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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 46-52

Noncommunicable disease risk profile of urban women in Indore city, India


1 Building Healthy Cities Project, John Snow India Private Limited, New Delhi, India
2 Building Healthy Cities Project, JSI Research and Training Institute, Inc., New Delhi, India
3 Center for Community Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Submission18-Dec-2020
Date of Acceptance17-Mar-2021
Date of Web Publication21-Apr-2021

Correspondence Address:
Dr. Damodar Bachani
John Snow India Pvt. Ltd. (JSIPL), Nelson Mandela Marg, Vasant Kunj, New Delhi - 110 070
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_91_20

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  Abstract 


Background: Lifestyle changes are affecting the health risk profile of women in developing countries. This study assesses risk factors for noncommunicable diseases (NCDs) and access to NCD screening services among women in Indore city, India.
Materials and Methods: A NCD risk factor survey was undertaken in Indore city through the United States Agency for International Development-funded Building Healthy Cities project. The survey used the World Health Organization STEPwise methodology and tools. A total of 1987 women and 1083 men aged 18–69 years were randomly selected from 90 settlements across 30 wards of the city. Weighted analysis based on sampling strategy and response rate was conducted.
Results: A total of 22% of women (95% confidence interval [CI]: 21, 24) had raised blood pressure and 13% (95% CI: 11, 14) had raised fasting blood sugar or had already been diagnosed with hypertension or diabetes. While only 6% of women were current tobacco users and <1% consumed alcohol in the last 30 days, 60% of women were overweight or obese. Central obesity was observed in 70% of women; 89% of women were not consuming adequate fruits and vegetables, and 20% were physically inactive. Only 41% and 20% of women had their blood pressure and blood sugar measured, respectively, in the last 12 months; <1% were screened for oral and cervical cancers.
Conclusion: Women living in Indore have higher levels of metabolic risk factors, and current NCD screening programs have poor uptake. Gender-sensitive solutions targeting awareness, access, and community environment need further exploration.

Keywords: Informal settlements, noncommunicable disease risk, urban, women


How to cite this article:
Bachani D, Stevens AP, Anand K, Amarchand R. Noncommunicable disease risk profile of urban women in Indore city, India. Int J Non-Commun Dis 2021;6:46-52

How to cite this URL:
Bachani D, Stevens AP, Anand K, Amarchand R. Noncommunicable disease risk profile of urban women in Indore city, India. Int J Non-Commun Dis [serial online] 2021 [cited 2021 Jun 19];6:46-52. Available from: https://www.ijncd.org/text.asp?2021/6/1/46/314214




  Introduction Top


Noncommunicable diseases (NCDs) threaten women's health and development worldwide, impacting not just morbidity and mortality outcomes but also income, productivity, and reproductive health. The greatest burden of death and disability among women in low- and middle-income countries is currently attributed to NCDs, and women are at greater risk of NCDs than men.[1],[2],[3],[4] The lack of data on urban women's risk of NCDs and leading risk factors requires more research.[5],[6] This paper reports the results of a recent survey conducted in the city of Indore, India, to address this gap in the literature.


  Materials and Methods Top


This survey was jointly supported by the United States Agency for International Development-funded Building Healthy Cities (BHC) project and Indore Smart City Development Limited (ISCDL), the governing body of Smart City (the Government of India started the Smart City Mission in 2015 covering 100 secondary-level cities of the country including Indore city) work in Indore. NCDs were chosen as the topic of study because of their associations with urbanization. We collected cross-sectional data in 2018 using the World Health Organization (WHO) STEPwise methodology for NCD risk factor surveillance and self-reported NCD behavioral risk factors and diseases. Using tools validated for the National NCD Risk Factor Survey previously conducted in India, we analyzed the relationship between gender and risk of NCDs using and six out of nine NCD global targets identified in the WHO Global NCD Action Plan for the Prevention and Control of NCDs 2013–2020.[7] These included tobacco use, alcohol use, physical inactivity, salt/sodium intake, raised blood pressure, and obesity/diabetes.[8] We then assessed the relationship between these six targets and self-reported education level, housing type, and wealth.

Data collection was carried out by trained investigators in May and June 2018. A total of 1987 women and 1083 men from 90 settlements and across 30 wards of the city were randomly selected. Study participants ranged in age from 18 to 69 years; the mean age for men was 37 and 36 for women. Care was taken to ensure the sample included a representative number of households from informal settlements, where approximately 30% of the Indore population lives.[9] Protocol and tool development, training of the survey team, data cleaning, and analysis were supported by All India Institute of Medical Sciences in New Delhi. Approval of the Institutional Review Board of Mahatma Gandhi Memorial Medical College in Indore was obtained before conducting this study.

