1349-54

66 | P a g e
10. Gupta R-Meta analysis of prevalence of hypertension in Indian Heart J:1997;490-500

11. BMC Public Health, Research article: Hypertension in Parsi community of Bambay: A study on
prevalence, awareness and compliance to treatment.

12. Census-2001,BANBEIS

13. Bangladesh Bureau of Statistics. Key indicators of report on Sample Vital Registration
System.[cited on April 2, 2010]

14. Ahmed S. et al. Geriatric Health Problems in Rural Community of Bangladesh. Ibrahim Med.
Coll. J.2007;1(2):17-20

15. Rahman KMM, Tareque MI, Rahman MM. Gender Difference in Economic Support , Well-
being and satisfaction of the Rural Elderly in Naogaon District, Bangladesh. Journal of Indian
Academy of geriatrics.2008;4:98-105

16. Ernes E, Resch KL; smoking as a CVD risk factor a meta-analysis and review of literature A
.Intern Med;118;956-63

17. Khalil SA, Elzubier AG. Drug compliance among hypertensive patients in Tabuk, Saudi Arabia.
Journal of hypertension1997;15(5):561-5

18. Amal M Al-Mehza, Fatema A Al-Muhailije. Drug compliance among hypertensive patients; an
area based study. Eur J Gen med 2009;6(1):6-10

67 | P a g e
Annexure

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Status of Blood Pressure and Treatment compliance in selected
rural area of Dhamrai Upazilla, Dhaka

Questionnaire
Identity no:

Date:

A. Particulars of the respondent


1. Name of the respondent:
2. Present address:
Village Ward no Union
Upazilla District

B. Socio-economical information
1. How old are you? (Years) .

2. Which religion you follow?

a) Islam b) Hindu c) Christian d) Buddhism e) Others (mention).

3. What is your educational status?

a) Illiterate b) Informal c) Primary d) Secondary

e) SSC/Equivalent f) HSC/Equivalent g) Degree or Degree+ /Equivalent

4. Your marital status?

a) Unmarried b) Married c) Divorced

d) Separate living e) Widow f) Widower

5. What is your occupation?

a) Household work b) Agriculture c) job

d) Business e) Day laborers f) Student g) others

69 | P a g e
6. Do you physical work?

a) Yes b) No

7. What is the monthly income of your family (Taka)?

a) <5000 b) 5000-10000 c) 10000-15000 d) 15000-20000

C . Information on Diet & Habit


1. Do you eat fat containing food much?

a) Yes b) No

If yes, how many days a week? .

2. Which type of proteins do you eat most of the times?

a) Fish b) Meat c) Egg d) Milk e) Others

3. Do you walk every day?

4. If yes, do you walk quickly for at least 30 minutes for 3 days in a week?

a) Yes b) No

5. Do you say your prayer regularly?

a)Yes b) No

6. Do you smoke?

a) Yes b) No

7. If yes, how many cigarettes on average per day? .


8. If yes, for how many years? ..

9. Do you take any oral contraceptive pill? (Married woman only)

a) Yes b) No

70 | P a g e
10.Do you take extra salt in food?
a) Yes b) No

D. Information about Blood Pressure


1. Have you ever measured your blood pressure before?

a) Yes b) No

If yes, i) Normal ii) Abnormal

2. Do you know whether you have hypertension or not?

a) Yes b) No

3. Do you take any medicine for hypertension?

a) Yes b) No

4. If yes, for how long are you taking medicine for hypertension? ..
5. Do you take anti-hypertensive medicine regularly?

a) Yes b) No

6. Are you suffering from any kind of complication related to hypertension?

a) Yes b) No

If yes, what type of complication?

a) Heart disease b) Stroke c) Kidney disease d) Others

For how long? .. Month/years

7. Do other members of your family have hypertension?

a) Yes b) No

8. Do you have any other diseases except hypertension?

a) Yes b) No

71 | P a g e
If yes, what are the diseases?

a) Obesity b) Diabetes mellitus c) Others

E . Information regarding treatment


1. Whom from have you come to know that you are suffering from hypertension?

a) MBBS doctor b) Specialized doctor


c) Assistant of doctor d) Ayurvedic physician
e) Village doctor f) Homeopath g) Others

2. Do you check your blood pressure regularly by a qualified doctor?

a) Yes b) No

3. Do you take medicine regularly?

a) Yes b) No

4. Are you feeling well after taking medicine?

a) Yes b) No

5. What is the currently measured blood pressure?


A) Systolic blood pressure: Left arm:.

Right arm:...

Average:.

B) Diastolic blood pressure: Left arm:.

Right arm:...

Average:.

Name of the data collector:

MC No: . Group: .. Batch: .

72 | P a g e
Map of Dhamrai Upazilla showing study areas

Sutipara
a

Choybaria Barigao

73 | P a g e
Photographs during the visit

Group members with instructors

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Students measuring blood pressure during data collection

75 | P a g e