Worldwide, hypertension or high blood pressure (BP) stands as the primary modifiable risk factor for cardiovascular disease (CVDs) and premature mortality1. In 2019, 10.8 million deaths were attributed to hypertension2. The prevalence of hypertension and the overall burden is substantially increasing, with a staggering 90 per cent rise in the number of individuals worldwide who have high BP, especially in low- and middle-income countries (LMICs). The global rates of treatment, awareness, and control of hypertension are alarmingly inadequate. The global burden of hypertension is anticipated to reach 1.56 billion individuals by the year 2025. It is estimated that two-thirds of this burden will be borne by developing countries3.

In India, hypertension has become the foremost cause of mortality and disability. According to a recent systematic review and meta-analysis by Koya et al4, only 13.2 per cent of hypertensive individuals in India achieved blood pressure control. This rate is notably lower compared to the global average of 21 per cent reported in 2021.

The National Family Health Survey round five (NFHS-5), conducted between 2019 and 2020, reported an increase in the prevalence of hypertension. The survey findings revealed that 24 per cent of men and 21 per cent of women were diagnosed with hypertension4. This represents a notable increase compared to the previous round conducted in 2015-2016, where the prevalence was reported as 17 per cent among men and 19 per cent among women. These rising figures indicate the urgent need for effective interventions and management strategies to address the growing burden of hypertension in India.

The National Non-Communicable Disease (NCD) Monitoring Survey (NNMS) provides evidence of the burden of NCDs and their risk factors in India. The NNMS indicated that only 27.9 per cent of hypertensive individuals were aware of their diagnosis, a figure lower than that reported by NFHS-55. This low awareness underscores the need for better communication between healthcare providers and the general population. Contributing factors to this low awareness include an inadequate emphasis on risk communication in medical education and training, a shortage of counsellors in NCD clinics, and gaps in the training programmes for medical officers. Despite the lower awareness rates, the NNMS reported a higher proportion of participants receiving treatment (14.5% compared to 13.7%) and having their blood pressure under control (12.6% compared to 7.8%) than NFHS-55.

The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) was launched in 2010 to prevent and control major NCDs6. This initiative emphasizes enhancing health promotion, early diagnosis, and effective management. While the programme currently includes dietary assessment, physical activity evaluation, and screening of behavioural risk factors, integrating a self-care awareness programme for hypertension can significantly enhance its effectiveness.

An estimated one billion people worldwide reside in slums, and projections suggest that this number will double by 2030. In India alone, there are approximately 100,000 slums, housing over 17 per cent of the country’s population. A significant portion of India’s urban population also resides in slums, which are characterized by impoverished socio-environmental conditions. Further, it is important to recognize in this context that the disparities in health outcomes (hypertension and NCD being no exception) between the urban poor and non-poor are a significant concern within the country4. Notably, factors leading to poor hypertension control include limited access to healthcare, insufficient awareness, inadequate treatment, and poor medication adherence. Efforts are therefore essential to enhance the detection, treatment, and control of hypertension in India4,7.

In India, reported hypertension prevalence varies between studies from 10 per cent and 30.9 per cent. Studies conducted in slum areas have reported high prevalence rates of hypertension, ranging from 14 per cent to 26 per cent8-12. Slum dwellers often neglect self-care, rendering them more susceptible to lifestyle-related diseases. Factors such as irregular employment, the constant threat of eviction, overcrowding, alcoholism, and other social challenges contribute to poor health outcomes in slum areas. These circumstances also present challenges in providing adequate health services to these communities13. Hypertension-affected individuals face the challenges of implementing measures at home to ensure effective self-care, and management practices. Adhering to these self-care practices is crucial for successfully managing hypertension and reducing the risk of associated complications14,15.

Self-care has been acknowledged as a significant factor in attaining optimal blood pressure control at the individual level. The World Health Organization (WHO) defines self-care as ‘the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and cope with illness and disability, with or without the support of a healthcare provider.’ This definition highlights the importance of individuals taking an active role in managing their health and well-being16.

In hypertension self-care management, the primary focus should be on two key aspects: medication adherence and lifestyle modifications. By incorporating self-care awareness in hypertension management monitoring, individuals can gain valuable knowledge and skills to better hypertension management. This proactive approach empowers people to understand the importance of self-care practices, such as abstaining from smoking and limiting alcohol consumption, adopting a low-salt diet to reduce sodium intake, aiming for weight reduction in case of overweight or obesity, increasing physical activity levels, practicing self-monitoring to track and manage high BP17. Such integration not only improves individual health outcomes but also strengthens the overall effectiveness of controlling hypertension and reducing related complications.