Descriptive analysis of the survey data was completed using age-sex survey weights to ensure representativeness of the city population. Statistical tests including analysis of variance and bivariate regression were applied to test the level of significance. Results are reported as point estimates with a 95% confidence interval (CI). Wealth quintile estimates are based on a wealth index created using the same approach as Demographic and Health Surveys.[10]


  Results Top


Response rates and coverage are summarized in [Figure 1].
Figure 1: Survey response rates and coverage

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Tobacco and alcohol

It was observed that consumption of tobacco products and alcohol was prevalent in adult men. Thirty-seven percent (95% CI: 34, 40) of men were current tobacco users, with 28% (95% CI: 25, 31) using smokeless tobacco compared with 12% (95% CI: 10, 15) using smoking forms; some men reported using both. Only 6% (95% CI: 5, 7) of women reported being current smokeless tobacco users, and none reported using smoking forms. Exposure to secondhand smoke for men was also higher in different settings, including at home (25%), at work (32%), or while traveling (57%), as compared with women (18%, 14%, and 35%, respectively) [Table 1].
Table 1: Tobacco and alcohol use among adult men and women

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A total of 87% of men reported being lifetime alcohol abstainers, while 10% (95% CI: 8, 12) reported consuming alcohol in the last 30 days and 4% (95% CI: 3, 5) reported indulging in heavy drinking. More than 99% of women reported being lifetime alcohol abstainers, only one woman reported consuming alcohol in the last 30 days, and none reported engaging in heavy episodic drinking [Table 1].

Diet, physical activity, and body composition

Mean daily consumption of fruits and vegetables was reported as two servings for men, and three servings for women, but 94% (95% CI: 92, 95) of men and 89% (95% CI: 87, 90) of women had inadequate consumption of fruits and vegetables when measured against the WHO recommendation of five servings per day.[11] Nearly one in four men and women reported adding salt before eating meals, though between 92% and 95% thought that lowering consumption of salt in diet was important and almost 75% of respondents reported taking steps to reduce salt intake [Table 2].
Table 2: Dietary practices, physical activity, and body composition of adult men and women in Indore city

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Physical inactivity was found to be marginally higher in men (28%; 95% CI: 25, 31) when compared with women (20%; 95% CI: 18, 22), but the difference was not statistically significant. Both men and women spent nearly 3 h every day on sedentary activities. Men spent 19 h per week on work, travel, and recreation-related physical activity compared with fewer than 17 h for women, and only 5% of men and women reported practicing yoga. The percentage of women considered overweight or obese was marginally higher compared with men, while rates of central obesity were significantly higher in women [Table 2].

Raised blood pressure and raised blood sugar

It was observed that mean systolic and diastolic blood pressures were higher among men than women. While 29% (95% CI: 26, 32) of men taking medication had high blood pressure, this number was only 22% (95% CI: 21, 24) among women. Conversely, mean fasting blood sugar and the proportion of women with high blood sugar (including known diabetics on medication) were higher than for men. Women had more opportunities to measure their blood pressure and blood sugar than men in the preceding 12 months, but opportunities for women to be screened for common cancers were very low [Table 3].
Table 3: Raised blood pressure, raised blood sugar, and screening for lifestyle diseases of adult men and women in Indore city

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Noncommunicable disease risk in women by education, housing, and wealth

This study also assessed associations between the six global targets discussed above and education level, housing type, and wealth among women. We found statistically significant inverse relationships between women's education levels and the prevalence of current tobacco use and raised blood pressure [Table 4]. The type of housing also impacted risk factors. The prevalence of tobacco use was 13% among those living in temporary housing compared with 3% in those living in permanent housing. Adding salt to food was also higher in women residing in temporary housing. Conversely, being overweight or obese and engaging in sufficient physical activity were higher in those with permanent housing. All four of these associations were statistically significant. Differences between housing type and hypertension as well as high blood sugar were not statistically significant [Table 5].
Table 4: Prevalence of noncommunicable disease risk factors in women by education level

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Table 5: Prevalence of noncommunicable disease risk factors in women by housing

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Similar associations were observed between wealth index quintiles and NCD risk factors. Tobacco use and adding salt to food were significantly higher in women in the lowest wealth quintile compared with the highest wealth quintile, while being overweight or obese increased with wealth levels, with statistically significant differences between women in the lowest versus the highest wealth quintiles. There were no significant relationships between wealth and physical activity, raised blood pressure, or high blood sugar [Table 6].
Table 6: Prevalence (weighted percentage) of noncommunicable disease risk factors in women by wealth

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Screening for noncommunicable diseases

Diabetes care for women in Indore is an important point of concern, as 75% of adult women are never screened for diabetes. However, once diagnosed, 96% of women sought care from an allopathic doctor, most of whom work at private or nongovernmental organization (NGO) health-care facilities [Figure 2]. Only half of women are ever screened for hypertension, but similar to those with diabetes, the majority (82%) sought care after their positive diagnosis, and 75% of these women received care from private or NGO health-care facilities [Figure 3].
Figure 2: Bottleneck analysis of diabetic care: Women

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Figure 3: Bottleneck analysis of hypertension care: Women

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  Discussion Top


Rapid urbanization is outstripping systems and infrastructure of various sectors in many cities, which can lead to fundamental changes in living conditions and demography, including a greater number of people living in slums. There is pressure on services including water supply, solid waste management, education, health care, and housing among other basic public services.

