This study is one of the first to use nationally representative data from the Longitudinal Aging Study in India (LASI) to analyze the gender disparities in hypertension prevalence, awareness, treatment, and control, as well as the factors associated with hypertension among adults in India. The findings revealed that for males, the factors most strongly associated with hypertension were being in the age group of 45–54 years, having no education, being currently employed, currently married, having a normal body mass index (BMI), being inactive in physical vigorous activities, never having smoked or chewed tobacco, being diabetic, having a history of stroke, being in the richest quintile of the Multidimensional Poverty Index, residing in rural areas, and living in the southern region of India. For females, the factors most strongly and significantly associated with hypertension were being in the age group of 55–64 years, having no education, never having worked, currently married, having a normal BMI, being widowed, being Muslim, being diabetic, having a history of stroke, being inactive in physical vigorous activities, and residing in India.
In this research, the prevalence of all hypertension was 45.1%, with males accounting for 41% and females accounting 58.9%. Our finding is contradictory to many studies, such as, a study on NFHS-4 India found the total prevalence of measured hypertension in males aged 15–54 years was 16.3% and in females aged 15–49 years was 11.5% (17), WHO findings of 2019 globally for 30–79 years adults, the total prevalence of smoked and chewed tobacco, non-alcoholic, being in the middle MPCE quintile, residing in the rural and south region hypertension in males was 30.6% and in females was 29.5% (18), a research conducted in Varanasi, the prevalence of measured hypertension was found to be 40.6% in males and 26.0% in females (19). According to these studies, the prevalence of measured hypertension was found to be significantly higher in males compared to females. However, it is difficult to pinpoint a specific explanation for this observation as various factors may contribute to the findings. One possible explanation for the higher prevalence of self-reported hypertension among males could be that in the past, men were typically the primary breadwinners and had more access to healthcare and resources, which may have resulted in increased stress and workload.
Our study found that individuals aged 75 and above, both males and females, have significantly lower awareness, treatment, and control of hypertension compared to those aged 45 to 74 years. This could be due to several reasons such as older people being more dependent on others for their care, as well as the fact that hypertension often lacks noticeable symptoms, making it more difficult for older individuals to detect and manage the disease. This is why hypertension is often referred to as the "silent killer". A study done by Zhang & Moran (20), demonstrates that youngsters are more likely than their older counterparts to acquire BP control with treatment. Males were more aware of hypertension than females in the 45–54 age range, while female treatment and control of hypertension were considerably more significant than males for the same age group. Previous studies have shown that “infrequent healthcare visits are an important risk factor for low awareness and management” (21). Our study revealed that Muslim females were more likely to have hypertension, be more aware of it, but less likely to effectively manage it compared to Hindu females. In contrast, there was no significant relationship between religion and hypertension among males. However, Muslim males were more aware of the disease but less likely to control it compared to Hindu males. This higher prevalence of hypertension among Muslim females than Hindu females may be partly attributed to cultural beliefs and dietary patterns that influence the lifestyle of Muslim females (17). Previous research has found an association between the consumption of non-vegetarian foods and hypertension, whereas a vegetarian diet has been shown to have a protective effect against hypertension (22, 23). In our study, females in the richest MPCE household had a higher prevalence, awareness, treatment, and control of hypertension than the poorest sections.
Our study found that males with higher levels of education were more likely to be aware of hypertension compared to those with no education. However, our findings also revealed that men with higher education had a greater risk of hypertension than men with no education. This could be because men with higher education tend to work primarily as professionals or clerks, and may have a more sedentary lifestyle, lack regular physical activity, and consume foods high in fat and sodium. On the other hand, other study found that women with higher levels of education had a lower risk of hypertension than women with no education (21). Previous research (5, 24) has found that individuals with higher levels of education tend to have higher blood pressure compared to those with lower levels of education. However, other studies have also shown that highly educated women have a better understanding of healthcare which can result in a decreased risk of hypertension, which is contradictory to our findings. This highlights the complexity of how education and hypertension are related, and that other factors may also play a role (25). Males in the highest income bracket, or richest quintile, had a higher prevalence and greater awareness of hypertension compared to those in the lowest income bracket, or poorest quintile. These findings are consistent with previous research that suggests that individuals with higher income levels have greater access to healthcare, better education, and may experience more stress due to their occupation compared to lower income individuals. This access to healthcare and education may also help them to be more aware of hypertension and its management (17, 24, 26).