To address this pressing need for optimal hypertension management in urban slum populations, the present study aimed to assess self-care practices among hypertensive affected individuals in Mysuru city, and identify influencing factors, and investigate their relationship with hypertension status in individuals.

Material & Methods Study design

A community-based cross-sectional study design was employed. It was carried out during March 2022 to August 2023, from the School of Public Health, JSS Medical College, JSS Academy of Higher Education & Research, Mysuru, Karnataka. The study was conducted in 63 urban slums of Mysuru city after obtaining the ethical approval from the Institutional Ethical Committee. The flow chart of the study is presented in Figure 1.

Fig. 1. Flow chart of the study.

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Study population and recruitment

The study enrolled hypertensive-affected individuals residing in 63 urban slums of Mysuru city who met the inclusion criteria. The study population included individuals aged ≥18 yr with a confirmed diagnosis of hypertension, residing in urban slums for at least 12 months. Exclusion criteria were established to exclude individuals who were unable to provide informed consent, terminally ill patients, and those not maintaining their health records.

The study utilized a purposive sampling method to enroll the participants. The interviewer cum investigator approached the potential study participants residing in urban slum households who met the inclusion criteria. When multiple hypertensive affected individuals were present in a single household, participants were selected using a lottery method to ensure random selection. Before data collection, all participants provided written informed consent.

Demographic details such as age, gender, body weight, occupation, education, marital status, religion, family type, sociodemographic character, Health insurance, and family history of hypertension were recorded. BP was measured using a sphygmomanometer. The confidentiality and safekeeping of data was ensured.

Sample size calculation

The study enrolled 650 participants to achieve a sample size that allowed for an absolute precision of four per cent at a 95% confidence level (CI), based on a prevalence rate of 44.3 per cent for practicing self-care behaviour18. From each of the 63 slums, 10 to 11 study participants were enrolled.

Study tools

Hypertension Self-Care Profile (HBPSCP): The HBP SCP scale, developed by Han et al19 consists of 20 items measured with each question having five response options: Never = 1, Rarely = 2, Sometimes = 3, Frequently = 4, and Always = 5. This questionnaire assesses self-care awareness among hypertensive patients, with scores ranging from 20 to 100 with higher score indicating better self-care practice. The questions are related to high-salt products being replaced by low-salt products, eating less than one teaspoon of salt per day, eating fruits and vegetables daily and drinking and smoking practices20.

The self-care practice was evaluated using the Hypertensive Self-Care Activity Level Effects (H-SCALE) tool21. The H-SCALE is segmented into six domains: medication adherence, regular blood pressure monitoring, physical activity, low-salt diet, and alcohol consumption, and smoking. Responses of ‘yes’ were interpreted as demonstrating good self-care practices, while ‘no’ responses indicated poor self-care practices. This questionnaire is designed to assess self-care behaviors among hypertensive-affected individuals.

Operational definitions

Low salt diet: ‘A low salt diet is a diet that includes no more than 1,500 to 2,400 mg of sodium per day’.

Hypertension control: ‘Hypertension control is defined clinically as SBP<140 mmHg and DBP<90 mmHg’.

Statistical analysis

The data are presented using descriptive statistics, with categorical variables summarized through frequencies and percentages. To explore the association between sociodemographic characteristics and hypertension self-care scores, we dichotomized the HBP-SCP scores into good (≥ mean) and poor (≤ mean) self-care practices, assessing associations using the Chi-square test or Fisher’s test. A multiple-bar diagram was employed to visualize the self-care practice scores. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) version 22 (IBM Corp. Armonk, NY, USA) licensed to JSS AHER. A P-value of less than 0.05 was considered significant.

Results

The sociodemographic characteristics of the study participants are presented in Table I. More than half (54.9%) of the study participants were male, and the majority (58.6%) were within 31 to 50 yr age bracket. Approximately 60.8 per cent of them had normal weight, and 75 per cent (75.5%) were employed. Around 44.6 per cent of the study participants were illiterate. The majority (90.3%) were married, and the majority (88%) of the study participants were Hindu. More than half (59.1%) were from a joint family, and ⁓50.6 per cent belonged to the lower class. Around 63.2 per cent had a family history of hypertension, while only 13.1 per cent had health insurance.

