Hypertension, defined as a persistent elevation of systolic blood pressure (SBP) ≥140 mmHg and/or diastolic blood pressure (DBP) ≥90 mmHg, is the single most important modifiable risk factor for cardiovascular disease, stroke, and chronic kidney disease worldwide [1,2]. It is often labelled a "silent killer" because it remains asymptomatic in the majority of affected individuals until a catastrophic cardiovascular or renal event occurs [5]. Globally, over 1.28 billion adults aged 30–79 years are estimated to be living with hypertension, nearly two-thirds of whom reside in low- and middle-income countries [11,12]. The worldwide age-standardized prevalence of raised blood pressure has shown divergent trends over the past four decades, declining in high-income countries but rising steadily in South Asia and sub-Saharan Africa [13], a shift attributed to rapid urbanization, nutrition transition, increasing tobacco and alcohol use, and progressively sedentary occupational and leisure patterns [18]. India, undergoing an epidemiological transition, is witnessing a rising burden of non-communicable diseases (NCDs) alongside a persisting load of communicable diseases [6]. Early Indian studies from the 1990s reported a hypertension prevalence of only 2–5% in rural populations [25], but subsequent surveys have documented a marked rise, with pooled prevalence estimates from a large meta-analysis of Indian studies ranging between 25% and 33% among adults, and figures being consistently higher in urban compared to rural settings [3,4,19]. The Indian Council of Medical Research–India Diabetes (ICMR–INDIAB) study similarly reported a substantial burden of hypertension across different states of the country, with wide inter-state and rural-urban variation [16]. Several community-based studies conducted in different parts of India — including Chennai [7], Jaipur [24], Kerala [10,30], Central India [22], and rural Uttarakhand [8] — have consistently identified advancing age, male sex, family history of hypertension, overweight/obesity, diabetes mellitus, tobacco and alcohol use, high dietary salt intake, physical inactivity, and psychosocial stress as important determinants of hypertension. However, the magnitude and relative contribution of these factors vary across geographic and socio-cultural settings [9,21], underscoring the need for locally generated evidence to guide region-specific prevention strategies. A large proportion of hypertensive individuals in developing countries remain undiagnosed, untreated, or inadequately controlled [27,32], in part due to the asymptomatic nature of the disease and limited access to routine health screening, particularly in the productive 20–60 year age group that forms the backbone of the workforce. Uncontrolled hypertension in this age group not only predisposes to premature cardiovascular morbidity and mortality but also imposes a substantial economic burden through loss of productive years and catastrophic health expenditure [28,29]. The Government of India, through the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS), has emphasized opportunistic and population-based screening for hypertension as a key strategy for early detection [35]. Against this background, the present cross-sectional study was undertaken to estimate the prevalence of hypertension and to identify its associated socio-demographic and behavioural risk factors among the adult population aged 20–60 years, so as to generate local evidence that may inform community-level screening and prevention efforts. Objectives To determine the prevalence of hypertension among adults aged 20–60 years in the study population. To study the association between hypertension and selected socio-demographic and behavioural risk factors. To identify the independent predictors of hypertension using multivariate analysis

Study Design and Setting This was a community-based, cross-sectional, observational study conducted in the field practice area of a medical college over a period of twelve months. Study Population and Sampling All permanent residents aged 20–60 years, of either sex, residing in the study area for at least one year prior to the survey, were eligible for inclusion. Pregnant women, individuals who were critically ill or bed-ridden, and those who did not give consent were excluded from the study. Sample size was calculated using the formula n = Z2pq/d2, taking the expected prevalence of hypertension (p) as 30% based on earlier Indian studies [4], allowable error (d) of 3%, and a 95% confidence level (Z=1.96). This yielded a minimum sample size of 897, which was rounded up to 1200 after adding a 10% non-response allowance and applying a design effect of 1.2 for multistage sampling. A multistage random sampling technique was used. At the first stage, four sub-centres/wards were selected randomly from the study area; at the second stage, two to three villages/localities were selected randomly from each sub-centre; households were then selected by systematic random sampling, and one eligible adult per household was selected using the Kish grid method until the required sample size was achieved. Data Collection Tool and Technique Data were collected using a pre-designed, pre-tested, semi-structured interview schedule covering socio-demographic characteristics, personal and family history, dietary habits, physical activity, tobacco and alcohol use, and known co-morbidities. Anthropometric measurements (height, weight, waist circumference) were recorded using standard techniques. Body mass index (BMI) was calculated as weight (kg)/height (m)²and classified according to the Asia-Pacific criteria for Asian populations (normal <23, overweight 23–24.9, obese ≥25 kg/m²). Blood pressure was measured in a seated position after at least 5 minutes of rest, using a calibrated mercury sphygmomanometer, on the right arm at heart level. Two readings were taken five minutes apart and the average of the two was used for analysis, in accordance with standard WHO STEPS methodology [31]. Operational Definitions Hypertension: Mean SBP ≥140 mmHg and/or mean DBP ≥90 mmHg on the day of examination, or a self-reported current use of antihypertensive medication, based on JNC-7 criteria [2]. Obesity: BMI ≥25 kg/m² as per Asia-Pacific classification. Physical inactivity: Less than 150 minutes of moderate-intensity physical activity per week, as per WHO recommendations. Current smoker/alcohol user: Use of tobacco/alcohol at the time of the survey or within the preceding one month. High salt intake: Self-reported discretionary addition of salt to cooked food or frequent consumption of salt-preserved/processed foods (≥5 days/week). Statistical Analysis Data were entered in Microsoft Excel and analysed using SPSS software (version 26.0). Descriptive statistics were expressed as frequencies, percentages, mean and standard deviation. Association between hypertension and categorical risk factors was tested using the Chi-square test; odds ratios (OR) with 95% confidence intervals (CI) were calculated. Variables found significant on bivariate analysis (p<0.05) were entered into a multivariate binary logistic regression model to identify independent predictors, and adjusted odds ratios (AOR) were computed. A p-value <0.05 was considered statistically significant throughout. Ethical Considerations The study was conducted after obtaining approval from the Institutional Ethics Committee. Written informed consent was obtained from all participants prior to enrolment, and confidentiality of information was maintained throughout. Participants found to be hypertensive were referred to the nearest health facility for further evaluation and management

