Hypertension poses a significant public health challenge, impacting cardiovascular health and the healthcare infrastructure in India [1]. It accounts for over half of stroke-related deaths and approximately one-quarter of coronary heart disease fatalities in the country [2]. Recent research indicates that the prevalence of hypertension is around 25% in urban areas and 10% in rural regions of India [3]. In 2000, the combined prevalence among urban and rural populations was 20.6% for males and 20.9% for females, with projections for 2025 estimating an increase to 22.9% in males and 23.6% in females [4]. A meta-analysis revealed that awareness and control of hypertension in India range from 20% to 54% and 7.5% to 25%, respectively [5]. However, there is limited literature on the prevalence and awareness of hypertension in Odisha. A study among the Lepcha community in the India has reported hypertension prevalence of 30.77% in males and 25.77% in females [6], which is comparatively higher than the national average.

A multicenter study from India examining awareness, treatment, and control of hypertension found that only about 25.6% of treated patients had their blood pressure adequately controlled [7]. Evidence suggests that lifestyle modifications and proper medication can effectively manage hypertension and prevent complications like strokes [8]. Barriers such as insufficient knowledge about hypertension and its treatment, cultural beliefs, healthcare access issues, medication costs, and side effects contribute to poor blood pressure control [9]. Lack of knowledge about medication adherence and lifestyle changes is a significant factor in low blood pressure control, as reported in both developed and developing countries [10]. In India, the most significant barrier to adopting lifestyle modifications for hypertension management is a lack of awareness [12].

Recommended Lifestyle Interventions and Their Impact on Blood Pressure

Body Weight Reduction - Achieve and maintain a body mass index (BMI) between 18.5 and 24.9 kg/m² Losing 10 kg of body weight can decrease BP by 5-20 mm Hg

DASH Diet Pattern Consume a diet rich in vegetables, fruits, and low-fat dairy products, while minimizing saturated and total fat intake Dietary changes can lower BP by 8-14 mm Hg

Salt Intake Reduction Minimize salt consumption as much as possible; aim for 1.5 g/day of sodium or 3.8 g/day of sodium chloride Reducing salt intake can lower BP by 2-8 mm Hg

Exercise Engage in regular aerobic exercise for about 30 minutes most days of the week Physical activity can reduce BP by 4-9 mm Hg

Alcohol Consumption Limit alcohol intake to a maximum of 2 drinks per day for men and 1 drink per day for women and lighter individuals Reducing alcohol consumption can decrease BP by 2-4 mm Hg.

There is a notable disparity in hypertension awareness and control between rural and urban areas in India [2]. Furthermore, eastern India exhibits a hypertension prevalence similar to that of urban India. Rural areas face lower literacy rates and significant disparities in healthcare access and quality compared to urban regions [2]. Therefore, improving awareness of hypertension is crucial in this predominantly rural population.

Study Design and Setting This prospective cross-sectional study was conducted at SCB Medical College and Hospital, Odisha, over a period of two months, from February 2022 to April 2022.

Inclusion Criteria Adult patients over 18 years old, attending the medicine OPD and diagnosed with hypertension for more than six months without any co-morbidities, were included.

Exclusion Criteria Patients with acute conditions and those who did not provide consent were excluded from the study.

Study Size A total of 250 hypertensive patients, comprising 155 males and 95 females meeting the inclusion criteria, were selected using a purposive sampling method.

Procedure and Data Collection Methods Ethical clearance was obtained from the institutional ethical committee before data collection commenced. Face-to-face interviews were conducted after obtaining oral consent from the patients. The semi-structured questionnaire captured socio-demographic and clinical characteristics, duration of hypertension, and use of anti-hypertensive medications. Additionally, knowledge and adherence to six lifestyle modifications were assessed: engaging in aerobic exercise for at least 30 minutes per day, four days a week; reducing dietary salt intake to less than 6g NaCl per day; limiting alcohol consumption to less than three units per day for men and less than two units per day for women; avoiding smoking; maintaining a healthy weight; and consuming a diet high in fruits, nuts, and vegetables while low in fat. Data were collected in private rooms by two researchers. For illiterate patients, researchers conducted in-depth interviews, reading each question aloud and recording the responses.