Table I. Sociodemographic characteristics of hypertensive affected individuals in urban slum areas of Mysuru city (n=650)

Variable Category Frequency Percentage Gender Female 293 45.1 Male 357 54.9 Age group (yr) 18-30 28 4.3 31-50 381 58.6 51-70 212 32.6 >70 29 4.5 BMI category Underweight (<18.5) 26 4 Normal weight (18.5-24.9) 395 60.8 Overweight (25-29.9) 182 28 Obese (>30) 47 7.2 Occupation Unemployed 159 24.5 Employed 491 75.5 Education Illiterate 290 44.6 Schooling 271 41.7 Degree/Diploma 89 13.7 Marital status Married 587 90.3 Unmarried 33 5.1 Divorced/Widowed 30 4.6 Religion Hindu 572 88 Muslim 52 8 Christian 21 3.2 Others 5 0.8 Family type Joint 384 59.1 Nuclear 245 37.7 Three generation 21 3.2 Socioeconomic status Upper 5 0.8 Upper middle 57 8.8 Upper lower 135 20.8 Lower 329 50.6 Lower middle 124 19.1 Family history of hypertension Yes 411 63.2 No 239 36.8 Insurance Insured 85 13.1 Uninsured 565 86.9

Among the 650 study subjects, 409 (62.9%) individuals reported poor self-care awareness of hypertension, while only 241(37.1%) reported good self-care awareness. Self-care activity level effect (H-scale) is represented in Figure 2. The majority of the participants had awareness about adherence to the medical schedule i.e., 556 (85.5%). More than half of them were unaware of low salt diet intake, i.e., 396 (60.9%). Around 439 (67.5%) were non-smokers. More than half of them were non-alcoholic, i.e., 422 (64.9%). Most of them were not monitoring their BP regularly i.e., 435 (66.8%). More than half of them were not doing physical exercise, i.e., 408 (62.8%).

Fig. 2. Distribution of self-care practices among study participants (n=650).

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Table II shows the association between socioeconomic characteristics and self-care scores. A statistically significant association was observed between age group, education, occupation, type of family, marital status, socioeconomic status, and self-care scores. However, no statistically significant association was found between gender and self-care scores.

Table II. Association between socioeconomic characteristics and self-care behavior scores among hypertensive affected individuals in urban slum areas of Mysuru city (n=650)

Variable Category Self-care behaviour X2 value df P value Good, n (%) Poor, n (%) Gender Female 112 (46.5) 182 (44.5) 0.239 1 0.625 Male 129 (53.5) 227 (55.5) Age (yr) 18-30 15 (6.2) 12 (2.9) 11.75 3 0.008 31-50 137 (56.8) 245 (59.9) 51-70 85 (35.3) 127 (31.1) >70 4 (1.7) 25 (6.1) Education Illiterate 132 (54.8) 159 (38.9) 19.9 2 <0.001 Schooling 74 (30.7) 197 (48.2) Degree/Diploma 35 (14.5) 53 (13) Occupation Unemployed 121 (50.2) 38 (9.3) 137.39 1 <0.001 Employed 120 (49.8) 371(90.7) Type of family Joint family 99 (41.1) 285 (69.7) 52.02 2 <0.001 Nuclear family 129 (53.5) 116 (28.4) Three generation 13 (5.4) 8 (2) Marital status Married 205 (85.1) 382 (93.4) 11.69 2 <0.001 Unmarried 19 (7.9) 14 (3.4) Divorced/Widowed 17 (7.1) 13 (3.2) Socioeconomic status Upper 5 (2.1) 0 160.8 4 <0.001 Upper middle 46 (19.1) 11 (2.7) Upper lower 58 (24.1) 77 (18.8) Lower middle 80 (33.2) 44 (10.8) Lower 52 (21.6) 277 (67.7)

Table III presents the association between hypertension control and self-care scores. It was indicated that there was a statistically significant association between the control of hypertension and self-care scores among study participants.

