Review of Literature s3

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE

SYNOPSIS OF DISSERTATION

“A STUDY OF AWARENESS OF CORONARY HEART DISEASE (CHD) RISK FACTORS AMONG RURAL ADULT POPULATION (18 YRS AND ABOVE) OF BELLUR PHC COVERAGE AREA, MANDYA DISTRICT, KARNATAKA STATE”

SUBMITTED BY

Dr. Shanthi.M Post Graduate Student

DEPARTMENT OF COMMUNITY MEDICINE

1 ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES B.G.NAGARA – 571 448

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 Name of the Candidate and Dr. SHANTHI .M Address (in block letters) W/O Dr. K.K.VENKATESH KOTEBETTA ROAD, T.B. EXTENTION, NAGAMANGALA- 571432, MANDYA DISTRICT.

2. Name of the Institution ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES, B.G.NAGARA – 571 448.

3. Course of study and subject M.D. (COMMUNITY MEDICINE)

Date of admission to Course 31-05-2011 4. Research question What is the level of awareness of risk factors of coronary heart disease (CHD) among rural adult population (18 Yrs and above) of Bellur PHC coverage area?

5. Title of the Topic “A STUDY OF AWARENESS OF CORONARY HEART DISEASE (CHD) RISK FACTORS AMONG RURAL ADULT POPULATION (18 YRS AND ABOVE) OF BELLUR PHC COVERAGE AREA, MANDYA DISTRICT, KARNATAKA STATE”.

2 6. Brief resume of intended work: 6.1 Need for the study ANNEXURE – I 6.2 Review of literature ANNEXURE – II 6.3 Objectives of the study ANNEXURE – III

7. Materials and methods: 7.1 Source of data Primary data collected from respondents (Study subjects)

7.2 Method of collection of data ANNEXURE – IV (including sampling procedure, if any) ANNEXURE - V

7.3 Does the study require any investigations or interventions to be conducted on patients or NOT APPLICABLE other animals? If so please describe briefly.

7.4 Has ethical clearance been obtained from your institution NOT APPLICABLE in case of 7.3

8. List of references (About 4 – 6) ANNEXURE – VI

9. Signature of candidate

10. Remarks of the guide

3 11. Name & Designation of (in block letters)

11.1 Guide Dr. SURESH LANKESHWAR, M.D.,MBA, PROFESSOR AND HEAD DEPT. OF COMMUNITY MEDICINE A.I.M.S., B.G.NAGAR.

11.2 Signature:

11.3 Co-Guide (if any) ------

11.4 Signature: ------

11.5 Head of Department Dr. SURESH LANKESHWAR, M.D.,MBA, PROFESSOR & HEAD DEPT. OF COMMUNITY MEDICINE A.I.M.S., B.G.NAGARA

11.6 Signature:

12. 12.1 Remarks of the Chairman & Principal

12.2 Signature:

4 ANNEXURE -1

6.1 INTRODUCTION AND NEED FOR THE STUDY

Coronary heart disease (syn: ischemic heart disease) has been defined as “impairment of heart function due to inadequate blood flow to the heart compared to its needs, caused by obstructive changes in the coronary circulation to the heart”13. It is the cause of 25-30% of deaths in most industrialized countries. The WHO has drawn attention to the fact that coronary heart disease is our modern “epidemic”. Coronary heart disease ranked as No.1 killer disease.

Coronary heart disease is forecast to be the most common cause of death globally, including India, by 2020. Coronary heart disease prevalence increased in urban areas from

1% in 1960s to 9% in the1990. In rural areas the rate increased from 2% in the 1970s to 4%in the 1990s. Demographic shift in population age profile combined with lifestyle risk related increase in the cardiovascular risk factor are accelerating coronary heart disease epidemic in

India3. Coronary heart disease have common risk factors related to life style like tobacco use, unhealthy diet, physical inactivity, obesity, high blood pressure, abnormal lipid status and glucose levels. There is a paucity of data on the awareness of various risk factors for coronary heart disease. The present study will be done to the determine the awareness of coronary heart disease risk factors among the rural population. The risk factors of coronary heart disease are measurable and largely modifiable and thus continuing surveillance of the levels and patterns of risk factors is of fundamental importance to planning and evaluating preventive activities in control of coronary heart disease.

