2nd Professional MBBS

Examination July 2013

Roll No:

Registration No:

Batch:AFMC-

12

Session No:2009-2010

Signature of the guide

1| Page
 BANGLADESH UNIVERSITY OF
PROFESSIONALS
FACULTY OF MEDICINE

This research project Study of Status of

Blood Pressure & Treatment Compliance
among selected rural peoples of Dhamrai
Upazilla, Dhaka is submitted to the Faculty
of Medicine, Bangladesh University of
Professionals in partial fulfillment of the
requirements of the course of
nd
Community Professional MBBS Examination for the
Medicine, 2 session
2009-2010.

Students of AFMC 12

Armed Forces Medical College Roll No:

Dhaka Cantonment

e
r

2.

2| Page
 Acknowledgement

We are grateful to Almighty Allah- the most

merciful for enlighten our spectrum of knowledge
and giving us the opportunity to accomplish this
work with proper strength, skill, resources and
patience.

Our research would never have been possible to

complete without the support and the guidance of our
respected teachers and staffs of Armed Forces
Medical College (AFMC). We would like to thanks
them all.

At first we would like to express our gratitude to

Brigadier General Mohammad Ali, MBBS, DPH, M
Phil, Head of the Department of Community
medicine, Armed Forces Medical College, for his
approval and support to conduct our research. His
fatherly approach and knowledge guided us all the
way to proper research work. It is a privilege for us to
work under such a dedicated teacher. He stood up as a
role model of enthusiasm and inspiration to us.

We would like to thank, Lt Col Maksumul

Hakim,MBBS,and M Phil, Armed Forces Medical
College, for his kind patience and endless
effort for the perfection of this research. He
spent his valuable time and energy for teaching
us about the project. He gave full effort to make
our stay homely for the research work.

It is our pleasure to thank Lt Col Maksumul Hakim,

MBBS, and M Phil for spending his valuable time
on us and guide us the right way. His tireless
dedication to help in every possible way in completing
this research topic is undeniable.

We would like to thank Major Latifa, MBBS, MPH, M

Phil, Assistant Professor, Armed Forces Medical College for
her guidance and encouragement.

The person whose afford and encouragement cannot be

expressed through words is Entomologist Mehedi Hasan
Jewel. He guided us in every step, providing us all endless

3| Page
mental support behind the screen. We would like to
express our gratitude and humble gratefulness and
thanks to him from core of our heart.

We would like to thank all the staffs of the Department

of Community Medicine for their cooperation with the
process and also those who were with us from different
branches.

This research project would not have been possible

without the co-operation of populations of the study
area Dhamrai. They helped us all the way of our
project by providing necessary information, friendly
cooperation, enthusiastic participation and spontaneous
assistance. It is only because of their support and
their warm hospitality that we were able to collect data
accordingly. We also acknowledge the help provided
by Dhamrai Upazilla Health Complex. We hope that
our study would play an important role for their
benefit.

Our acknowledgement would be incomplete

without thanking our classmates, who took
individual responsibilities and went through
lots of hardship to make our research fruitful
showing the best example of a perfect teamwork.
Last but not the least I thank all those who have helped
us directly or indirectly in our research work.

e
 o

4| Page
 Content
Contents

List of tables 6
List of figures 7-8
Abstract 9

Chapter1: Introduction

Introduction 11-15
Justification of the study
Objectives 20
Key variables 21-22
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Chapter 2::Review of Literature 28-31

Chapter 3: Methodology

Chapter4: Results
36-57

Results
Tables & figures
Chapter 5: Discussion

Chapter 6: Conclusion & Recommendations

Conclusion
63
Recommendation

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 LIST OF TABLE

Table Title
1 Distribution of respondents according to age group
2 Distribution of the religion of respondents
3 Distribution of respondents according to their marital
4 Distribution of respondents according to their occupat
5 Distribution of respondents according to their family i
6 Distribution of respondents in relation to type of prote
7 Distribution of respondents according to blood pressur
6| Page
 List of Figures

Figure Title
1 Pie diagram showing distribution of the respondents accordi
2 Bar diagram showing educational status of the respondents
3 Pie diagram showing distribution of respondents in relation
work
4 Pie diagram showing distribution of respondents in relatio
food intake
5 Pie diagram showing distribution of respondents in relation
at least 30 minutes a day
6 Pie diagram showing distribution of respondents according t
habits among male
7 Pie diagram showing user of Contraceptive Pill among
female respondents
8 Pie diagram showing extra salt intake among the respondent
9 Pie diagram showing percentage of known
hypertensive among respondents
10 Pie diagram showing distribution of respondents
according to family history of hypertension
11 Pie diagram showing distribution of hypertention resp
relation to compliance to hypertensive drug
7| Page
 49

2
8| Page
 A
b
s
t
r
a
c
t

Elevated blood pressure often remains

asymptomatic presenting with complications.
Most of the people of our country are not
conscious about hypertension & its treatment,
let alone the rural population. The study was
undertaken to assess the status of blood pressure
& treatment compliance among the adult
population in Dhamrai Upazilla.

We selected two villages of Dhamrai Upazilla namely-

Khatra,Dighol
, a cross sectional type of descriptive study was
conducted from 10
th
November to 14November 2012 among people of
both sexes aged from 20 years & above. Cluster
sampling technique was adopted. A pretested
questionnaire was
used to collect data.
A total of 360 adult people were studied. Among them
39.72% were male & 60.78% were female. Among the
male, 27.77% were smoker & 72.23% were
nonsmoker. Among 360 adult people 323 (89.74)
measured blood pressure before & 37 (10.26)
did not measure. On the basis of blood pressure measurement,
we found
314(87.26%) normal, 12(3.35%) grade-i, 22(6.19%) grade-
ii, & 12(3.20%) grade-iii hypertensive cases. So,
among the total population, the occurrence of
hypertensive was found in 12.74% cases,
while the rest were normotensive. Among the
diagnosed hypertensive 41 (91.30%) take
antihypertensive medication & rest 4(8.70 %)
dont take

The scenario from the above point of view is

that very few people had hypertension but
treatment compliance was poor among them. If the
observed situation as found during survey period
is not changed & modified, it would create
complications among the respondents suffering
from hypertension.

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 C
h
a
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r

Introduction
10 | P a g e
 Blood is the most commonly tested part of the body, and it is truly the river of
life. Every cell
in the body gets its nutrients from blood.
Understanding blood will help us as our doctor
explains the results of our blood tests. In
addition, we will learn amazing things about
this incredible fluid and the cells in it.