A total of 1200 adults aged 20–60 years were studied. The overall prevalence of hypertension was found to be 33.3% (400 out of 1200 participants). The socio-demographic profile, prevalence pattern, and association with risk factors are presented below. Table 1: Socio-demographic Characteristics of the Study Population (n=1200) Characteristic Category Number (n) Percentage (%) Age group (years) 20–30 336 28.0 31–40 324 27.0 41–50 294 24.5 51–60 246 20.5 Sex Male 600 50.0 Female 600 50.0 Residence Urban 660 55.0 Rural 540 45.0 Education Illiterate 144 12.0 Primary/Middle 312 26.0 Secondary/Higher secondary 396 33.0 Graduate and above 348 29.0 Occupation Sedentary worker 468 39.0 Moderate worker 444 37.0 Heavy manual worker 288 24.0 Socioeconomic status* Upper & upper-middle 372 31.0 Lower-middle 444 37.0 Upper-lower & lower 384 32.0 *Modified B.G. Prasad's socioeconomic classification. Table 2: Age and Sex-wise Prevalence of Hypertension (n=1200) Age group (years) Total examined Hypertensive (Male) n (%) Hypertensive (Female) n (%) Total hypertensive n (%) 20–30 336 28 (16.7) 21 (12.4) 49 (14.5) 31–40 324 58 (34.9) 46 (28.0) 104 (32.1) 41–50 294 78 (52.7) 66 (45.5) 144 (49.0) 51–60 246 56 (45.9) 47 (38.5) 103 (41.9) Total 1200 220 (36.7) 180 (30.0) 400 (33.3) χ² for trend across age groups = 92.4, p<0.001; χ² for sex difference = 6.31, p=0.012. Table 3: Association between Selected Risk Factors and Hypertension (Bivariate Analysis) Risk factor Hypertensive n (%) Non-hypertensive n (%) χ² value p-value OR (95% CI) Age ≥41 years (n=540) 247 (45.7) 293 (54.3) 68.4 <0.001 3.21 (2.51–4.11) Family history of hypertension (n=384) 196 (51.0) 188 (49.0) 84.6 <0.001 3.42 (2.66–4.40) Obesity, BMI ≥25 kg/m² (n=468) 212 (45.3) 256 (54.7) 48.9 <0.001 2.44 (1.93–3.09) Diabetes mellitus (n=216) 108 (50.0) 108 (50.0) 31.5 <0.001 2.24 (1.66–3.02) Current smoking (n=312) 137 (43.9) 175 (56.1) 22.7 <0.001 1.85 (1.42–2.41) Current alcohol use (n=288) 116 (40.3) 172 (59.7) 8.9 0.003 1.46 (1.12–1.92) High dietary salt intake (n=456) 196 (43.0) 260 (57.0) 35.6 <0.001 2.02 (1.59–2.57) Physical inactivity (n=540) 222 (41.1) 318 (58.9) 34.2 <0.001 1.99 (1.57–2.52) Perceived psychosocial stress (n=372) 150 (40.3) 222 (59.7) 13.1 <0.001 1.53 (1.20–1.96) Urban residence (n=660) 244 (37.0) 416 (63.0) 9.7 0.002 1.44 (1.14–1.83) Table 4: Independent Predictors of Hypertension – Multivariate Logistic Regression Variable Adjusted OR 95% CI p-value Age ≥41 years 2.86 2.14–3.82 <0.001 Family history of hypertension 2.41 1.82–3.19 <0.001 Obesity (BMI ≥25 kg/m²) 2.18 1.64–2.90 <0.001 Diabetes mellitus 1.96 1.38–2.78 <0.001 Current smoking 1.72 1.24–2.39 0.001 High dietary salt intake 1.65 1.21–2.25 0.001 Physical inactivity 1.58 1.16–2.15 0.004 Male sex 1.31 1.01–1.71 0.041 Model: Backward stepwise binary logistic regression; Nagelkerke R² = 0.284; Hosmer–Lemeshow goodness-of-fit p=0.62. Table 5: Awareness, Treatment and Control among Hypertensives (n=400) Category Number (n) Percentage (%) Aware of their hypertensive status 236 59.0 Unaware (newly detected during survey) 164 41.0 On regular antihypertensive treatment 168 42.0 Blood pressure adequately controlled (<140/90 mmHg) 104 26.0

