|Year : 2018 | Volume
| Issue : 2 | Page : 227-235
Awareness of risk factors, warning signs, and immediate management measures of noncommunicable diseases: A multihospital-based study
Nitin Joseph, R Srinath, Aditya Ramanathan, Ashutosh Kumar Gupta, P Nandan, Rimsha Afnan
Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal University, Karnataka, India
|Date of Web Publication||20-Jun-2018|
Department of Community Medicine, Kasturba Medical College, Light House Hill Road, Manipal University, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Noncommunicable diseases (NCDs) account for more than one-third of outpatient visits and inpatient admissions and more than half of the proportional mortality rate from all causes of death in India. The burden of modifiable risk factors of NCDs in India is increasing significantly over the past five decades. Therefore, the reason behind this and the preparedness of people to deal with it need to be ascertained. Objectives: The objective of this study was to assess the awareness of people regarding risk factors, warning signs, and immediate management practices in specific NCDs. Materials and Methods: This cross-sectional study was conducted among people in a government and private tertiary care hospital of Mangalore city in February 2016. Data were collected by interviewing each participant using a pretested validated structured interview schedule. Results: All the 400 enrolled participants had heard about heart attack, hypertension, and diabetes mellitus. However, only 250 (62.5%) had heard about stroke. Good awareness about heart attack was present among 62.5%, stroke among 57.6%, hypertension among 59%, and diabetes mellitus among 55.8% of participants. Multivariate analysis using ordinal logistic regression analysis found that good educational status and being vegetarian were significant predictors of good awareness level about heart attack. Similarly, these factors along with urban residential status were significant predictors of good awareness level about stroke. Age above 55 years was a significant predictor of good awareness level about diabetes mellitus. Conclusion: The various sociodemographic groups identified to have poor knowledge about NCDs in this study require targeted intervention during health educational campaigns.
Keywords: Awareness, immediate management practices, noncommunicable diseases, risk factors, warning symptoms/signs
|How to cite this article:|
Joseph N, Srinath R, Ramanathan A, Gupta AK, Nandan P, Afnan R. Awareness of risk factors, warning signs, and immediate management measures of noncommunicable diseases: A multihospital-based study. J Nat Sc Biol Med 2018;9:227-35
|How to cite this URL:|
Joseph N, Srinath R, Ramanathan A, Gupta AK, Nandan P, Afnan R. Awareness of risk factors, warning signs, and immediate management measures of noncommunicable diseases: A multihospital-based study. J Nat Sc Biol Med [serial online] 2018 [cited 2019 Apr 20];9:227-35. Available from: http://www.jnsbm.org/text.asp?2018/9/2/227/234706
| Introduction|| |
Noncommunicable diseases (NCDs) in middle- and low-income countries account for three-fourths of the total deaths worldwide. They account for more than one-third of the outpatient department (OPD) visits and inpatient admissions and more than half of the proportional mortality rate from all causes of death in India., It also contributes to 44% of disability-adjusted life years lost.
The high risk of such NCD-related morbidity and mortality among Indians is due to several reasons. These include genetic predisposition to central obesity and metabolic syndrome along with other factors such as smoking and faulty lifestyle habits.
The burden of modifiable risk factors of NCDs in India is increasing significantly over the past five decades. Therefore, the reason behind this needs to be ascertained. Low awareness is still attributed as a reason for high prevalence of hypertension in both urban and rural parts of India.,, A minimal reduction in mean blood pressure levels has been reported to save over 100,000 deaths due to stroke and coronary heart diseases over here. Awareness generation of people regarding the warning signs of various NCDs is equally essential to enable early diagnosis and treatment.
Very few studies in India have researched on the awareness of people about specific NCDs.
Hence, this study was done to assess the awareness of risk factors and warning signs of heart attack, stroke, hypertension, and diabetes mellitus among people visiting various tertiary health-care centers. It also assessed their immediate management practices toward heart attack and stroke.
| Materials and Methods|| |
Study settings and study design
This cross-sectional study was conducted in a government and private tertiary care hospital of Mangalore city of South India in the month of February 2016.
Ethics committee approval
Institutional Ethics Committee approval was obtained before the commencement of this study. Permission to conduct this study at these hospitals was obtained from the respective medical superintendents.