Our study found that widowed females were more likely to have hypertension, be aware of it, and seek treatment compared to married females. However, they were less likely to effectively manage their hypertension. This could be due to the challenges of living alone at an age of 45 or older, particularly for women who may have relied on their partner for support. This is consistent with previous research which has found that married individuals have a lower prevalence of hypertension compared to single, divorced, or widowed individuals. (24). Surprisingly, our study did not find an association between smoking and drinking alcohol and the risk of hypertension in both males and females. One possible explanation is that our sample population consisted of late adults to elderly adults. As smoking and drinking alcohol are still stigmatized in Indian society, this could have led to underreporting of these behaviours. This is consistent with a previous study conducted in Korea which also found that smoking had no effect on hypertension treatment in either males or females (27). Our study found that among females, former smokers and current tobacco chewers were more likely to be aware of hypertension and to seek treatment for it. Additionally, we found that among males, alcohol consumption was associated with a lower likelihood of effectively managing hypertension. These findings contrast with previous studies that have consistently shown a strong association between alcohol intake and a high prevalence of hypertension in both males and females (19, 24, 25).
In this study, we found that being underweight was associated with a lower prevalence of hypertension in both males and females, while being overweight or obese increased the risk of hypertension, seeking treatment, and awareness of hypertension in both males and females. Our findings also revealed that underweight individuals were more likely to have better blood pressure control compared to those with normal weight. These results are consistent with previous research that has examined the relationship between body mass index (BMI) and hypertension (28, 29). The results of this study found that for males, being physically fit as measured by participation in vigorous activity was associated with a lower risk of hypertension. However, this association was not significant among females. These findings align with previous research that has reported a positive association between physical activity and hypertension control in both genders. (30, 31). Our study found that diabetes was strongly associated with hypertension prevalence, awareness, and treatment in both males and females. However, diabetic females were less likely to effectively manage their hypertension compared to non-diabetic females. Both diabetic males and females were more likely to have hypertension, be aware of it, and seek treatment. (32). Our study is in line with previous research that has found that diabetic men and women have a higher prevalence of hypertension than non-diabetic individuals. However, findings also suggest that diabetic women have an even greater risk of hypertension compared to non-diabetic women.(17, 33, 34). A study suggests that diabetes, which is known to be associated with hypertension, may be caused by unhealthy dietary habits, a sedentary lifestyle, and lack of physical activity. These are established risk factors for hypertension and are likely to contribute to the development of both diabetes and hypertension (35).
In our study, both currently employed males and females were found to have a lower prevalence of hypertension compared to their non-employed counterparts. Additionally, the results indicated that currently employed females were more likely to effectively manage their hypertension than males. However, these findings contradict previous studies on older adults which only found a relationship between hypertension treatment and control in relation to the employment status of males. (36, 37). WHO has recommended the implementation of workplace-based wellness programs as a strategy to address hypertension. (38). Interestingly, our analysis found no significant relationship between unemployment and hypertension, which contrasts with the findings of previous studies conducted in South Korea, which have identified unemployment as a risk factor for poor hypertension management among women. (39). Previous research has shown that unemployment can limit women's access to regular medical check-ups and facilities, increasing their likelihood of developing hypertension. Our study found that hypertension was more prevalent among urban males and females compared to rural inhabitants, and that they were more likely to be aware of their condition and seek treatment. The higher incidence of hypertension in urban populations may be attributed to factors such as busy lifestyles, lack of physical activity, and stressful environments commonly found in urban areas. (17). In India, the awareness of healthcare, health-seeking behaviours and access to quality health services, particularly among rural women, is still quite limited. (40).
Study’s Strength And Limitation
Our research advanced upon previous studies by using the newly published LASI data, which enabled us to estimate hypertension prevalence at multiple geographic levels. Our findings can be applied globally. Multivariate analysis was employed to identify the primary determinants of hypertension in India. However, we also identified limitations in our research. For example, previous studies had inconsistent definitions of hypertension, making comparisons difficult. Additionally, qualitative analysis is needed to fully understand the gender disparity in hypertension prevalence, awareness, treatment, and control. There is no data available on the frequency of healthcare visits. The cross-sectional design of the study raises the possibility of causal inference, but we were unable to gather information on patients' medication adherence, which limits our ability to study potential causes of inadequate treatment. Additionally, the data was self-reported, which is susceptible to social desirability, recall bias, and underreporting. Another limitation is that we did not inquire about the list of the participants taking antihypertensive medicines, which could have assisted us in estimating the prevalence of resistant hypertension in this group. Furthermore, the LASI survey took blood pressure at the participants' homes during a single visit, although it was collected three times in a single visit, which can lead to higher average readings, an overestimation of the incidence of hypertension, and an incorrect assessment of patient awareness of the condition and the effectiveness of treatment (41).