5 Magnitude of the problem:

World:

According to global estimates 2004, 7.2 million deaths are attributed to coronary heart disease14. The highest coronary heart disease mortality is seen in present in European region followed by south East Asia region. Burden of disease in DALYS due to coronary heart diseases for the year 2004 is 62, 58714. In United Kingdom heart disease cost the health care system 1.7 billion pounds, 2.9 billion pounds in loss of productivity. Heart disease alone cost

6% of National Health Service revenue at 1994-95 prices. Economic loss in USA total health care cost resulting from heart disease in 2002 was US$ 351.8 Billion. In United Kingdom heart disease, stroke, diabetes caused an income loss of 1.6 Billion Dollors. In 2005 estimated losses in National Income from heart disease, stroke and diabetes are 18 Billion $ in China, 11 Billion $ in Russian Federation, 3 Billion $ in Brazil, Pakistan 1.6, Canada 1.2,

Nigeria 0.52.

India:

The pooled estimates from studies carried out in 1990’s up to 2002 shows prevalent rate of coronary heart disease in urban areas as 6.4% and 2.5% in rural areas. In rural areas the estimate was 2.1% for males and 2.7% for females. The burden of coronary heart disease is 2.4 million every year. In 2005 estimated losses in national income from heart disease stroke, diabetes is 9 Billion $ in India2.

6 Indices of burden of disease for CHD15

Indices Urban Rural Prevalence rate/1000 64.37 25.27 Death rate/1000 0.8 0.4 DALY/100,000 2703.4 986.2

Coronary heart disease risk factors1:

Non Modifiable risk factors Modifiable risk factors  Age (adults and advancing age)  Tobacco smoking

 Sex  High Blood Pressure( Hypertension)

 Family History  Abnormal lipid profile (dyslipidemia)

 Genetic factors  Diabetes mellitus

 Obesity

 High alcohol intake

 Dietary factors (increased salt and

increased fat intake)

 Sedentary habits

 Stress and strain

7 Non modifiable risk factors:

 Age:

. Coronary heart disease is generally disease of adults and increases with age1.

 Sex:

CHD males are at higher risk on hypertension. Young and middle age males are at

higher risk, late in life (Post menopausal) the difference narrows and the pattern may

even be reversed1.

 Genetic factors:

The family history of coronary heart disease is known to increase the risk of

premature death. Genetic factors are probably the most important determinants of a

given individuals TC and LDL levels12.

Modifiable risk factors:

Tobacco smoking:

Tobacco smoking has been identified as a major coronary heart disease risk factor responsible for 25% of coronary heart disease deaths under 65 years of age in men. Tobacco smoking is important in causing sudden death from coronary heart disease in men under 50 years of age. Risk of developing coronary heart disease is directly related to number of tobacco smoked per day. The risk of death from coronary heart disease decreases on cessation of smoking. Those who have had a myocardial infarction, the risk of a fatal recurrence may be reduced by 50% after giving up smoking1.

8 High Blood Pressure:

The blood pressure is the single most useful test for identifying individuals at a high risk of developing coronary heart disease. Hypertension accelerates the atherosclerotic process, especially if hyper lipidemia is also present and contributes to coronary heart disease9.

Diabetic mellitus:

Risk of coronary heart disease is 2 to 3 times higher in diabetic than in non diabetic.

Coronary heart disease is responsible for 30 to 50% of deaths in diabetic over 40 years of

age 10 .

Abnormal lipid profile:

Elevated serum cholesterol causes increased risk for the development of myocardial infarction13. LDL cholesterol is most directly associated with CHD1. The risk of coronary heart disease rises steadily with the serum cholesterol concentration.

Obesity:

Obesity is a risk factor for coronary heart disease 1. The greater the weight gained the greater the risk of high blood pressure. Central obesity indicated by waist to hip ratio has been positively correlated with high blood pressure. There is good evidence that abdominal obesity is important in the development of insulin resistance and in metabolic disorder that link obesity with coronary heart diseases.

Dietary factors:

The risk of coronary heart disease and hypertension is inversely related to the consumption of dietary fibers. Most fibers reduce plasma total and LDL cholesterol. High

9 salt intake (ie., 7 to 8 grams per day) increases blood pressure proportionately, low sodium intake has been found to lower the blood pressure. Potassium antagonizes biological effects of sodium10.

Sedentary lifestyle:

Sedentary life style is associated with a greater risk of the development of early coronary heart diseases. There is evidence that lack of regular physical exercise increases the body weight and blood pressure which are not beneficial to cardiovascular health1

Alcohol:

High alcohol intake, 75 grams or more per day &every day is an independent risk factor for coronary heart disease, hypertension and stroke9.

Socio-economic Status:

In societies that are transitional or pre-transitional higher prevalence of hypertension have been noted in upper socio-economic groups. This probably represents the initial stage of the epidemic of coronary heart diseases. In countries that are in post transitional stage of economic & epidemiological changes consistently higher levels of blood pressures have been noted in the lower socio-economic status11.

