Behavioral risk factors for noncommunicable diseases in working and nonworking women of urban slums.

BACKGROUND: Noncommunicable diseases (NCDs) are an emerging public health problem, accounting for 80% of deaths in low and middle-income countries leading to a global epidemic. The increasing burden of NCDs is affecting poor and disadvantaged women population disproportionately, contributing to widening health gaps between and within countries. Globalization and urbanization have led to lifestyle changes among urban poor, which need to be understood, as the urban areas are undergoing rapid transitions.
OBJECTIVES: To know prevalence and pattern of behavioral risk factors for NCDs in working and nonworking women of urban slums to initiate steps for preventive interventions.
MATERIALS AND METHODS: This was community based cross-sectional study conducted among women of urban slums in the age-group of 30-45 years on a voluntary basis. Data were collected by the house-to-house survey using predesigned and pretested proforma World Health Organization-Stepwise Approach to Chronic Disease Risk Factor Surveillance (WHO-STEPS 1 and 2 questionnaires). Descriptive statistics and Chi-square test were used for analysis.
RESULTS: Majority, 49% women were in the age-group of 30-35 years, with 60.5% belonging to Class IV socio-economic status. Stress was present in 38% working women as compared to 17% nonworking women (χ(2) = 22.12, df = 1, P < 0.0001, HS). Nonworking women (25%) were less aware about common NCDs compared to (48%) working women (χ(2) = 22.82, df = 1, P < 0.0001, HS). It was also found that 11% women were newly diagnosed with hypertension.
CONCLUSION: Most of the women were not aware of the risk factors leading to NCDs. Screening and IEC activities need to be strengthened and hence that diagnosis and preventive measures can be implemented at an early stage of life.

INTRODUCTION

Noncommunicable diseases (NCDs) are becoming epidemic and global issue, as two out of three deaths in the world are related to NCDs, affecting all age groups, nationalities and socio-economic classes, now increasing in developing countries leading to increased morbidity and mortality, as well as to a high financial burden.[1] Impact of NCDs continue to grow, accounting for 60% of all deaths worldwide, and 80% of these deaths occur in low and middle-income countries, where the toll is disproportionate during the prime productive years of youth and middle age.[2] In India, NCDs have contributed to 53% of deaths and 44% of disability-adjusted life years lost,[3] and by 2020, are projected to account for 73% of deaths and 60% of disease burden.[4] This advancing epidemic is propelled by contributory causes which include, demographic shifts with altered population age profiles, lifestyle changes due to recent urbanization, delayed industrialization and overpowering globalization, probable effects of fetal under-nutrition on adult susceptibility to vascular disease and possible gene-environment interactions influencing ethnic diversity.[5] Growing Indian economy at 7%/year has also led to increased life expectancy, consequently leading to a rise in proportion of the population older than 35 years from 28% in 1981 to 42% in 2021.[6] This progress is now threatened by crises of our own creation-climate change, finance and food insecurities.[7] Hence, long-term care for patients suffering from NCDs is emerging as a major health care issue. Most of the behavioral risk factors (BRFs) for NCDs such as unhealthy diet, stress, physical inactivity, smoking and alcohol consumption are potentially modifiable and preventable.[8]

This rapidly increasing burden of these diseases is especially affecting poor and disadvantaged women population disproportionately, contributing to widening health gaps between and within countries.[9] India being a patriarchal society, women have very little role to play in their health care issues.[10] With very few studies being documented on NCDs and their effect on health of women in urban slums, an attempt was made through this study to know the prevalence of BRFs in working and nonworking women of urban slums and to study the pattern of the same in order to initiate steps for preventive interventions.

MATERIALS AND METHODS

Study design and setting

This study design was community based, cross-sectional study, which was carried out for a period of 1-year, from August 2011 to July 2012. The study was conducted among women population living in the urban slums, field practice area of Urban Health Center, attached to a tertiary care hospital. The Urban Health Center covers a population of 30,000 and provides quality primary health care to the urban slum dwellers and the population of nearby catchment area.