Sample size calculation and sampling method
Sample size was calculated based on the formula Zα2 pq/d 2, where “p” was taken as 34% based on the findings of a previous study  which reported that 34% of participants were aware about the warning signs of stroke. At 95% confidence intervals, with an allowable error (d) taken as 15% of “p” and substituting “q” as 100-p, the sample size was calculated as 332. It was rounded off to 400 participants. Awareness of people about warning signs of stroke in particular was chosen for sample size calculation as it is usually the least understood among various NCDs. The participants were enrolled in this study by convenience sampling method.
Inclusion and exclusion criteria
- Patients and their attenders visiting OPD of these hospitals were included in this study
- Participants aged below 18 years and seriously ill patients were excluded from this study.
Consent for participation
The participants were explained the nature and purpose of the study and were assured confidentiality of the information provided by them. Written informed consent was taken from all consenting participants.
Data collection methodology
Data were obtained by interviewing each participant in a private room close to the OPD using a structured interview schedule. The schedule was translated into the local language Kannada and was language and content validated by experts. It was pretested in a group of ten participants who were not included in this study.
Sociodemographic details such as age, gender, marital status, education, occupation, education and occupation of head of the household, total monthly family income, type of family, and place of residence were inquired of each participant by interviewing them. They were also inquired about the past history and family history of comorbidities, substance abuse, dietary habits, and awareness of any medical emergency number. In relation to the study objectives, the participants were inquired whether they had heard about specific NCDs such as heart attack, stroke, hypertension, and diabetes mellitus. If they had heard, they were further inquired about risk factors and warning symptoms and signs of each of the four NCDs.
However, the awareness of participants regarding immediate management measures was inquired only for medical emergencies such as heart attack and stroke. If more than one correct answer was given for each item by the participant, a total of two points were awarded. Only one point was awarded for a single correct answer and zero point was awarded for no response or for an incorrect answer.
Cumulative score of 0–1 was categorized as poor, 2–3 as moderate, and 4–6 as good awareness level regarding heart attack and stroke. For hypertension and diabetes mellitus, cumulative score of 0–1 was categorized as poor, 2–3 as moderate, and 4 as good awareness. The cutoff scores 2–3 indicating moderate awareness level were based on a single correct answer by participants to risk factors, warning symptoms/signs, and immediate management measures for each NCD.
Data entered and analyzed using Statistical Package for Social Sciences software package (SPSS Inc., Chicago, IL, USA) version 16.0. Univariate analysis using Chi-square test and multivariate analysis using ordinal logistic regression analysis were done to identify the predictors of good awareness level of participants. P < 0.05 was taken as statistically significant association.
| Results|| |
The mean age of the total 400 participants was 36.9 ± 13.0 years. Among them, 211 (52.8%) were from the government and the rest 189 (47.2%) were from the private hospital. Majority of participants were males (270 [67.5%]), were educated till high school level or above (253 [63.2%]), were unskilled workers (110 [27.5%]), were from upper lower socioeconomic status (SES) (46.5%), and were from rural areas (246 [61.5%]) [Table 1].
All participants had heard about heart attack, hypertension, and diabetes mellitus. However, only 250 (62.5%) of them had heard about stroke. The most common risk factor of heart attack identified by the participants was stress (108 [27%]), of stroke was hypertension (30.8%), of hypertension was stress (141 [35.3%]), and of diabetes mellitus was excessive sugar intake (164 [41%]) [Table 2].
|Table 2: Awareness of risk factors of various noncommunicable diseases among participants (n=400)|
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The most common warning symptom of heart attack identified by the participants was chest pain (228 [57%]), of stroke was weakness of extremities (56%), of hypertension was anger (133 [33.3%]), and of diabetes mellitus was delayed wound healing (165 [41.3%]) [Table 3].
|Table 3: Awareness of warning symptoms/signs of various noncommunicable diseases among participants (n=400)|
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In this study, 241 (60.3%), 265 (66.3%), and all participants were aware of at least one warning sign or symptoms about heart attack, diabetes mellitus, and hypertension, respectively. With respect to stroke, awareness of at least one sign or symptom was present among 179 (71.6%) out of 250 participants who had heard about stroke [Table 3].