Stress and strain :

The term hypertension itself implies a disorder initiated by tension or stress. Psychosocial factors operate through mental process, consciously or unconsciously to produce hypertension. Studies have revealed significantly higher noradrenalin levels in hypertensive than in normotensives and indirectly increases the risk of coronary heart disease occurrence.

10 ANNEXURE-II

6.2 REVIEW OF LITERATURE

Coronary heart diseases comprise the most prevalent serious disorders in industrialized nation and are rapidly growing problem in developing nations. The efficient transfer of low cost preventive and therapeutic strategies could alter the natural course of this epidemic and there by reduce the excess global burden of preventable coronary heart diseases. Many studies that have been conducted regarding the awareness of risk factors of coronary heart diseases are given below.

Thankappan K.R, Mini G.K, conducted a study “surveillance of CVD risk factors and health promotion instrumentation in a rural community in Trivandrum district” in 2006 concluded that 57% identified obesity as risk factor for coronary heart disease. 81%, 77%, 76%, 85%,

77% identified smoking, physical inactivity, high alcohol intake, high fat, increased salt consumption as risk factor for coronary heart disease correctly and respectively in the age group of 15 to 64years4.

Saeed O, Gupta V, Dhawan N, Streja L, Shin S.J, Melvin Ku etal in a study “Knowledge of modifiable risk factors of Coronary Atherosclerotic Heart Disease (CASHD) among a sample in India” in 2008 concluded that 41% of the sample surveyed had a good level of knowledge.

68%, 72%, 73% and 57% of the population identified smoking, obesity, hypertension and high cholesterol as risk factors of coronary heart disease correctly and respectively. 30% identified and diabetes mellitus as modifiable risk factors of CASHD in the age group of 18 years and above 5.

11 Agarwal VK, Basannar DR, Sing RP, Dutt M, Abraham D, Mustafa. M.S , in a study

“Coronary risk factors in a rural community” done among rural population of Maharashtra aged 30yrs & above concluded that awareness of coronary heart disease risk factors was present in 30% population (men 24.6% to 36.9%, women 24% to 36.1%)3.

Schweigman K, Eichner J, Welty T.K, Zphang Y conducted a study “Cardiovascular disease factor awareness in American Indian communities: The strong heart study” in July

1993, among 46 to 80 years age group and concluded that awareness of risk factors of cardiovascular disease range from 70% to 90%. 90% identified obesity, 88% hypertension,

87% smoking, 85% decreased physical activity, 84% high cholesterol, 84% high fat diet,

82% stress/anxiety, 76% diabetes, 70% family history as risk factors for coronary heart disease 6.

Dodani S, Mistry R, Farooqi M, Khwaja A, Qureshi R, Kazmi K in a study “Prevalence and awareness of risk factors and behaviors of coronary heart disease in an urban population of Karachi, the largest city of Pakistan: a community survey” among 18 years and above age group concluded that 12% identified smoking, 9.9% Lack of physical activity, 36.8% high fat diet, 19.2% obesity, 9% family history as risk factors of coronary heart disease. 16%, 15.6% ,

64.6% identified high blood pressure, high cholesterol, stress as risk factors of coronary heart disease correctively and respectively7.

12 ANNEXURE-III

6.3 Objective of the study

 To assess the awareness of risk factors of coronary heart disease among rural

population aged 18 years and above (both male and female) of Bellur PHC coverage

area, Mandya district, Karnataka state.

13 ANNEXURE-IV AND V

7.0 MATERIAL AND METHODS.

7.1 Study area : Bellur PHC coverage area

Study Design : Cross sectional study

Study Period : Jan2012-Dec 2012

Study Subjects : Both male and female above18 years of age.

Inclusion criteria : Both male and female above 18 years of age,

who are willing to participate in the study.

Exclusion criteria : 1.Less than 18 years of age.

2.18 Years and above age group who are not willing to take

part in study.

3. Psychiatric patients

4. Pregnant women.

Sources of data : Primary data will be collected from respondents (study

Subjects)

Institutional Ethical committee approval and oral consent from study subjects will be taken.

14 7.2 Methods of collection of data

1. Personal interview with pretested questionnaire for assessment of socio-demographic

features and awareness assessment of coronary heart disease risk factors -----.>

(ANNEXURE-A)

Socio-economic status:

Modified BG Prasad’s classification (Rural) is applied for assessing socio-economic status of study subjects10.

