District Level Variation in Hypertension Epidemiology in India and Influence of Social Determinants: National Family Health Survey-5

BACKGROUND Enumeration of state and district-level variation in hypertension prevalence in India and to evaluate the influence of social determinants. METHODS We used data from the Fifth National Family Health Survey (NFHS-5) from 707 districts and 825,954 participants (women 724,115, men 101,839 men) on prevalence of hypertension defined according to standard criteria. Data on multiple social determinants were also obtained from NFHS-5 report. RESULTS Age-standardized prevalence of hypertension was 22.4% (women 21.3%, men 24.0%) with the highest prevalence in women and men, respectively, in Sikkim (34.5 and 41.6%) and Punjab (31.2 and 37.7%) and lowest in Rajasthan (15.4 and 17.9%) and Ladakh (15.7 and 17.4%). Prevalence was more in western and southern Indian districts. High prevalence of hypertension in the young (<30y) was observed in northeastern and northern states. District-level hypertension prevalence correlated negatively with multi-dimensional poverty index (R2 women 0.299, men 0.245) and positively with female literacy (women 0.165, men 0.134). Among women, districts with the highest availability of electricity, clean water, sanitation, clean cooking fuels, healthcare service delivery and better nutrition were associated with more hypertension on univariate and multivariate analyses (p<0.05). CONCLUSIONS The study shows significant geographical variation in hypertension prevalence in India. Hypertension is more in men with high prevalence of premature hypertension. Better district-level development (less poverty, more literacy) and healthcare services are associated with greater hypertension prevalence in women. What is known about the topic What this study adds ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics clearance has been obtained by the Institutional Ethics Committee of Indian Institute of Population Sciences, Mumbai, India. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data from NFHS-5 are available at the National Family Health Survey website at