The most common immediate management practice for heart attack and stroke as stated by over 70% of participants was medical assistance [Table 4].
|Table 4: Awareness of immediate management practices in various noncommunicable diseases among participants|
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Good awareness level about heart attack, stroke, hypertension, and diabetes mellitus was seen among 62.5%, 57.6%, 59%, and 55.8% participants, respectively [Table 5].
|Table 5: Awareness level of participants with respect to different types of noncommunicable diseases|
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Education, occupation, SES, place of residence, and type of diet were associated with awareness level about heart attack among participants. Educational status, place of residence, and type of diet were associated with awareness level about stroke among participants. Educational status was associated with awareness level about hypertension among participants. Age, SES, and family history of diabetes mellitus were associated with awareness level about diabetes mellitus among participants [Table 6]. This infers that a greater number of risk factors were associated with awareness level about heart attack among participants.
|Table 6: Association between sociodemographic variables and other risk factors with awareness level of participants about various noncommunicable diseases|
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Of the total participants, 322 (80.5%) had heard of emergency number which needs to be dialed during medical emergencies. However, only 165 (51.2%) of them knew this number correctly.
Multivariate analysis identified several predictors of good awareness level among participants regarding individual types of NCDs. Educational status of high school level and above and being a vegetarian were significant predictors of good awareness level about heart attack, taking illiterate and nonvegetarians as the reference population, respectively. Educational status of intermediate level and above, being a vegetarian, and from an urban area were significant predictors of good awareness level about stroke, taking illiterate, nonvegetarians, and rural residents as the reference population, respectively. Age above 55 years was a significant predictor of good awareness level about diabetes mellitus, taking 18–25 years as the reference population [Table 7].
|Table 7: Ordinal logistic regression analysis of predictors of awareness level of various noncommunicable diseases among the participants (n=400)|
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| Discussion|| |
Good awareness level was seen among a greater proportion of participants (62.5%), regarding heart attack compared to other NCDs. Among the total number of various risk factors associated with the awareness level of different NCDs in this study, majority was again for heart attack. This indicates that awareness about heart attack is quite common among people. In a population-based study done in Kuwait, 40% of participants were not aware of any heart attack symptoms similar to 39.8% observed in this study. In addition, only 50.4% were aware that chest pain is a warning symptom for heart attack in the former study  compared to 57% reported here.
In a study done in Nellore, India, only 35% of participants were aware about stroke and only 30% of participants knew limb weakness as a warning sign of stroke. These findings were again lesser than that reported in the present study where 250 (62.5%) had heard about stroke and of them, 56% knew that it can manifest with weakness of extremities.
In a multivariate analysis in the former study  and in a systematic review, high educational status was found to be associated with good awareness level of stroke as also observed in this study along with other risk factors observed here such as being vegetarians and from urban areas.
There has been a tremendous increase in stroke-associated morbidity and mortality in India over the years to an extent that it has exceeded the statistics of industrialized Western countries. Therefore, it is a matter of concern that 37.5% of participants in this study had not heard about stroke and among those who had heard, 28.4% were not aware of its warning symptoms/signs.
In other studies, it was reported that 20%–50%,, were not aware of any risk factors and 23%–80%, of the participants were not aware of even a single warning sign for stroke. The time within 60 minutes of onset of symptoms of stroke is called the golden hour for stroke management. Hence, awareness of this condition and early recognition of its warning signs and symptoms need further improvement for timely initiation of treatment within this time window.
Awareness level regarding stroke was significantly better among urban residents in the present study. Similarly, in a study done in Mysore, India, awareness about diabetes mellitus, hypertension, dyslipidemia, and stroke was significantly higher among participants from urban area. Better awareness among them might be due to easy accessibility to medical care and health clubs, more of mass media and internet facilities, and better literacy rate in urban compared to rural areas.
In this study, awareness of hypertension was seen significantly better among those who were illiterate or those educated up to primary school level compared to others. The moderate-to-good awareness level about hypertension in this study was 99%, which was also much higher than that reported in previous studies where it ranged from 36.9% to 60%.,,, This might be because of opportunistic screening of blood pressure (for those aged above 30 years) by health-care providers, which is done routinely nowadays, under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke. This strategy under NPCDCS which was implemented throughout India in 2015 might have generated awareness about hypertension even among the less educated groups. Previous studies , reported awareness about hypertension to be significantly better among women, which was different from our observations where no association with gender was observed.