Measurements and Calculations To assess patients' knowledge of lifestyle modifications for managing hypertension, a scoring system was used. Patients were categorized as having either less than 50% knowledge (knowing fewer than three interventions) or 50% or more knowledge (knowing three or more interventions). Those with less than 50% knowledge were considered to have inadequate knowledge. Body mass index (BMI) and waist circumference were measured to check for healthy weight maintenance. Blood pressure was measured three times using a standardized mercury sphygmomanometer after a five-minute seated rest. Blood pressure was considered high if the average systolic blood pressure was ≥ 140 mm Hg or diastolic blood pressure was ≥ 90 mm Hg.

Data Analysis Data were analyzed using R software. The Fisher exact test was employed to examine the association between variables, with a p-value of ≤ 0.05 considered statistically significant. The likelihood of event occurrence was tested using odds ratios at a 95% confidence level.

In this study, which included 250 hypertensive patients, 155 were females and 95 were males. Among them, 230 were on pharmacological treatment, but only 80 patients managed to control their blood pressure adequately. Blood pressure control was observed in 50 females and 30 males, showing no significant difference [P=0.89, OR 1.01, CI 95% (0.31-2.38)]. Of the 90 patients with sufficient knowledge, 75 adhered to all recommended interventions, 40 followed some, and 35 did not follow any, despite being aware of them. Meanwhile, 100 patients had less than 50% knowledge of these interventions.

Table 1: Distribution of Studied Hypertensive Population According to Their Socio-Demographic Profile (N=250)

Among the knowledgeable patients, 105 were aware of salt restriction, 88 knew about regular exercise, 80 were informed about abstaining from smoking, but only 30 understood the DASH eating plan. Six patients consumed alcohol regularly. In the group aware but not adhering to interventions, 15 were smokers and 5 consumed alcohol regularly.

In the group with insufficient knowledge (N=60), 27 knew about salt-restricted diets, 12 were aware of smoking cessation, and 17 were informed about regular exercise. None knew about the DASH eating plan. Thirty patients were smokers, and 60 routinely consumed alcohol.

Among those with adequate knowledge, 50 were vegetarians, compared to 15 in the inadequately knowledgeable group. Out of the total 250 patients, 130 were either uneducated or had only basic education. This included 65 out of 150 with basic education or less, and 65 out of 100 patients in the same category. The effect of gender on knowledge about lifestyle modifications for hypertension management was insignificant [P=0.81, OR 0.69, 95% CI (0.41-1.83)], whereas educational background had a significant effect [P=0.05, OR 0.39, 95% CI (0.21-0.89)]. The urban-to-rural ratio was 53:9 among the aware group and 19:21 among the unaware group, showing higher awareness in urban populations [P=<.0001, OR 8, 95% CI (2.86-23.44)]. Blood pressure control was significantly better in the group with adequate knowledge [P=0.03, OR 3.1, 95% CI (1.01-6.33)]. Differences in BMI, smoking/tobacco use, or alcohol consumption were insignificant (P=0.69, P=0.79, and P=0.201, respectively).

Table 2: Knowledge on Lifestyle Modifications in Studied Population

To bridge the gap between awareness and actual practice, Table 3 illustrates the extent to which patients with adequate knowledge of lifestyle interventions put this knowledge into practice. This highlights the discrepancy between knowing and implementing recommended lifestyle changes for hypertension management.