Modified B.G.Prasad classification (2009)

Family income/month (in Rs.) Grades of Socio-economic status 3653 and above Grade I 3652-1826 Grade II 1825-1096. Grade III 1095-548. Grade IV <547. Grade V

SAMPLE SIZE ESTIMATION.

. The following formula is used for sample size estimation.

15 n = 4pq/ L² Where n = sample size P = prevalence of CHD risk factor awareness based on Previous studies q= (100-p) L = allowable error (10% of p)

STEP 1: Based on previous study7 about CHD risk factors awareness,

Lower prevalence is taken up (to have maximum sample size)

P = 10.0% , q is (100 – 10) and allowable error 10% of p.

The expected sample size is

n = 4pq/L² p = 10.00 q= 100 - 10.00 = 90.00 L = 10% of p = 1.00

n = 4x10.00x90 1x1

= 3600

STEP 2: To compensate for sample attrition, 5% (5% of 3600) is added to the

Calculated sample size to get final sample size

n = 3600 + 5% of 3600 = 3600+180 =3780

SAMPLING PROCEDURE

16 Cluster sampling technique will be used in the present study.

Estimated sample size is 3780.

 There are 32 villages coming under Bellur PHC coverage area of having total

population of 25,677.

Step1: All the clusters (villages coming under the BELLUR PHC coverage area) will be

listed with their population size (upto 1000, 1000-2000, >2000)

Step 2: Then statistically (randomly) required number of clusters (villages) will be selected

from the listed clusters giving weightage to population size of clusters.

Step 3: From the statistically selected clusters all the subjects aged 18 years and above both

male and female will be included in the study after applying inclusion and exclusion criteria.

PROFORMA APPLICATION FOR ETHICS COMMITTEE APPROVAL

SECTION – A a. Title of the study “A STUDY OF AWARENESS OF

17 CORONARY HEART DISEASE (CHD) RISK FACTORS AMONG RURAL ADULT POPULATION (18YRS AND ABOVE) OF BELLUR PHC COVERAGE AREA, MANDYA DISTRICT, KARNATAKA STATE”. b. Principal investigator (Name & Designation) Dr. SHANTHI .M P.G. in COMMUNITY MEDICINE c. Co investigator (Name & Designation) NIL d. Name of Collaborating department/ institutions NIL e. Whether permission has been obtained from the head of the collaborating NA departments/institutions

SECTION B – Summary of the project ANNEXURE – VII SECTION C – Objectives of the study ANNEXURE – III SECTION D – Methodology ANNEXURE – IV & V a. Where the proposed study will be undertaken Rural population under Bellur PHC coverage area. b. Duration of project 12 months c. Nature of subject Does the study involve adult patients? Yes Does the study involve children? No Does the study involve normal volunteers? Yes Doses the study involve Psychiatric patients? No Does the study involve pregnant women? No d. If the study involve healthy volunteered 1. Will they be institute students? No 2. Will they be institute employees? No 3. Will they be paid? No 4. If they are to paid, how much per session? Not applicable

e. Is the study a part of a multicentral trail? No f. If yes, who is the coordinator? Not applicable (Name and designation) has the real been

18 approved by the ethics committees of the other centres? If they study involves the use of drugs, please indicate whether, 1. The drug is marketed in India for the indication in which it will be used in the study. 2. The drug is marketed in India for the indication in which it is proposed to be used. 3. The drug is marketed in India, but not for the indication in which it is proposed to be used. 4. Clearance from the Drugs Controller of India has been obtained for. - Use of drug in healthy volunteers - Use of drug in patients for a necessary indication - Phase one and two clinical trails - Experimental use in patients and healthy volunteers. g. How do you propose to obtain in the drugs to be Not applicable used in the study? - Gift from a drug company - Hospital supplies - Patients will be asked to purchase - Other sources (Explain) h. Funding (if any) for the project None Please state - None - Amount - Source - To whom payable i. Does any agency have a vested interest in the No outcome of the project?

j. Will the data relating to subjects/Controls be Yes stored in a computer? k. Will the data analysis be done by: The researcher

19 - The researcher? - The funding agency? - l. Will technical /nursing help be required from the Not applicable staff of hospital. If yes, will it interfere with their duties? Will you recruit other staff for the duration of the study? If yes, give details of 1. Designation 2. Qualification 3. Number 4. Duration of employment m. Will informed consent be taken? If yes, Yes

Will it be written informed consent No Will it be oral consent? Yes Will it be taken from the subject them selves? Yes Will it form the legal guardian? No If no, give reasons: n. Describe design, methodology and techniques Annexure IV & V (use a separate sheet)

Date: Chairman Ethical Committee Adichunchanagiri Institute of Medical Sciences, B.G.Nagara – 571 448.