The present cross-sectional study, conducted among 1200 adults aged 20–60 years, found an overall prevalence of hypertension of 33.3%, which is comparable to the pooled prevalence of 29.8% reported in a large meta-analysis of Indian studies [4], and consistent with findings from the ICMR–INDIAB study [16]. Our findings are, however, considerably higher than the 2–5% prevalence reported in Indian rural surveys conducted in the early 1990s [25], reflecting the rapid epidemiological transition and rising burden of non-communicable diseases described by Reddy et al. [6] over the past two decades. The prevalence of hypertension increased significantly with advancing age, from 14.5% in the 20–30 year group to a peak of 49.0% in the 41–50 year group, a pattern similar to that reported from Jaipur [24] and Chennai [7], and consistent with the well-documented age-related decline in arterial compliance and increase in peripheral vascular resistance [25. Male preponderance observed in the present study (36.7% versus 30.0% in females) mirrors the findings of Bansal et al. [8] in rural Uttarakhand and Kaur et al. [9] in urban south India, and has been attributed to a higher prevalence of tobacco and alcohol use, occupational stress, and dietary indiscretion among men. Family history of hypertension emerged as the strongest independent predictor in our study (AOR 2.41), lending support to the substantial genetic and shared-environment contribution to blood pressure elevation described in earlier work by Singh et al. [26] Obesity was independently associated with more than twofold higher odds of hypertension (AOR 2.18), corroborating the findings of Deepa et al. in the CURES study from Chennai [17] and the broader relationship between adiposity and blood pressure elevation described by Hu [20]. The association between diabetes mellitus and hypertension observed here (AOR 1.96) is consistent with the well-recognized clustering of cardiometabolic risk factors first highlighted in the National Urban Diabetes Survey [23]. Behavioural factors, namely current smoking, high dietary salt intake, and physical inactivity, were independently associated with hypertension in the present study, in agreement with community-based studies from Kerala [10,30] and Central India [22]. High discretionary salt intake remains particularly relevant in the Indian context, where average salt consumption considerably exceeds the WHO-recommended limit of 5 g/day [31]. Urban residence was also associated with a higher prevalence of hypertension in bivariate analysis, a finding consistent with comparative studies showing a higher burden of hypertension and its risk factors in urban compared to rural Indian populations [3,9], likely reflecting differences in dietary patterns, physical activity levels, and stress. A particularly important finding of the present study was that 41.0% of hypertensive individuals were previously undiagnosed and were detected only during the survey, while only 26.0% of all hypertensives had adequately controlled blood pressure. This "rule of halves" phenomenon — wherein a large proportion of hypertensives remain unaware, untreated, or inadequately controlled — has been consistently described in Indian and other developing-country settings [27,32], and highlights persistent gaps in early detection and long-term management of hypertension at the primary care level, despite the existence of national programmes such as the NPCDCS [33,34,35]. These findings collectively underscore the need for opportunistic screening for hypertension in all adults above 30 years of age, particularly those with a family history of hypertension, obesity, diabetes, or an unhealthy lifestyle, along with sustained community-based health education addressing dietary salt reduction, tobacco cessation, and promotion of physical activity, as also recommended by global and regional guidelines [14,21]. Limitations Being a cross-sectional study, temporal and causal relationships between risk factors and hypertension could not be established. Blood pressure was measured on a single occasion (two readings on the same day), which may have led to some degree of misclassification due to the 'white-coat effect'. Self-reported information on dietary salt intake, physical activity, tobacco and alcohol use is subject to recall and social-desirability bias.

The present study revealed a high prevalence of hypertension (33.3%) among adults aged 20–60 years, with nearly one in three individuals affected. Prevalence increased significantly with age and was higher among males. Family history of hypertension, obesity, diabetes mellitus, current smoking, high dietary salt intake, and physical inactivity were identified as independent predictors of hypertension. A substantial proportion of hypertensive individuals were previously undiagnosed or had poorly controlled blood pressure, indicating major gaps in early detection and management. These findings emphasize the urgent need for population-based screening programmes, targeted health education on modifiable risk factors, and strengthening of primary healthcare services for early detection, treatment, and long-term control of hypertension, in order to reduce the future burden of cardiovascular morbidity and mortality in the community.

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