In another study  done in different parts of Kerala, India, moderate-to-good awareness level about diabetes mellitus was found to be 72.2% compared to 99% reported in the present study. However, knowledge of particular risk factors such as physical inactivity and obesity resulting in diabetes mellitus was reported in 11.9% of participantsin a Chennai, India  based study which was more than our observations where only 5.3% and 9% of participants, respectively, knew it. This indicates the urgent requirement of need-based diabetes education programs in both urban and rural India. It should target those who were found particularly to be less aware about diabetes mellitus in the present study such as younger population groups.
| Conclusion|| |
Good awareness level about various NCDs ranged from 55.8% to 62.5% among participants in this study. There is thus a need for further improvement of awareness of people regarding various NCDs. These awareness programs should be so designed to improve awareness regarding those risk factors of NCDs which are not widely known among people such as those identified in this study. This will help them in the implementation of suitable preventive measures against these risk factors. Awareness on warning symptoms and signs and immediate management measures will additionally ensure early diagnosis and treatment. The various sociodemographic groups identified to have poor knowledge in the present study need to be provided targeted intervention during these health educational campaigns. These measures will help in containing the current increasing burden of NCDs in India.
A population-based study would have given a better estimate of the awareness level of various NCDs in comparison to any hospital-based study.
The authors thank the medical superintendents of the hospitals for their cooperation in the conduct of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mendis S, Davis S, Norrving B. Organizational update: The World Health Organization global status report on noncommunicable diseases 2014; one more landmark step in the combat against stroke and vascular disease. Stroke 2015;46:e121-2.
World Health Organization. Noncommunicable Diseases Country Profiles 2011. Geneva: World Health Organization; 2011.
Srinath Reddy K, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005;366:1744-9.
Gupta R, Guptha S, Sharma KK, Gupta A, Deedwania P. Regional variations in cardiovascular risk factors in India: India heart watch. World J Cardiol 2012;4:112-20.
Gupta R, Joshi P, Mohan V, Reddy KS, Yusuf S. Epidemiology and causation of coronary heart disease and stroke in India. Heart 2008;94:16-26.
Gupta R, Gupta S. Hypertension in India: Trends in prevalence, awareness, treatment and control. RUHS J Health Sci 2017;2:40-6.
Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004;18:73-8.
Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, et al.
Hypertension in India: A systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens 2014;32:1170-7.
Patel V, Chatterji S, Chisholm D, Ebrahim S, Gopalakrishna G, Mathers C, et al.
Chronic diseases and injuries in India. Lancet 2011;377:413-28.
Menon B, Swaroop JJ, Deepika HK, Conjeevaram J, Munisusmitha K. Poor awareness of stroke – A hospital-based study from South India: An urgent need for awareness programs. J Stroke Cerebrovasc Dis 2014;23:2091-8.
Awad A, Al-Nafisi H. Public knowledge of cardiovascular disease and its risk factors in Kuwait: A cross-sectional survey. BMC Public Health 2014;14:1131.
Stroebele N, Müller-Riemenschneider F, Nolte CH, Müller-Nordhorn J, Bockelbrink A, Willich SN, et al.
Knowledge of risk factors, and warning signs of stroke: A systematic review from a gender perspective. Int J Stroke 2011;6:60-6.
Banerjee TK, Das SK. Fifty years of stroke researches in India. Ann Indian Acad Neurol 2016;19:1-8.
] [Full text]
Pandian JD, Jaison A, Deepak SS, Kalra G, Shamsher S, Lincoln DJ, et al.
Public awareness of warning symptoms, risk factors, and treatment of stroke in Northwest India. Stroke 2005;36:644-8.
Advani R, Naess H, Kurz MW. The golden hour of acute ischemic stroke. Scand J Trauma Resusc Emerg Med 2017;25:54.
Thippeswamy T, Chikkegowda P. Basic risk factors awareness in non-communicable diseases (BRAND) study among people visiting tertiary care centre in Mysuru, Karnataka. J Clin Diagn Res 2016;10:OC04-7.
Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, et al.
Risk factor profile for chronic non-communicable diseases: Results of a community-based study in Kerala, India. Indian J Med Res 2010;131:53-63.
] [Full text]
Institute of Medicine (US) Committee on Preventing the Global Epidemic of Cardiovascular Disease: Meeting the Challenges in Developing Countries; Fuster V, Kelly BB, editors. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington (D.C.): National Academies Press (US); 2010.
World Health Organization. Global Status Report of Non communicable Diseases 2014. Geneva: World Health Organization; 2014.
Mohan D, Raj D, Shanthirani CS, Datta M, Unwin NC, Kapur A, et al.
Awareness and knowledge of diabetes in Chennai – The Chennai urban rural epidemiology study [CURES-9]. J Assoc Physicians India 2005;53:283-7.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]