Awareness, treatment, and control of hypertension in adults aged 45 years and over and their spouses in India: A nationally representative cross-sectional study

Author summary Why was this study done? We found only one study that reported estimated rates of awareness, treatment, and control (ATC) of hypertension in India using a nationally representative sample covering all states, but that study was restricted to adults aged 15 to 49 years. Another study estimated rates of hypertension ATC among older adults, but that study covered only 6 states. This study aimed to provide nationally representative estimates of hypertension ATC in the older population of India and to describe differences in these indicators of hypertension management across sociodemographic groups and states. What did the researchers do and find? We used a nationally representative sample of adults aged 45 years and over and their spouses covering all states (except one) of India in 2017 to 2018. We used measured blood pressure (BP) and self-reported diagnosis and treatment for high BP to estimate hypertension prevalence and the percentages of those with hypertension who were aware of their condition, treated for it, and had achieved BP control. We found that a slight majority of those with hypertension were aware of their condition, around half were being treated, and less than a third had controlled their BP. While these rates indicated substantial gaps in hypertension management among the older population of India, they were higher than estimates previously obtained from samples restricted to, or including, younger people. We found substantial variation in the indicators of hypertension management across states. Older Indians who were poorer, less educated, socially disadvantaged, male, rural, and working were less likely to be aware, treated, and to have achieved BP control. What do these findings mean? Hypertension prevalence is high in India, particularly in the older population. In this critical population group, low rates of ATC point to deficiencies in diagnosis and management of the condition and in the prevention of cardiovascular diseases (CVDs). Effectively addressing these deficiencies requires subtle targeting of interventions that balances attention to prevalence, which is higher in the high-income states and socioeconomically advantaged groups, with attention to gaps in ATC, which are greater in the low- or middle-income states and disadvantaged groups. Background Lack of nationwide evidence on awareness, treatment, and control (ATC) of hypertension among older adults in India impeded targeted management of this condition. We aimed to estimate rates of hypertension ATC in the older population and to assess differences in these rates across sociodemographic groups and states in India. Methods and findings We used a nationally representative survey of individuals aged 45 years and over and their spouses in all Indian states (except one) in 2017 to 2018. We identified hypertension by blood pressure (BP) measurement >= 140/90 mm Hg or self-reported diagnosis if also taking medication or observing salt/diet restriction to control BP. We distinguished those who (i) reported diagnosis ("aware"); (ii) reported taking medication or being under salt/diet restriction to control BP ("treated"); and (iii) had measured systolic BP <140 and diastolic BP <90 ("controlled"). We estimated age-sex adjusted hypertension prevalence and rates of ATC by consumption quintile, education, age, sex, urban-rural, caste, religion, marital status, living arrangement, employment status, health insurance, and state. We used concentration indices to measure socioeconomic inequalities and multivariable logistic regression to estimate fully adjusted differences in these outcomes. Study limitations included reliance on BP measurement on a single occasion, missing measurements of BP for some participants, and lack of data on nonadherence to medication. The 64,427 participants in the analysis sample had a median age of 57 years: 58% were female, and 70% were rural dwellers. We estimated hypertension prevalence to be 41.9% (95% CI 41.0 to 42.9). Among those with hypertension, we estimated that 54.4% (95% CI 53.1 to 55.7), 50.8% (95% CI 49.5 to 52.0), and 28.8% (95% CI 27.4 to 30.1) were aware, treated, and controlled, respectively. Across states, adjusted rates of ATC ranged from 27.5% (95% CI 22.2 to 32.8) to 75.9% (95% CI 70.8 to 81.1), from 23.8% (95% CI 17.6 to 30.1) to 74.9% (95% CI 69.8 to 79.9), and from 4.6% (95% CI 1.1 to 8.1) to 41.9% (95% CI 36.8 to 46.9), respectively. Age-sex adjusted rates were lower (p < 0.001) in poorer, less educated, and socially disadvantaged groups, as well as for males, rural residents, and the employed. Among individuals with hypertension, the richest fifth were 8.5 percentage points (pp) (95% CI 5.3 to 11.7; p < 0.001), 8.9 pp (95% CI 5.7 to 12.0; p < 0.001), and 7.1 pp (95% CI 4.2 to 10.1; p < 0.001) more likely to be aware, treated, and controlled, respectively, than the poorest fifth. Conclusions Hypertension prevalence was high, and ATC of the condition were low among older adults in India. Inequalities in these indicators pointed to opportunities to target hypertension management more effectively and equitably on socially disadvantaged groups.