Sampling method

The overall (working and nonworking women) sample size calculated was 400, using the formula 4 pq/L2, where p is the prevalence (50%), q = 1-p (50%) and L the permissible error, taken as 10%, the sample size worked out to be 400 at 5% alpha error. The total population of urban field practice area is 30,000. Considering average family size of five, there were 6000 families in the study area. To achieve the sample size calculated, every 10th family was considered and only one women was considered from each family, as she was considered to be representative of the selected family.[11]

Sampling procedure

A house-to-house survey with systematic random sampling was done (every 10th family was considered).

Inclusion and exclusion criteria

Middle-aged women between 30 and 45 years, residing in the study area for more than 1 year, who consented to participate on a voluntary basis, were included in the study. Women not complying with the inclusion criteria and who were suffering from any of the NCDs prior to the onset of the study were excluded.

Certain definitions considered in our present study for study participants are mentioned below

Working women

Women who were paid wages for the work done by them.

Nonworking women

Women confined to their house, with no wages being paid for their services.

Healthy diet

Consumption of at least one serving of vegetables and fruits daily was considered as having a healthy diet.[8]

Junk food

Any food which is low in essential nutrients and high in everything else-particularly calories and sodium. Junk food contain little or no proteins, vitamins or minerals but are rich in salt, sugar, fats and are high in energy (calories).[12] Salted snack food, candy, gum, fried fast foods, carbonated beverages and pre-prepared or packaged food are some of the examples for junk food.[13]

Physical activity

One hundred and fifty minutes (30 min for 5 days a week) of moderate-intensity aerobic physical activity throughout the week.[14]

Stress

Negative events, chronic strain or trauma in the recent past, in close (personal, occupational or societal issues) environment.[15]

Body mass index

Overweight was defined as body mass index (BMI) ranging from 23 to 24.9 and obesity as BMI ≥25.[16]

Hypertension

Defined based on a systolic blood pressure (BP) ≥140 mm of Hg or diastolic BP ≥90 mm of Hg.[17]

Data collection

Data were collected from 400 participants (200 were working and 200 nonworking women) by the house-to-house survey with the help of a predesigned and pretested questionnaire along with World Health Organization-Stepwise Approach to Chronic Disease Risk Factor Surveillance (WHO-STEPS 1[18] and 2[19]) questionnaires. WHO-STEPS instrument covers three different levels of steps of risk factor assessment. These steps include questionnaire (STEP-1), physical measurements (STEP-2) and biochemical measurements (STEP-3). For the purpose of our study WHO-STEPS questionnaire 1 (history of risk factors) and 2 (simple physical measurements) were suitably modified and translated to local language to collect data with the help of medico social workers. It included questions on the socio-demographic status, data on tobacco and alcohol use, measures of dietary habits and physical activity. The study also attempted to obtain information on the existence of mental stress (assessed on a five point Likert scale) and assessment of knowledge of respondents about common NCDs. Standard procedures were followed for anthropometric and BP measurements. The weight of the individual (correct to 0.5 kg) and height (correct to 0.1 cm)[4] were measured. BP was measured in the supine position using mercury sphygmomanometer. All measurements were taken at domiciliary level.

The study was approved and ethical clearance was obtained from Institutional Ethics Committee. Informed written consent was obtained from each participant on a voluntary basis. Data were analyzed using SPSS software version 16.0 (SPSS Inc., Chicago, USA). Descriptive statistics and Chi-square test was performed to find an association between two attributes and P < 0.05 was considered as statistically significant.

RESULTS

A total of 400 women (200 working and 200 nonworking women) were included in the study. The mean age was 35.1 years and 37.9 years for working and nonworking women, respectively. Table 1 describes the sociodemographic characteristics, where more than half, 212 (53%) of the study participants were Hindus. Half, 50% of women were illiterates, whereas68 (34%) of the working women had completed primary schooling and only 12 (6%) nonworking women were educated until high school. Majority of women 276 (69%) belonged to nuclear families and 242 (60.5%) were from Class IV socioeconomic status (SES, Modified B.G. Prasad's Classification - India - 2011).[20]

Table 1

Sociodemographic characteristics of the study participants

Table 2 describes about BRFs that leads to NCDs, it was found that the majority of the women 338 (84.5%) were having mixed diet and 370 (92.5%) were not in a habit of consuming fruits adequately. Most of the working women 182 (91%) had adequate vegetable intake when compared to 154 (77%) of nonworking women. Most of the women also opined that they consume junk food once in 7 days. It was found that 350 (87.5%) were physically inactive and among the physically active, walking, and yoga were preferred by 12.5% of women and were done for 150 min in a week. Habit of tobacco chewing was present among 86 (21.5%) women, of which 40 (20%) were working and 46 (23%) were nonworking women. Of the working women, 76 (38%) had stress when compared to 34 (17%) nonworking women, of which commonly cited cause was unhappy married life (42.1%), followed by financial problems by 39.4% of the women.