Blood is a mixture of two components: cells

and plasma. The heart pumps blood through
the arteries, capillaries and veins to provide
oxygen and nutrients to every cell of the
body. The blood also carries away waste
products.

The adult human body contains approximately 5 liters (5.3 quarts) of blood; it
makes up 7 to
8 percent of a person's body weight.
Approximately 2.75 to 3 liters of blood is
plasma and the rest is the cellular portion.

Plasma is the liquid portion of the blood. Blood

cells like red blood cells float in the plasma.
Also dissolved in plasma are electrolytes,
nutrients and vitamins (absorbed from the
intestines or produced by the body),
hormones, clotting factors, and proteins such
as albumin and
immunoglobulin (antibodies to fight infection). Plasma distributes the
substances it contains
a A sgood
engine chead and aagood
room,responsible
itworks
i rbyulbeating hearth always
fort pumping
te s100000 ro u galife-sustaining
formidable t condition.The
h o umillionth times dheart
e b aoyear is the bodys
yin.total
organ
B lo o dup
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ia a billion
6 0 ,0 0 0beat times
m over a day,40
i leans average
l on g lifen time.
et w o r k of vessels.The
Clocking heart
The cellular portion of blood contains red blood cells (RBCs), white blood
cells (WBCs) and
platelets. The RBCs carry oxygen from the
lungs; the WBCs help to fight infection; and
platelets are one of the constitutional parts of
blood clotting mechanism. All blood cells are
produced in the bone marrow.

What does "Blood Pressure" Mean?

The average hearts beats almost 90,000 times

per day. With each beat, the heart expels
blood into the arteries strong, muscular
tubes that carry blood to all parts of body,
branching into smaller and smaller tubes along
the way. When the heart beats, it generates
force, which is transferred to the blood. As blood leaves the heart, it carries
this force with it
into the arteries. This force pushes on the
walls of the arteries and the arteries push back,
helping to propel the blood forward into the body.
This force also causes pressure within the
arteries, which is called blood pressure. Blood pressure measurements
consist of two
numbers. The systolic pressure is measured
while the heart is contracting, and is the larger
of the two numbers. The diastolic pressure is
measured while the heart is relaxing, and is
smaller
than the systolic pressure. These two pressures are written together,
like this: 120/80, and
11 | P a g e
Chapter 1
pronounced "120 over 80." Both the systolic and
diastolic blood pressure are important determinants of
cardiovascular risk, so both are used in evaluating
overall blood pressure status.

High blood pressure, also called hypertension, is elevated

pressure of the blood in the arteries. Hypertension results
from two major factors, which can be present independently
or together:

The heart pumps blood with excessive force.

The body's smaller blood vessels (known as
the arterioles) narrow, so that blood flow exerts
more pressure against the vessels' walls.
H
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(2)Secondary
Although the body can tolerate increased blood
pressure for months and even years, eventually the
heart may enlarge (a condition called hypertrophy),
which is a major factor in heart failure.
Some studies suggest that in people over 45 years
old, every 10 mm Hg increase in pulse pressure
increases the risk for stroke rises by 11%, cardiovascular
disease by 10%, and overall mortality by 16%. (In
younger adults the risks are even higher.)

Blood pressure (BP) is the pressure exerted by

circulating blood upon the walls of blood vessels, and
is one of the principal vital signs. When used without
further specification, "blood pressure" usually refers to
the arterial pressure of the systemic circulation.
During each heartbeat, BP varies between a maximum
(systolic) and a minimum (diastolic) pressure. The
mean BP, due to pumping by the heart and resistance to
flow in blood vessels, decreases as
the circulating blood moves away from the heart through arteries. The
measurement
blood
pressurewithout further specification usually refers to
the systemic arterial pressure measured at a person's
upper arm. It is measured on the inside of an elbow at
the brachial artery, which is the upper arm's major
blood vessel that carries blood away from the heart. A
person's BP
is usually expressed in terms of the systolic pressure over diastolic
pressure (mmHg), for
example 140/90. Along with body temperature,
respiratory rate, and pulse rate, BP is one of the four
main vital signs routinely monitored by medical
professionals and healthcare providers.

Types of blood pressure:

Depending on the nature of blood vessels-
(
1
)

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12 | P a g e
Chapter 1
Classification of blood pressure in adults:

Categor y Systolic ( mm Hg)

Diastolic (mm Hg)
Optimal <120 <80

Normal 120- <130 80-

<85

High normal 130-139 85-89

Grade 1 Hypertension/ Mild 140159 9099

Grade 2 Hypertension /Moderate 160179 100109

= 180 = 110
Grade 3
Hypertension/
severe
Measurement of
blood pressure:
(1) Direct method
(2)Indirect method-a.Palpatory method. b.Auscultatory method.

For many patients control of blood pressure means

consistent monitoring and modifying of previous behaviors
and lifestyle habits associated with high blood pressure.
Overweight, high cholesterol, tobacco and alcohol use, salt,
heavy diet and low exercise have been found to contribute
to high blood pressure. To control hypertension, patients
must be vigilant regarding these aspects of behavior and
lifestyle for the remainder of their lives.

For many patients lifestyle modification alone will

not reduce blood pressure to normal ranges. These
patients must take medication to regulate their blood
pressure. A number of medications are available, but
patients must continue to take these drugs for the rest of
their lives or face the consequences of untreated high
blood pressure. As with any long term disease
process, patient compliance is essential for long term
positive outcomes.

However, high blood pressure is called the silent

killer, because nearly one-third of those people with
hypertension don't know they have it. Many adults
develop high blood pressure after the age of 50.
Uncontrolled high blood pressure can lead to stroke,
heart attack or kidney failure. It is a major risk factor for
coronary heart disease, stroke, diabetes mellitus and renal
disease. Hypertension refers to arterial pressure being
abnormally high, as opposed to hypotension, when it
is abnormally low. Blood pressure that is too low is
known

13 | P a g e
Chapter 1
as hypotension. Hypotension is a medical concern only if
it causes signs or symptoms, such as dizziness, fainting, or
in extreme cases, shock.

Many epidemiological hypertension studies have been

conducted to identify the risk factors for hypertension
in various populations around the world. However,
because each population has its unique genetic
makeup, lifestyle and dietary habits, the risk factors for
hypertension may be different from population to
population, and therefore each population must
conduct studies to assess their specific risk factors.
Traditionally, hypertension studies involve clinical
measurements of subjects blood pressures, with their
associated costs.