While there have been improvements in reproductive health services across India since the implementation of the National Health Mission, NCDs among women have become the most prevalent cause of disease burden and mortality. Women often have higher risks of diabetes and being overweight, while men often have higher rates of smoking and hypertension.[12],[13] Our results support these findings in Indore. Higher central obesity rates among women could be due to the combined effect of unhealthy diets and lack of physical activity. In some communities, there are restrictions in physical activity during and after delivery.[14] Dietary practices, particularly after delivery, favor gain in weight and may lead to obesity. This study also observed that obesity is common in low-income women as 34% of low-income women were overweight or obese. The observation that urban women with low education level had a high prevalence of high blood pressure (29%) and high blood sugar (16%) in the present study [Table 4], calls for interventions in communities with lower education levels including educating women about healthy dietary practices, promoting physical activity, and getting women screened for early diagnosis and management of NCDs. This requires greater involvement and capacity building of community-based frontline workforce including accredited social health activists and anganwadi workers employed under the National Urban Health Mission and Integrated Child Development Services, respectively.

Another important risk factor observed in the study was the use of tobacco products and exposure to tobacco smoke. While tobacco and alcohol use is much higher in men compared with women, exposure to secondhand smoke, particularly in homes, is significant for women and children. We found that 18% of women were exposed to tobacco smoke in homes. Coupled with poor housing conditions in slums, smoking by men within congested homes is detrimental to women's health. While men need to be made aware about harms of smoking and smokeless tobacco use, they should be warned about ill effects of smoking within homes on the health of women and young children exposed to secondhand smoke.

While the use of smokeless tobacco products was found to be only 6% in women compared with 28% in men, use of smokeless tobacco was 18% among women in the lowest socioeconomic quintile living in slums compared with only 1% in the highest wealth quintile. This is of concern, as low-income women using tobacco products are at risk of tobacco-related cancers. There is a need to control the use of tobacco products, and guidelines issued by the Indian Ministry of Health and Family Welfare need to be followed by city authorities.[15]

The city administration has introduced various interventions to promote healthy lifestyles and behaviors. Some of these interventions include more green spaces and parks, pedestrian pathways, effective solid and liquid waste management, compliance to provisions under Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003, improved traffic management, and food safety.

To improve health outcomes, there is a need to strengthen screening services to diagnose NCDs. A study conducted in a resettlement colony of Delhi suggested that the current strategy of opportunist screening in India has failed to reach large segments of vulnerable populations.[16] In this study, we found that only 41% of women had their blood pressure measured in the last 12 months, while only 20% of women had their blood sugar measured within the same timeframe. The fact that <1% of women were screened for common cancers including oral cancer and cervical cancer requires attention, particularly because of high smokeless tobacco use among urban low-income women. Screening for cervical cancer as well as menstrual hygiene and safe sexual practices should be an integrated part of maternal health services to identify women at risk of human papillomavirus and women showing signs of precancerous lesions.[17]

This city-based study is the first of its kind to use validated tools used in a National NCD Risk Factor Survey in India. It was also a first attempt to conduct a simultaneous assessment of environmental factors that may influence the prevalence of NCD risk factors. To make it a low-cost survey, we trained students from city-based academic institutions in data collection. While an attempt was made in the sampling design to get an adequate sample, representativeness of a fast expanding city with nearly one-third of its population categorized as urban low income was a challenge. Another limitation of the study was a comparatively low response rate for fasting blood sugar estimation in a community due to surveillance conducted during a month of fasting.

The BHC project aims to support ISCDL in making Indore a Smart and Healthy City. Toward this goal, it is important to acknowledge the particular health challenges women face, including the risk of NCDs and related risk factors prevalent in the city including tobacco use, unhealthy diet, and obesity.


  Conclusion Top


The BHC project aims to support ISCDL in making Indore a Smart and Healthy City. Toward this goal, it is important to acknowledge the particular health challenges women face, including the risk of NCDs and related risk factors prevalent in the city including tobacco use, unhealthy diet, and obesity.

Ethical approval statement

Survey protocol was approved by Institutional Review Board of MGM Medical College, Indore on 11th May 2018 stating that the Ethics and Scientific Committee provides permission for the survey. The Project proposal has been approved.

Acknowledgments

Building Healthy Cities is a 5 year cooperative agreement funded by the United States Agency for International Development (USAID) under Agreement No. AID OAA A 17 00028, beginning September 30, 2017. The Building Healthy Cities project is implemented by JSI Research and Training Institute, Inc. with partners International Organization for Migration, Thrive Networks Global, and Urban Institute, and with support from Engaging Inquiry, LLC. This study was conducted in partnership with ISCDL and the All India Institute of Medical Science, New Delhi. We would like to thank the Government Nursing College, Indore, and the Indore School of Social Work for their help in the data collection effort and to ISCDL for their continued support of this activity in Indore. The contents of this paper are the responsibility of Building Healthy Cities and do not necessarily reflect the views of USAID or the United States Government.

Financial support and sponsorship

Building Healthy Cities is a 5 year cooperative agreement funded by USAID under Agreement No. AID OAA A 17 00028, beginning September 30, 2017. The contents of this paper are the responsibility of Building Healthy Cities and do not necessarily reflect the views of USAID or the United States Government.

Conflicts of interest

There are no conflicts of interest.



 
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