ANNEXURE-VI

References

20 1. Park K. Park’s Text Book of Preventive and Social Medicine. 20thed. Jabalpur:

Banarsidas Bhanot publishers; 2009.p.336-53.

2. WHO. Preventing Chronic Diseases vital investment. World Health Organization.

Geneva: 2005.

3. Agarwal VK, Basannar RP, Sing RP, Dutt M, Abraham D, Mustafa MS. Coronary

risk factors in a rural community. Indian J Public Health 2006 Jan-mar;50(1):19-

4. Thankappan K.R, Mini G.K. Surveillance of CVD risk factors and health

promotion instrumentation in a rural community in Trivandrum district. Available

from:http://www.whoindia.org/.../NMH_Resources_CVD_Prevention_tvm.pdf

[Last accessed on 2011 Nov 21].

5. Saeed O, Gupta V, Dhawan N, Streja L, Shin S.J, Melvin Ku etal. Knowledge of

modifiable risk factors of Coronary Atherosclerotic Heart Disease (CASHD)

among a sample in India. BMC international health and human rights 2009;9(2):1-

6. Schweigman K, Eichner J, Welty T.K, Zhang Y. Cardiovascular disease factor

awareness in American Indian communities: The strong heart study .Ethn

Dis.2006; 16:647-52.

7. Dodani S, Mistry R, Farooqi M, Khwaja A, Qureshi R, Kazmi K .Prevalence and

awareness of risk factors and behaviors of coronary heart disease in an urban

population of Karachi, the largest city of Pakistan: a community survey .J public

health 2004;26(3):245-49.

21 8. Suryakantha AH. Community Medicine with Recent Advances.2nd ed. Newdelhi:

Jaypee Brothers Medical Publishers; 2009.p.679-80.

9. WHO. Primary prevention of CHD EURO Rep and studies 98. Copenhagen:

World health organization; 1985.

10. WHO. Diabetes Mellitus Report of a WHO study group. Technical report series

no.727. Geneva: World health organization; 1985.

11. WHO. Hypertension control. Technical report series.no.862.Geneva: World health

organization; 1996.

12. WHO. Primary Prevention of Essential hypertension. Technical report

series.no.686. Geneva: World health organization; 1983.

13. WHO. Prevention of Coronary Heart Disease. Technical report series no.678.

Geneva: World health organization; 1982.

14. WHO. The Global Burden of disease, 2004 update. World Health Organization.

Geneva: 2008.

15. Report of the ICMR –WHO study on assessment of burden of non communicable

diseases, final report. New Delhi: Indian Council of Medical Research; 2004.

ANNEXURE-A

General Information, awareness of risk factors of coronary heart disease.

I. General Information

Name : age…..years sex: M/F

22 Literally status: literate / illiterate Religion: Hindu/Muslim/Christian/Jain/others.

Occupation: Agriculturist / Labour class / Skilled/others

Family Income:……..Rs per month:

II. Assessment of awareness about coronary heart disease risk factors

a. Do you know the cause /risk factors of coronary heart disease? Yes/no

If yes,

b. What are the causes (risk factors) of coronary heart disease?

2 Male sex

3 Family history of heart disease

4 Tobacco smoking

5 High alcohol consumption

6 Hypertension (High blood pressure)

7 Diabetes mellitus

8 Obesity

9 Dyslipidemia/abnormal lipid levels in blood.

10 Sedentary Life style/lack of physical activity

11 Dietary habits,

-increased salt intake

-Increased fat intake

12 Stress & strain

Annexure-VII

Summary of project

23 World is in the stage of epidemiology transition and the non communicable are overtaking the communicable diseases. The phenomenon is not only seen in developed countries but is also evident in the developing countries like India. Among the major non communicable diseases cardiovascular disease (especially coronary heart disease) are recognized as major public health problem by WHO. Mortality and morbidity provide index of health and define the burden of acute illness and chronic disability. But epidemiology provides many other useful and powerful contributions are risk factors measures that predict disease in currently healthy individuals.

The present study will be taken up with the objective of assessing the awareness level of risk factors of coronary heart disease in rural population of Bellur PHC coverage area.

Cluster sampling technique will be used in the present study. The study subjects will be male and female in the age group 18 years and above. General information and coronary heart disease risk factors awareness status will be recorded.

The present study will help in assessing the awareness level of coronary heart disease risk factors among adults (18 years and above) in rural areas.