High blood pressure, termed "hypertension," is a condition

that affects almost 1 billion people worldwide and is a
leading cause of morbidity and mortality. More than
20% of Americans are hypertensive, and one-third of
these Americans are not even aware they are
hypertensive. Therefore, this disease is sometimes
called the "silent killer." This disease is usually
asymptomatic until the damaging effects of hypertension
(such as stroke, myocardial infarction, renal dysfunction,
visual problems, etc.) are observed. Hypertension is a major
risk factor for coronary artery disease and "heart
attacks," which may require coronary artery bypass
surgery.
Hypertension is a major cardiovascular risk factor with a
global prevalence of 26.4% in 2000, projected to increase
to 29.2% by 2025, and is the leading contributor to
global mortality. The data of the previous studies suggest
the existence of more undiscovered blood pressure related
common variants. Cross-sectional studies of the general
population have required extremely large sample sizes to
detect such small effect sizes.

In Bangladesh most of the people live in villages and

most of them are of low socio economic condition.
They are busy to earn their bread and butter and are not
aware of health. Health
care facilities are not also easily accessible to them. There
ar e many remote villages, where the health care services
do not reach. So the health status of the people of these
areas is almost unknown. In case of any emergency
condition such as stroke or heart failure they do
not get service near to hand, which lead to death in most of the cases. So, an
elevated blood
pressure may be the cause of high mortality among
them. The current topic of study may contribute to lend
a hand in gathering the knowledge and information
about the blood pressure status of the elderly people in
rural areas of Bangladesh and also the treatment status
of the hypertensive people. Hence the study is justifiable
and need based.

14 | P a g e
Chapter 1
There are two reasons for studying the blood pressure
measurements along with related test results in rural
community. First, it gives a rough idea of the health
scenario of general population of a country. And this
information helps to allocate resources between projects
and other measures which are designed to improve
health. Health impact data inform the discussion on
the external efficiency of investments of budget on
the chronic non- communicable diseases. Second,
knowledge of this study assists with designing projects
so that they optimize their impact on health at a
given cause which reflects the internal efficiency.
Findings from this study may help to inform needs
for public health interventions/recommendations, to
identify potential risk factors and guide prevention
strategies, and to set a baseline for monitoring the
changing pattern of disease in an area that is hopefully
experiencing a socioeconomic transition associated with
poverty alleviation.
15 | P a g e
Chapter 1
Justification of the study

According to recent estimates, nearly one in three U.S.

adults has high blood pressure (hypertension). High
blood pressure killed 49,707 Americans in 2002. It was
listed as a primary or contributing cause of death in
about 261,000 U.S. deaths in 2002. High blood pressure
was listed as a primary or contributing cause of death
for 326,000 Americans in 2006.Although its underlying
causes are mostly unknown, high blood pressure is
easily detected. However, once diagnosed, it cannot be
cured; it can only be controlled.

All societies are confronted with the problem of

defining a strategy to control high blood pressure. Large,
prospective epidemiologic studies unequivocally show a
strong, direct relation between high blood pressure and
mortality due to cardiovascular disease (CVD). Although
the relative contribution of CVD deaths to total mortality in
developing countries is smaller than that in developed
countries, developing countries, because of their large
populations, contribute nearly twice as much as do
developed countries to the global CVD burden. Because
hypertension is the most common cardiovascular condition in
the world, its prevention and treatment are important public
health issues.

By the year 2020, non-communicable diseases such as

cardiovascular diseases (CVD) will be the major causes
of morbidity and mortality in developing countries,
accounting for almost four times as many deaths as
from communicable diseases. This shift potentially
coincides with socio-economic changes and the =nutrition
transition associated with poverty alleviation. Further,
risk factors for HTN, such as dietary habits, are not
clearly defined in these populations. This is especially
important because of the global effort to improve the
socio- economic status of this region and associated
changes, which could potentially have both beneficial
and adverse consequences.

16 | P a g e
Chapter 1
Countless epidemiological surveys have shown that
there are striking inter individual and inter population
differences in blood pressure. In mostbut not all
populations, blood pressure generally rises (more or less)
with age from youth into older age. The exceptions are
isolated preliterate groups in remote locations, where
average systolic and diastolic blood pressures are
optimal at all adult ages, manifesting little or no upward
slope with ageand where lifestyles differ markedly
compared to those of other populations worldwide.
Data
from migration studiesfor example, the Luo Migrant
Study in Kenya and the Ye Migrant Study in China
strongly indicate that changes in lifestyle and nutrition
explain increases in blood pressure and vascular disease
following migration and adoption of diets broadly
similar to those of host populations. Furthermore, an inverse
relation between socioeconomic status (SES) and blood
pressure has also been recorded repeatedly in many
population studies of specific ethnic groups.

Although Bangladesh was classified as being in the earliest

stage of this transition, a recent review of prevalence
surveys conducted in Bangladesh indicated that the
prevalence of hypertension has increased from 3% to 9%
since 1976. Parallel to this increase, the
prevalence of chronic energy deficiency [body 2 ) 18.5 on the basis of

mass index (BMI; in kg/m

international criteria] in adults decreased by 14% from
1981 to 1996. Nutritional epidemiology in Bangladesh
and other low income countries with widely varying
dietary practices faces the challenge of identifying
prudent, affordable, and culturally acceptable diets.
Recently, dietary pattern analysis has emerged as an
alternative approach to studies of diet and chronic
diseases. Instead of evaluating the influences of
individual nutrients or foods, pattern analysis examines
the effects of the overall diet. Major dietary patterns have
been related to CVD risk in studies conducted in
Western countries. Recent intervention trials such as
the Dietary Approaches to Stop Hypertension
(DASH) trial in the United States found short-term
beneficial effects of the DASH diet (fruit, vegetables,
low-fat dairy products, and reduced fat) on blood
pressure in hypertensive and borderline hypertensive
patients. However, no large epidemiologic studies have
systematically evaluated associations of dietary factors
or patterns with blood pressure in a low-income
population. The nutritional determinants of
hypertension in Bangladesh and other low-income
countries are largely unknown.

Hypertension is now regarded as a disease of modern

civilization. According to WHO it is one of the most
important preventable causes of premature morbidity and
mortality in developed and developing countries. Bangladesh
is a developing country; it is one of the commonest
cardiovascular disorders, posing a major public health
challenge to population socio-economic and epidemiological
transition.