Table 2

BRFs for NCDs among the study participants

Table 3 explains the awareness regarding risk factors leading to common NCDs. As natural history of all NCDs is not yet clearly delineated due to their polygenic, multi-factorial inheritance, the assessment of respondents' awareness regarding their causation was restricted to medically established commonly known causes. About 88 (44%) working women stated excessive consumption of sweets will lead to diabetes compared to only 12 (6%) nonworking women. Lack of exercise will also lead to diabetes was opined by 40 (10%) women. Regarding hypertension, 106 (26.5%) women told that excessive salt intake will be the major cause of hypertension followed by lack of exercise (9.5%). When dreaded disease like cancer was interrogated, 220 (55%) of the study participants were unaware regarding the causes that leads to common cancers among women in India (cancer cervix, cancer breast). Regarding cancer, unhealthy diet was considered most common cause by 100 (25%) of the study participants, followed by lack of hygiene 68 (17%). Awareness regarding only cancer cervix and cancer breast was considered as these are the leading causes of cancer deaths in women in India.

Table 3

Awareness regarding risk factors leading to common NCDs among the study participants

Table 4 shows the comparison of health status of working and nonworking women, it was found that mean weight of working and nonworking women was 56.65 kg and 50.57 kg respectively. Overweight was found among 35 (17.5%) working women, when compared to 28 (14%) nonworking women. Obesity was present among 24 (12%) working women, when compared to only 12 (6%) of nonworking women. Generalized weakness was the most common health problem faced by working women (60%) and headache (59.5%) among nonworking women. Majority 76.5% of women preferred consulting doctor during their illness.

Table 4

Comparison of health status of working and nonworking women

Table 5 compares the association between working status of women and presence of BRFs for NCDs. It was found that working women were more physically inactive and inactivity was higher compared with that of nonworking women (χ2 = 40.32, df = 1, P < 0.0001). Stress was found to be drastically more in working women as compared to nonworking women (χ2 = 22.12 df = 1, P < 0.0001). It was also found that hypertension was diagnosed to be more in working women as compared to nonworking women during the study (χ2 = 35.47, df = 1, P < 0.0001), which was highly significant and notable.

Table 5

Association between working status of women and presence of BRFs for NCDs

DISCUSSION

The present study revealed a substantially high existence of some BRFs among working and nonworking women of urban slums, which could be attributed to illiteracy, low SES and lack of awareness about the ill-effects of BRFs on health. This, along with advancing health transition has led the lower socioeconomic group to be increasingly affected by chronic lifestyle diseases.

In our study majority of the women, 50% were illiterates and 60.5% belonged to class IV SES, which was less compared to a study done in North Indian urban community of Delhi by Laskar, et al.,[19] where 68% had completed secondary education and 25% were graduates and 25.35% were from upper middle income group. This may be due to the fact that, Delhi being metropolitan city, there is better availability of education, living standards and health care facilities.

The inadequate consumption of fruits, vegetables and lack of physical exercise are known to enhance disease propensity. Our study showed adequate consumption of vegetables by majority of the participants (84%), which was much higher compared to a study done by Nath, et al., in New Delhi.[18] This could be due to the availability of local vegetables at an affordable cost in our place. In our study, 92.5% women did not consume fruits, which is almost similar to 87% in a study done by Sugathan, et al., in Kerala,[8] but which is much below the recommendations of National Institute of Nutrition, India[21] because most of the women in our study belonged to low SES. Most of women in our study were physically inactive (87.5%), which was slightly higher than analogous studies done in (74%) Kerala[8] and (80%) in New Delhi.[18] The reason for physical indolence among the nonworking women (77%) could be attributed to lack of awareness of the benefits of physical exercise, while in working women (98%) lack of time could be the cause in our study group.