Table 3: Practice of Lifestyle Interventions Among Patients with Adequate Knowledge (N=90)

Hypertension is a prevalent chronic health condition and a leading cause of mortality and morbidity worldwide [14]. Effective control of hypertension through lifestyle modifications can significantly reduce healthcare costs by minimizing the need for pharmacological and invasive cardiovascular treatments [15,16]. This study aimed to assess the level of knowledge regarding lifestyle modifications among hypertensive patients. The findings revealed that the majority of patients, 135, were aged between 41 and 60 years, which aligns with other studies showing a high prevalence of hypertension among older adults [17,18]. There were more female participants, likely due to factors such as postmenopausal hormone deficiency, obesity, and stress, similar to findings from other research [19].

Regarding knowledge about lifestyle behavior modifications, more than half of the patients had fair to good knowledge (Table 1). A comparable study also found that over half of hypertensive patients were aware that family history, smoking, and excessive salt intake increase the risk of hypertension [20]. However, this contrasts with studies where knowledge about lifestyle modifications, such as exercise, was poor [21]. Another study showed that while more than half of the patients had fair knowledge, 23.8% had poor knowledge, and only 8.9% had good knowledge about lifestyle behavior modifications [22]. In our study, 60 patients had inadequate knowledge about lifestyle changes, similar to another study reporting that up to 80% of hypertensive subjects were unaware of the role of various lifestyle modifications like the DASH eating plan and maintaining a healthy body weight [23].

Among those with adequate knowledge, awareness about salt restriction was highest, followed by regular exercise and smoking cessation, whereas knowledge about the DASH eating plan was the lowest. Nine patients consumed alcohol regularly, consistent with a study where excessive salt intake was the most recognized risk factor (77.4%), while the least awareness was regarding alcohol moderation (47.6%) [24]. Another study found that over 70% of patients were aware that stress, high cholesterol, and obesity are risk factors for hypertension, but 52.7% were unaware that lack of physical activity is also a risk factor [25]. A similar study reported good awareness of stress, excessive salt intake, and obesity, but poor awareness regarding excessive alcohol intake, smoking, and a sedentary lifestyle [26]. Our study also found limited awareness of the DASH eating plan and the importance of maintaining a healthy weight in controlling hypertension, akin to other research [23].

One study indicated that 60%, 62%, and 59% of respondents were aware of lifestyle modifications like regular exercise, reduced salt intake, and a diet rich in fruits and vegetables, respectively. Additionally, 38% were aware of avoiding cigarette smoking, and 46% were aware of reducing alcohol intake [27].

In the United States, a study showed that 78% of hypertensive patients reported receiving advice on regular exercise, 69.3% on reducing salt intake, 61.9% on healthy eating, and 43.5% on reducing alcohol intake [28]. In South Africa, 30% of hypertensive patients received advice on exercise, 69% on reducing salt intake, 50% on a balanced diet, 44% on reducing alcohol intake, and 35% on smoking cessation [29]. These studies suggest that healthcare providers should offer comprehensive counseling on lifestyle modifications to ensure sufficient awareness and adherence.

Despite adequate awareness, many patients did not practice these interventions, as shown in Table 3. This finding is consistent with a study where 80% of hypertensive patients knew they should limit salt intake, but only one-third consistently avoided salty foods [30]. Another study revealed that while 60% of respondents were aware of regular aerobic exercise, only 40% practiced it. Similarly, 62% were aware of reducing salt intake, but only 42% followed this practice. Regarding smoking cessation, 36% were aware, but 20% were smokers [27].

A significant association was found between educational background and knowledge of lifestyle interventions. A study in China showed that about 77.3% of hypertensive patients were illiterate, making it difficult for them to comprehend hypertension knowledge [31]. Another study noted that most hypertensive patients lacked information due to insufficient educational resources [33], which may explain the lack of awareness in our study. Poor educational levels have been linked to limited awareness of lifestyle interventions in other research [22].

Urban populations were more aware of interventions than rural ones, likely due to better exposure to educational resources and healthcare facilities. This result aligns with findings from a meta-analysis [2].

Awareness and practice of lifestyle interventions are crucial in managing hypertension. Healthcare providers should ensure comprehensive counseling on risk factors and interventions, particularly in rural areas with older populations and limited healthcare facilities.

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