Chap
ter 1
The public-private initiatives have been taken in the health
sector since independence of Bangladesh is treated
positive, but the health services didnt reach to the
most of the peoples yet. The epidemiological studies in
Bangladesh are largely confined to the primary health care
facilities, basic
sanitation, maternal and child health. But recent health
scenario shows increasing occurrence of cardiovascular
diseases, diabetes mellitus, and renal diseases among
affluent populations of the country as well as in rural
community. High blood pressure imposes potential threat on
occurrence of these diseases by 80%. So, high blood pressure
(hypertension) has become a major concern in recent years.

Nearly one- third on the people generally are not aware of

having hypertension which makes it an Iceberg disease and
makes it more difficult to address the whole scenario of the
country. It follows the rules of halves:

1
3

5 7
2
4 6 8

50% of the
hypertensive patients

are aware of

hypertension. 50% of

aware patients are

treated.

50% of treated patients are adequately treated.

The epidemiological studies and surveys on blood pressure

can be beneficial in understanding the risk factors that are
involved in progressive rise of blood pressure in our
country. Also the study can help in uncovering a portion of
in apparent, submerged populations at risk of developing
hypertension and its sequels.

18 | P a g e
Chapter 1
As the nutritional determinants of hypertension in
Bangladesh and other low-income countries are largely
unknown, blood pressure survey can address the
determinants which are directly or indirectly imposing
threat on mass health.

Hypertension is a non-curable disease. Due to its

chronicity, the duration of treatment is prolonged and
requires life-style modification. This study would help
to understand the peoples knowledge about this disease,
awareness and treatment compliance in our country.

An elevated blood pressure or hypertension is now

regarded as a disease of modern civilization.
According to WHO it is one of the most important
preventable causes of premature morbidity and mortality
in developed and developing country. As Bangladesh is a
developing country; it is one of the commonest
cardiovascular disorders, posing a major public health
challenge to population socio economic and
epidemiological transition.

The complications due to hypertension are highly fatal such as

stroke, left ventricular failure, congestive cardiac failure, aortic
dissection etc. It also causes nephropathy, retinopathy and
peripheral vascular disease. The higher the pressure, the
greater the risk and lower the expectation of life. So, in
case of most of the undiagnosed case people are aware of
hypertension after reaching to the door of death. But
hypertension is a preventable disease.
It has its own risk factors and most of them are
modifiable. Modification of life style such as weight
reduction, physical activity, reducing salt intake, intake of
dietary fiber etc. are effective in preventing and also
controlling blood pressure. But the key reason for
poor blood pressure control in people with treated
hypertension is the use of mono therapy that is only
the antihypertensive drugs.

In Bangladesh most of the people live in villages

and most of them are of low socio economic
condition. They are busy to earn their bread and
butter and are not aware of health. Health care
facilities are not also easily accessible to them. There
are many r emote villages, where the health care
services do not reach. So the health status of the people
of these areas is almost unknown. In case of any
emergency condition such as stroke or heart failure they
do not get service near to hand, which lead to death in
most of the cases. So, an elevated blood pressure may be
the cause of high mortality among them. The current topic
of study may contribute to lend a hand in gathering the
knowledge and information about the blood pressure
status of the elderly people in rural areas of
Bangladesh and also the treatment status of the
hypertensive people. Hence the study is justifiable and
need based.

19 | P a g e
Chapter 1
Objectives

General objectives:

T
o

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b
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.

Specific objectives:

To identify the prevalence and cause of primary and secondary

hypertension in different age group.
To evaluate the prevention and treatment of hypertension.
To evaluate the awareness ofhypertension.

20 | P a g e
Chapter 1
Key Variables

Socio-economic variables:

A
g
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a
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d

s
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x

R
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T
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o
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f
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 Number of family members

Variables related to diet & food habit:

D
a
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y

d
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t
a
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y

f
a
t

D
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S
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P
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O
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21 | P a g e
Chapter 1
Variables related to blood pressure status:

M
e
a
s
u
r
e
m
e
n
t

o
f

b
l
o
o
d

p
r
e
s
s
u
r
e
M
e
d
i
c
a
t
i
o
n
Co
mpl
icat
ion
rela
ted
to
hyp
erte
nsio
n
Fa
mili
al
hyp
erte
nsio
n
Other diseases
 | Page
22
Chapter 1
O
p
e
r
a
t
i
o
n
a
l
D
e
f
i
n
i
t
i
o
n
s
 Blood pressure:

Blood pressure may be defined as a lateral

pressure exerted by the flowing blood on
the wall of the arteries.It decreases as the blood moves through
the arteries,the capillaries and the vein .

Hypertension:

Persistent systolic blood pressure more than 139

mmHg and diastolic blood pressure more than 89
mmHg in average two readings on different dates
using the left arm with the subject in sitting position.

Normotensive:

A person is said to be normotensive when his systolic

blood pressure is below 140 mmHg and the diastolic
pressure is below 90 mmHg.

Cerebrovascular accident (CVA):

The sudden death of some brain cells due to lack of
oxygen when the blood flow to the brain
is impaired by blockage or rupture of an artery to the
brain. A CVA is also referred to as a stroke.

| P a g e
23
Chapter 1
 Myocardial infarction:

It is a condition when the heart can no longer pump

blood adequately to supply the brain and other organs of
the body due to sudden blockage of the coronary arter y
leading to ischemic necrosis of heart. Almost all heart
attacks occur in people who have coronary artery disease
(coronary atherosclerosis).

Smoker:

Smokers ar e those persons who smoke cigarettes,

cigar, biri, hukkah or pipe regularly for at least one
year and usually more than once a day on an average.

Non- smoker:

Those persons who have never smoked cigarettes, biri, cigar, hukkah or pipe.

Physical exercise:
It refers to physical movements in addition to the
normal day to day routine activities so as to burn the
extra energy or calorie intake and hence preventing
the unnecessary accumulation of fat in the body.

| Page
24
Chapter 1
 Sedentary job:

It implies the desk job without any physical labor and

is performed by the staff in their day to day activities
in the office.