Stress was documented in 27.5% of the respondents, higher compared to a study done in Kerala,[8] in which it was found to be 23%, of which unhappy married life and financial problems were the most commonly cited reasons. Our study showed that 21.5% of the women consumed tobacco, which was much higher compared to National Family Health Survey-3 estimate of 10.3%.[22] None of the women consumed alcohol, akin to the findings of other studies.[719]

Overall 36.5% and 37% of our study participants were aware regarding risk factors leading to diabetes and hypertension, when compared to a study done by Thankappan, et al., in Kerala,[23] where awareness level for diabetes was 65% and in case of hypertension it was 48.3%, which was more compared to our study, and could be due to the fact that Kerala has highest literacy rate. This shows that more the educational status, better the level of awareness. It was also found that 17% of women opined that unhealthy diet as a risk factor for cancer, as compared to 22.7% in a study done in Chandigarh.[24]

On analysis of the health status of the participants, prevalence of obesity was much less (10%) in our study participants as compared to other similar studies in Kerala[8] and Delhi,[19] where obesity was present among 33% and 14.8% women, respectively. This draws attention to the fact that, earlier developing countries had a high prevalence of under-nutrition, but this era of transition has also brought a double burden[25] of under-nutrition and over-nutrition in these countries.

Our finding of 11.5% prevalence of hypertension, with preponderance in the working women faction, was higher compared to 7.99%, in a study done by Krishnan, et al.,[4] This could be ascribed to detrimental dietary pattern, lack of exercise and presence of stress. Periodic medical examination was practiced by 13.5% of the respondents, which was much lower compared to 41.7% in New Delhi study.[19]

It has been noted well that these BRFs are modifiable. A significant portion of the NCDs are preventable and controllable by the target of ‘4-by-4’ approach (four major NCDs-cardiovascular diseases, cancer, diabetes and chronic respiratory diseases and their four risk factors-tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol), which is well supported by national and international health organizations. As newer risk factors are evolving, the present approach has to be changed to ‘5-by-5’ strategy, addressing neuropsychiatric disorders as the fifth NCD and transmissible agents that underlie the neglected tropical diseases and other NCDs as the fifth risk factor.[26] This strategy has to be given highest priority, in order to reduce the disease burden, disability and premature death.[27] Various BRFs in midlife and late adulthood are predictors of subsequent disability, if detected at early stage, populace with better health will have disability postponed and limited to only fewer years at the end of life along with longer survival.[28] Finally, lifestyle behaviors have the majority of their positive consequences in the present and the majority of their negative outcomes in the future.[29]

CONCLUSION

In our study, the prevalence of BRFs for NCDs was high when compared to other analogous studies and this reiterates the requirement of programs for promotion of healthy lifestyle and control of NCDs, which need to adopt a “life course” approach that attempts to reduce the BRFs at an earlier stage of life through appropriate public health interventions, so that premature deaths due to NCDs can be avoided. As NCD epidemics gather pace in India and threaten harm to individuals, families, and the society at large, a comprehensive strategy for their prevention and control is needed. In the fields of diet and physical activity, the process must move from contemplation to action. An endeavor at health education will assure better awareness levels, especially among the nonworking faction, who are limited from their exposure to the world in terms of their working status. India being a patriarchal society, discrepancy in well-being of women is anticipated. Hence, efforts for promotion of the health of the women need to be upgraded.

RECOMMENDATIONS

The findings observed in our study point towards the urgent need to develop strategies to have a comprehensive look at the NCD risk factors using standard methodology to ensure comparability. Health systems which are presently geared to provide prioritized services related to maternal and child health care need to be reoriented to adequately incorporate the needs of NCD prevention and control, by enhancing the skills of health care providers and equipping health care facilities to provide services related to health promotion, risk detection and risk reduction. Community based intervention programs, which adopt health education of women in urban slums and promote strategies for modification of BRFs should be undertaken. Steps should be taken to publicize various screening programs available for NCDs among women at a price that the community can afford. We also recommend further studies to be done using WHO-STEPS questionnaire 3 (biochemical measurements), which was not a part of our study.