Table III. Association between the hypertension control and self-care behaviour scores among hypertensive affected individuals in urban slum areas of Mysuru city (n=650)

Hypertension control Self-care behaviour scale X2 value df P value Good, n (%) Poor, n (%) Controlled 230 (42.04) 317 (57.96) 36.55 1 <0.001 Uncontrolled 11 (10.67) 92 (89.32) Discussion

This study conducted in the city of Mysuru revealed a male predominance among the study participants (54.8%), which contrasts with the findings from a study conducted in Andra Pradesh in 201922. The potential reasons for this gender disparity in hypertension could be due to sample differences or population-specific differences due to genetic predispositions. Moreover, differences related to lifestyle, such as smoking and alcohol consumption, could be linked to an elevated risk of hypertension. More than half of the hypertensive study participants (58.7%) were within the 31-50 yr age group, which was consistent with the findings from a study in Ethiopia (2022)23.

A majority of the participants had normal body weight (395, 60.8%), followed by 182 (28%) who were classified as overweight, 47 (7.2%) as obese, and only 26 (4%) as underweight. Maintaining a healthy weight is vital for hypertension management, as obesity is a well-established risk factor for its development and progression. However, this finding contradicts a study conducted in southern Iran in 201615. Approximately 44.8 per cent of the study participants in our study were illiterate. This finding aligned with that of a study conducted in Kathmandu in 202224. Moreover, our findings indicated that illiteracy and low education levels could serve as barriers to comprehending and adopting self-care practices.

The majority (75.5%) of the study subjects were employed. This finding aligns with the findings of a study conducted in southern Iran in 201615. It underscores the importance of considering occupational factors when designing interventions, as occupational demands and resources can significantly influence self-care behaviour and health outcomes. The majority of the study subjects were married (90.5%), as was the findings of a study from Eastern Ethiopia in 201625. Marital status can influence social support and the ability to engage in self-care practices, emphasizing the importance of involving spouses or partners in hypertension management.

Half of the study participants belonged to the lower class (50.6%), followed by the upper class (20.8%), lower middle class (19.1%), and upper middle class (8.8%). This distribution highlights the association between socioeconomic status and health outcomes, with lower socioeconomic status being associated with a higher prevalence of hypertension and poorer access to healthcare resources, similar to a study conducted in Bangladesh in 202226. Most of the study participants (86.9%) did not have health insurance, indicating a potential barrier to accessing healthcare services. This finding highlighted the need for policy interventions to ensure equitable access to healthcare and financial protection for individuals with hypertension. More than half of the study participants (63.2%) had a family history of hypertension. This suggested a potential genetic predisposition to hypertension and the importance of family-based interventions promoting awareness, screening, and lifestyle modifications for individuals with a family history of the condition. However, the findings of our study contradicted that of a study conducted in Ethiopia in 202223.

The study participants belonging to 31-50 age group had higher proportions of individuals with low self-care behaviour, which was consistent with a study conducted in Northwest Ethiopia (2021)27. The study revealed a significant association between education level and self-care behaviour, with individuals who attained a degree or diploma demonstrating the highest percentage of good self-care practice. This finding is supported by a study conducted in Kolkata in 201613. There was a significant association between the occupation and self-care behaviour. However, this finding aligned with a study conducted in Turkey in 202028.

The study revealed a significant association between socioeconomic status and self-care behaviour. Individuals from higher socioeconomic classes demonstrated good self-care behaviour compared to those belonging to lower socioeconomic classes. This finding contradicted the findings of a study conducted in Nepal (2021)29. There was a statistically significant association between the control of hypertension and self-care behaviour, which was similar to the point highlighted in an systematic review (2023)30, underlining the relationship between self-care and controlled hypertension.

One of the limitations of our study is its cross-sectional design, which restricts establishing temporal relationships between explanatory and outcome variables. Sampling strategy followed by us also introduced selection bias as there was purposive selection and this approach limited the generalizability of the findings to other populations. The absence of ROC analysis for determining the HBP-SCP scale’s cut-off score was another limitation. Additionally, reliance on self-reported data, especially for self-care practices and awareness, might have introduced recall bias. The study also did not consider potential confounding factors like comorbidities or variations in healthcare access, which might have adversely impacted inferences.

Overall, this study emphasized the necessity of integrating self-care awareness into existing health programmes. By incorporating components focused on self-care education and empowerment, these programs can better equip individuals with the knowledge and skills necessary for effective hypertension management. Overall, the findings underscored the urgency of implementing targeted interventions and policy initiatives to address the growing burden of hypertension, particularly among vulnerable populations residing in urban slum areas.