Extra salt intake:

It refers to the intake of salt other than that used in the

food during cooking accounting to a total of 7-8
gm/day.
 | Page
25
Chapter 1
Limitations of the study

In spite of our best efforts, there were many limitations in our study which are as
follows:

As the information regarding blood pressure status

and treatment compliance collected from a selected
rural area of Dhamrai Upazilla, the result does not
represent the real picture of the hypertensive
populations and also their treatment compliance of
Bangladesh throughout. So, universal acceptable
conclusion cannot be depicted.

The study was conducted in a very short period of

time. The time allocated for data collection was not
sufficient enough due to tight study schedule.

Money allocated for the study was not sufficient enough for such kind of
study.

During the period of data collection, some

respondents were unable to understand the questions
due to socio-cultural barrier. Most of time they
interpreted their savings. In those cases, monthly
family income has been estimated from monthly or
daily expenditure and monthly savings.

Many respondents failed to give the exact figure of their monthly family
income.

We collected the data from 9:00 am to 2:00 pm.

During that time male members of the family were
outside of their houses for working purposes. For
 this reason we faced difficulties to find the male
respondents.

Confounding factors may not be equally

distributed between the groups being compared
and this unequal distribution may lead to bias and
subsequent misinterpretation.

Regarding the dietary survey, it may measure

current diet in a group of people with a disease.
This current diet may be altered by the presence of
disease. So it is hard to find out if the previous
dietary habit responsible for the disease process.

Many other variables contributing to high blood

pressure were not included in the study due to
limited time and inadequate resources.

Diurnal variations of blood pressure of the

respondents could not be measured due to obvious
reasons.

| Page
26
Chapter 1
Maximum number of respondents belongs to almost similar socio-economic
group of people.

Investigations related to blood pressure level could not be done for resource
constraints.

At the beginning as the study area was selected

purposively, the result may suffer from selection bias.

The allocated time for study was not enough to carry on comprehensively.
27 | P a g e
Chapter 1
 C
h
a
p
t
e
r

2
Review of literature
28 | P a g e
Coronary heart disease (CHD) is estimated to be the
most common cause of death globally by 2020 and
hypertension is one of the most important modifiable
risk factors for CHD and in Western and Asian
population. Studies from India and Bangladesh
have shown an increasing in the prevalence of
hypertension. So all societies are confronted with the
problem of defining a strategy to control high blood
pressure. There is an increasing emphasis in the
major general and specialized scientific journals on the burden of
cardiovascular disease in
terms of mortality and morbidity and of hypertension is a
leading risk factor in low income countries like ours. The
instruments and strategies prepared to deal with this
problem however derived mostly from experimental and
observational studies. Observational studies
in low income countries aiming to assure not only the
causal side of the risk but the critical question of
transferability of measures recommended to identify
patients at risk and to influence their clinical outcomes.
Different literatures such as books, journals and
magazines were reviewed in order to gain through
knowledge on the status of the blood pressure and
treatment compliance among rural people. Some
contributory studies have been found in our country as
well as in international sphere. A few have been
reviewed having special significance with our present
study.
Hypertension & Cardiovascular Risk:

| Page
29
Chapter 2
Most population based studies confirm that hypertension
increases on individual's risk of various cardiovascular
consequences approximately two to three times. Large
population based cohort studies consistently show
continuous, strong, graded relation between blood pressure
and cardio-vascular system but no clear threshold value
separates hypertensive patients who will experience future
cardiovascular events from those who will not multiple
high quality long term cohort studies and randomized
clinical trials have shown that the risk
from raised blood pressure can be partially reversed. Hypertension is
implicated in 35% of all
atherosclerotic cardiovascular events including 49% of all cases of heart
failure.

As hypertension is only one of the many risk factors for

CVS, a patients progress depends more on the sum of
their risk factor than on their pressure. Numerous factors
definitely CVS
risk including age, male sex, family raised cholesterol,
smoking, diabetes mellitus, obesity, sedentary life style
and left ventricular hypertrophy guidelines for the
management of the both the hypertension and
cardiovascular disease generally now recommended the use
of simplified version of several risk prediction model such
as- Framingham, disease life expectancy model, coronary
risk disk, PROCAM risk function, British regional heart
study function.

Cholesterol:
A strong graded r elation raised serum cholesterol
and coronary artery in run total values above
220mg/dL. The protective effect of high density
lipoprotein cholesterol runs to be at least as strong as
the effect of the low density fraction particularly in
woman.

Smoking:

The risk of cardiovascular disease in smokers is

proportional to the number of cigarette smoked & how
deeply the smoker inhales, and it is approximately greater
for woman than man. The risks of pipes & cigar
smokers sum to fall between those of non-smokers and
cigarette smokers relative risk 1.3, 95% confidence interval
1.1 to 1.5 for heart disease, with a dose response relation.

Diabetes Mellitus:

| Page
30
Chapter 2
It is one of the strongest modifiable risk factors for
cardiovascular disease and its effect in woman is
relatively greater than in man for all cardiovascular events
except congestive heart failure. Diabetes often co-exist
with obesity, hypertension and (syndrome x); these
patients are particularly predisposed to atherosclerotic
diseases.

Sedentary life style:

A high quality cohort study in middle aged man followed

for 16 years showed that physical fitness is graded and
independent predictor of cardiovascular mortality; after
adjustment for baseline risk factors, the relative risks were
0.41(0.20-0.84) in the fittest group, 0.45 (0.22 to 0.92) in
the second fittest group; and 0.59 (0.28 to 1.22) in next
fourth compared with the group with the lowest fitness
ranges.

Left Ventricular hypertrophy:

Left Ventricular hypertrophy is a common effect of

hypertension and a strong independent predictor of future
cardiovascular events. Left Ventricular hypertrophy with
repolarization changes on the electrocardiogram carries a
higher risk than hypertrophy diagnosed solely on voltage
criteria.
31 |
Chapt
er 2
 C
h
a
p
t
e
r

Materials & Methods

32 | P a g e
Type of study:

It was descriptive type of cross sectional study.

Sites of study:

The study was done in the

following villages, named-
Khatra ,Dighol - of Dhamrai
Upazilla of Dhaka district.

Duration of study:

The study was conducted for a period of 4 days starting

from 10th November to 14th November, 2012.

Study population:

The study population was adult household members of the above mentioned
villages.

Selection criteria of study population:

Inclusion criteria:

The study population was

permanent resident of
Dhamrai Upazilla.
 Those who will be
present during the time
of data collection.

Those who will take part in interview willfully.

| Page
33
Chapter 3
 Exclusion criteria:

Travelers or temporary resident of Dhamrai

Upazilla.

Individuals within unsound mental

state/psychologically abnormal.

Individuals who disagreed to provide

necessaryinformation.

Sample size:

The sample size was 360 persons of above mentioned villages.

Sampling technique:

Purposive sampling was followed for this study.

Data collection tools/instruments:

Data was collected on a semi-structured questionnaire

Methods of data collection:

Before data collection, the purpose of the study was explained to each
respondent.
 .Data was collected for 3 consecutive days from 9:00 am to 1:30
pm. At first day the data was collected from
Khatra, next day from Dhigol and on third
Data was collected through face to face
interview based on semi
structured questionnaire.

Chap
ter 3
34 |
Procedures of blood pressure measurement:

The person should sit for several

minutes in a quiet room. He should not
engage in physical activity, tobacco
taking or eaten within 30 minutes.

The arm should be supported and at level

with the heart.

The cuff should be placed on bare arm,

about 2cm above from the elbow crease
and the cuff should cover the two- third
the circumference of the elbow.

The bell of the stethoscope should be

placed over the brachial artery, using
sufficient pressure to provide good sound
transmission without over compressing the
artery.

Once pulse obliteration pressure is

determined, initiate the auscultatory blood
pressure measurement by rapidly inflating
the cuff to a level of 20 to 30 mmHg above
the pulse obliteration pressure. Then deflate
the cuff at a rate of 2 mmHg per second
while listening to the korotkoff sound.

Phase 1 (first tapering sound) and phase

2 (disappearance) is used to determine
korotkoff sound to identify systolic and
diastolic blood pressure values respectively.

Obtain minimum of two blood pressure

 measurements at intervals at least 1 minute.
Then the average blood pressure is measured.

Data processing and analysis:

Data was checked daily after collection for

missing values and inconsistency and was
corrected and then a master sheet was prepared
from collected and corrected data in Microsoft
Office application. Data was analyzed by a calculator.
Results were presented on the tables and figures.

| Page
35
Chapter 3
Chapter 4
Result
36 | P a g e
 Table 1: Distribution of
respondents according
to age group

Age Frequency Percenta

range(yrs) (%)
20-29 62 17.33
30-39 84 23.18
40-49 106 29.45
50-59 51 14.14
60-69 36 9.89
70-79 13 3.70
80-89 8 2.31
Total 360 100

Most of the respondents were between the age group

40-49 years least respondents belonged to 80-89 age
group.
34 | P a g e
Pie Chart
1:
Distri
butio
n of
the
respo
ndent
s by
sex
Pie chart showing distribution of respondents by
sex. Most of the respondents were female 60.78%.
35 | P a g e
 Religion Frequency
Percentage (%)
Islam 348 96.74
Hindu 12 3.26
Others 0 0
Total 360 100

Most of the respondents were Muslim whereas rests were

Hindus. No other religion was found.
36 |P a g e
BAR DIAGRAM 1:EDUCATIONAL
STATUS OF THE RESPONDENTS
37 /P a g e
Most of the respondents 321 (89.13%) were married.
38| P a g e
Most of the respondents (47.11%) do household work.
39 | P a g e
PIE CHART 2:DISTRIBUTION OF
RESPONDENTS IN RELATION PHYSICAL
LABOUR

Pie chart showing that most (81%) of the respondents do

physical work.

40| P a g e
TABLE 5: DISTRIBUTION OF
RESPONDENTS ACCORDING TO THEIR
FAMILY INCOME

Family income of most of the respondents belongs to

5000-10000 TK group.
41 |P a g e
 PIE CHART 3:DISTRIBUTION OF
RESPONDENTS IN RELATION TO FATTY
FOOD INTAKE

Pie chart showing that most of the respondents (78.33) do

not take fatty food in their diet.
42 |P a g e
46 | P a g e
Chapter 4
TABLE6:DISTRIBUTION OF
RESPONDENTS IN RELATION TO TYPE
PROTEIN INTAKE

Most of the respondents (63.66%) take fish as their

protein.
43 | P a g e
PIE CHART 4: DISTRIBUTION OF
RESPONDENTS IN RELATION TO WALKING
AT
LEAST 30 MINS A DAY
Pie chart shows that 67.78% respondents walk at least 30
minutes a day.

44 | P a g e
PIE CHART 5:DISTRIBUTION
RESPONDENTS ACCORDING TO
SMOKING
HABITS AMONG MALE
Pie chart shows that most of the male respondents (72.23%) do
not smoke.
45 |P a g e
 PIE CHART 6: PIE CHART SHOWING
USES OF CONTRACEPTIVE PILL
AMONG FEMALE
RESPONDENTS

29.93% of female respondents use contraceptive pill whereas

other do not
46 |P a g e
 PIE CHART 7:PIE DIAGRAM
SHOWING EXTRA SALT
INTAKE
AMONG THE RESPONDENTS

.
Pie chart shows that most of the respondents
(91.54%) take extra salt in their food

47| P a g e
PIE CHART 8:PIE CHART SHOWING
PERCENTAGE OF KNOWN HYPERTENSIVE
AMONG RESPONDENTS
Among the respondents 89.74% were hypertensive
whereas rest were normotensive

48| P a g e
PIE CHART 9:DISTRIBUTION OF
RESPONDENTS ACCORDING TO OF
FAMILY HISTRY OF
HYPERTENSION
60.59% of the respondents had a history of hypertension in their
family and 39.49% did not

4|9 P a g e
TABLE 7:DISTRIBUTION OF RESPONDENTS
ACCORDING TO BLOOD PRESSURE
STATUS
87.26% of the respondents were normotensive and 3.20%
had grade 3 (severe) hypertension

50|P a g e
 | Page
55
Chapter 4
 | Page
56
Chapter 4
PIE CHART10:DISTRIBUTION OF
HYPERTENTION RESPONDENTS IN
RELATION TO
IN RELATION COMPLIANCE
HYPERTENSIVE DRUG
Approximately 91.30% hypertensive respondents took anti-
hypertensive medication regularly

51 | P a g e
 C
h
a
p
t
e
r

Discussion
58 | P a g e
The study entitled 'status of blood pressure and
treatment compliance among adult population in
DHAMRAI Upazilla' was a descriptive cross sectional
study. The study was carried out from 14 November to
20 November 2012. The objective of this study was to
assess the blood pressure status and socio-demographic
characteristics of the respondents. A total
of 360 respondents were included in this study aged 20 years or above.
Information about
socio demographic characteristics, life style, risk
factors were collected, compiled and analyzed.

There was a distinct pattern in the distribution of the

respondents in the age categories. The distribution of
the respondents was found to be diffuse among all the
age groups above 20 years. The percentage of the
respondents in age group 20-29 was found to be
17.33%, in 30- 39 age group it was found to be
23.18%, in age group 40-49 it was 29.45% and
above 50 years of age the respondents were around
30.04%.It has been reported that increase in blood
pressure occurs progressively throughout the age and
that about two third of the elderly can
9
be defined as hypertensive with stage 2 hypertension.
 There is an evidence of variability in blood pressure according to the sex. In
our study among
the respondents 60.78% were female and only 39.72%
males. But this picture of reference is quite contradictory to
the overall sex ratio of the country which is
0.9males/female. The reason for
this discrepancy is that the study was conducted in time (from l0:00 am
to 2:00pm) which

59 | Cha
pter
5
suggests that most of the male person had been
working outdoor at that time and which is the reason
for having less male respondent.

Education status is one of the main statuses with wide range

of factors depending on it which include the life style,
habits, the beliefs and economic conditions. According to
our study, 46.26% of total respondents received institutional
education. This literacy rate is very close to the
national adult (15+) 12 The relation of the hypertension according to our
rate (47.5). study was
very discrete.

Our study included Muslim respondent mostly. That

means 96.74% respondents were Muslim. This doesn't
the true picture of the population distribution based on
religion at the local and national level. The national
religion-wise distribution of population of Bangladesh
showed89.3s%Muslim &9.64%Hindus. 13

Monthly family income of the respondents was

recorded and they were categorized in different
income groups. It was reflected that, out of all the
respondents the highest number 259 were in the
income group of Tk.5000-10000. Followed by 81 in
the income group
<Tk.5000. A similar study conducted in April, 2007 at Sreepur, Gazipur
district estimated that
14 which is close to our study finding.
the mean income of the respondents
was TK 5857.52.

Respondents in our study were almost same socio

economic status compared to the study of Rahman
KMM conducted in the rural areas of Naogaong.

15

Other than physical labor questions were also asked regarding

regular walking for at least 30 minutes which we took as a
form of exercise due to lack of facilities like a heal club in
rural areas. We found out that 67.78% of the respondents did
walk for 30 minutes and 32.23% did not.

| Page
60
Chapter 5
In our study 27.77% of the male
respondents were smoker and 72.23%
were non-smokers. The risk of CVD in
smokers is proportional to the number of
cigarettes smoked smoked per day and
how deeply the smokers inhales. This was in with a research by Ernest E et al.
16

In a similar study carried out in

Dhaka cantonment around 10 years
back, only little as l0% had previously
measured their BP. This reflects an
increase in awar eness and
cautiousness
Even in rural areas.So we have found that 89.74% are known hypertensive among the
respondents and 91.20% respondents take antihypertensive drug.

Hypertension has been again linked

to the intake of food rich in fats and
oils which contribute to the rise of
serum cholesterol level. In our
study, the respondents were asked
about the consumption of their food.
It was found that a good 78.33% of
the respondent did not take fatty
food much whereas only 21.67% took fatty food regularly. Amongst the
regular fatty food
consumers most of them were
hypertensive. Several others
statistical units like BMI and blood
cholesterol level are used to identify
dietary pattern in the society but due
to lack of logistics and equipment
we could not do it.

61 | P a g e
 Chapter 5

C
h
a
p
t
e
r
 6
Conclusion & Recommendation

62 | P a g e
According to the survey findings it could be stated that knowledge about blood
pressure and
the low level of compliance to anti-hypertensive medication
found in this study, which is consistent with findings in other
countries, emphasizes the need for population-wide primary
prevention of elevated BP and cardiovascular disease. Such
measures include educational, legislative, and fiscal actions to
encourage the adoption of a healthy diet (particularly lower
salt intake) and to increase facilities and opportunities for physical
activity in leisure. It has
been estimated in the Asia- Pacific region, for example,
that reducing the population systolic BP by as little as
3% would prevent 15% of all stroke deaths and 6% of all
coronary deaths.

Nonetheless, anti-hypertensive medication is among

the most cost-effective high-risk interventions for non-
communicable diseases. Detection and treatment of
hypertension must therefore be considered in both
industrialized and developing countries, particularly
for patients with other risk factors. Less than optimal
compliance in many hypertensive patients, such as found
in this study, stresses the need to improve adherence
to medication. Poor adherence to therapy is largely
unrecognized in clinical practice and monitoring
compliance could be a useful way of detecting poor
adherence to medication as the cause of poor BP
control, particularly in patients with high overall
cardiovascular disease risk. These issues may be
particularly critical in developing countries where anti-
hypertensive treatment can drain health care resources.

More gener ally, the influence of knowledge, attitudes,

and practices among patients and health professionals
(e.g. how chronic disease is perceived and treated, and
the role of traditional medicine) on compliance to
medication should be examined and relevant measures
should be taken accordingly.

Patients non-adherence to therapy is increased by

misunderstanding of the condition or treatment, denial
of illness because of lack of symptoms or perception of
drugs as symbols of ill health, lack of patient
involvement in the care plan, or unexpected adverse
effects of medications. The patient should be made to
feel comfortable in telling the clinician all concerns
and fears of unexpected or disturbing drug reactions. The
cost of medications and
the complexity of care (i.e., transportation, patient difficulty
with poly-pharmacy, difficulty in scheduling appointments,
and lifes competing demands) are additional barriers that must
be overcome to the problem of hypertention.

63 | P a g e

Chapter 6
 Recommendations

Blood pressure control is of prime importance in treatment of

hypertension. So that following measure Should be taken:

Large scale community based study regarding

blood pressure status should be carried out.

Health education should be given by health

workers regarding the self-maintenance and
monitoring of blood pressure.

Health education and mass awareness should be

arranged to raise awareness among people
regarding hypertension and its consequences
through mass media.

Governent should contribute

by providing logistic and

financial support. Life style

should be changed by

following activities.
Life style changes:

1. Weight

reduction

and regular

exercise

(like,

jogging)

2Reducing

Sugar in

diet.

3Reducing sodium (salt) in the diet decreases blood pressure in

about 60% of people

4. Increasing daily calcium intake has been shown to be highly

effective in reducing blood pressure. 5Tobacco smoking should

be avoided.

6. Alcohol consumption should be avoided.

64 | P a g e
Chapter 6
7. Should practice of eating vegetables & low fat diet.

8. Relaxation therapy should be taken to reduce environmental stress, like from

meditation,
reducing high sound levels and over-illumination.
Muscle Relaxation
paced breathing.

Life Style changes canreduce the blood pressure to a safe level, But
Drug Therapy can still not be avoided
 | Page
65
Chapter 6
References:

1. Park K. Textbook of Preventive th

edition 2010.
and Social Medicine, 20

2. Rashid KM, Rahman M & Hyder S. Textbook of Community Medicine and

Public Health, 5
th

edition 2010.

3. The Seventh Report of the Joint National

Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure.

4. Nutritional influence on risk of high blood pressure in

Bangladesh: a population-based cross- sectional study by
Yu Chen, Pam Factor-Litvak, Geoffrey R Howe,
Faruque Parvez, and Habibul Ahsan.

5. Journal of Human Hypertension (2010): Prevalence

and correlates of hypertension: a cross- sectional
study among rural populations.

6. www.nationmaster.com
 7. www.MedicineNet.com

8. www.wikipedia.org

9. Amery, A. 1985.Mortality & morbidity results from

the European working Party on High Blood Pressure
in the elderly. Lancet,1:1349-54

66 | P a g e
10. Gupta R-Meta analysis of prevalence of hypertension in Indian Heart
J:1997;490-500

11. BMC Public Health, Research article: Hypertension in

Parsi community of Bambay: A study on prevalence,
awareness and compliance to treatment.

12. Census-2001,BANBEIS

13. Bangladesh Bureau of Statistics. Key indicators

of report on Sample Vital Registration System.
[cited on April 2, 2010]

14. Ahmed S. et al. Geriatric Health Problems in Rural Community of

Bangladesh. Ibrahim Med.
Coll. J.2007;1(2):17-20

15. Rahman KMM, Tareque MI, Rahman MM. Gender

Difference in Economic Support , Well- being and
satisfaction of the Rural Elderly in Naogaon District,
Bangladesh. Journal of Indian Academy of
geriatrics.2008;4:98-105

16. Ernes E, Resch KL; smoking as a CVD risk factor a meta-analysis and
review of literature A
.Intern Med;118;956-63
 17. Khalil SA, Elzubier AG. Drug compliance among hypertensive patients in
Tabuk, Saudi Arabia.
Journal of hypertension1997;15(5):561-5

18. Amal M Al-Mehza, Fatema A Al-Muhailije. Drug

compliance among hypertensive patients; an area
based study. Eur J Gen med 2009;6(1):6-10

67 | P a g e
A
n
n
e
x
u
r
e
68 | P a g e
Status of Blood Pressure and
Treatment
compliance in
selected rural
area of Dhamrai
Upazilla, Dhaka

Questionnaire
Ide

ntit

no:

Dat

e:
A. Particulars of the respondent
1. Name of the respondent:


2. Present address:
V
i
l
l
a
g
e

W
 a
r
d

n
o

U
n
i
o
n

U
p
a
z
i
l
l
a

D
i
s
t
r
i
c
t

B. Socio-economical information
1. How old are you? (Years) .
 2. Which religion you follow?

a) Islam b) Hindu c) Christian d) Buddhism e) Others

(mention).

3. What is your educational status?

a) Illiterate b) Informal c) Primary d)

Secondary

e) SSC/Equivalent f) HSC/Equivalent g) Degree or

Degree+ /Equivalent

4. Your marital status?

a) Unmarried b) Married c) Divorced

d) Separate living e) Widow f) Widower

5. What is your occupation?

a) Household work b) Agriculture c) job

d) Business e) Day laborers f) Student g)

others

69 | P a g e
 6. Do you physical work?

a) Yes b) No

7. What is the monthly income of your family (Taka)?

a) <5000 b) 5000-10000 c) 10000-15000

d) 15000-20000

C . Information on Diet & Habit

1. Do you eat fat containing food much?

a) Yes b) No

If yes, how many days a week? .

2. Which type of proteins do you eat most of the times?

a) Fish b) Meat c) Egg d) Milk

e) Others

3. Do you walk every day?

4. If yes, do you walk quickly for at least 30 minutes for 3 days

in a week?

a) Yes b) No

5. D

o you

say
your

prayer

regularl

y?

a)Yes

b) No

6. Do you smoke?

a) Yes b) No

7. If yes, how many cigarettes on average per day?

.
8. If yes, for how many years? ..

9. Do you take any oral contraceptive pill? (Married woman

only)

a) Yes b) No

70 | P a g e
 10.Do you take extra salt in food?
a) Yes b) No

D. Information about Blood

Pressure
1. Have you ever measured your blood pressure before?

a) Yes b) No

If yes, i) Normal ii) Abnormal

2. Do you know whether you have hypertension or not?

a) Yes b) No

3. Do you take any medicine for hypertension?

a) Yes b) No

4. If yes, for how long are you taking medicine for hypertension?
..
5. Do you take anti-hypertensive medicine regularly?

a) Yes b) No

6. Are you suffering from any kind of complication related to

hypertension?

a) Yes b) No

If yes, what type of complication?

a) Heart disease b) Stroke c)

Kidney disease d) Others For how

long? .. Month/years

7. Do other members of your family have hypertension?

a) Yes b) No

8. Do you have any other diseases except hypertension?

a) Yes b) No

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If yes, what are the diseases?

a) Obesity b) Diabetes mellitus

c) Others

E . Information regarding
treatment
1. Whom from have you come to know that you are suffering from
hypertension?

a) MBBS doctor b) Specialized doctor

c) Assistant of doctor d) Ayurvedic physician
e) Village doctor f) Homeopath

2. Do you check your blood pressure regularly by a qualified

doctor?

a) Yes b) No

3. Do you take medicine regularly?

a) Yes b) No

4. Are you feeling well after taking medicine?

a) Yes b) No

5. What is the currently measured blood pressure?

A) Systolic blood pressure:

Left arm:

.
 Right arm:

...

Average:

B) Diastolic blood pressure: Left arm:

.

Right arm:

... Average:

Name of the data collector:

MC No: . Group:
.. Batch: .

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Map of Dhamrai Upazilla showing study
areas

S
u
t
i
p
a
r
a
 a

Choybaria
Barigao

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Photographs during the visit

Group members with instructors

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Students measuring blood pressure during data collection
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