Keywords
economic status - health expenditures - health facilities - hypertension - rural population
Introduction
High blood pressure, or HTN, is a major global health concern and one of the main
causes of cardiovascular morbidity and death.[1] In countries with low and middle income, health systems frequently find it difficult
to control chronic disease-related treatment and lifestyle modifications seen in HTN.[2] In India, HTN is gradually increasing in rural and urban populations, especially
among the rural population. Treating HTN poses unique issues for rural communities
because of financial barriers, lack of awareness, and limited access to health care.[3] These factors worsen the health and financial ill-effects of HTN by contributing
to underdiagnosis and undertreatment among the rural population. The prevalence of
HTN has been steadily increasing in rural India, which is in line with more general
epidemiological changes.[4] A recent systematic review disclosed that 12% of the studies showed poorer HTN control
among rural patients than urban patients. [5] The prevalence was slightly higher in urban areas at 12.5% (12.25–12.80%) than in
rural areas at 10.6% (10.50–10.78%).[6] Despite this heavy burden of HTN, rural communities frequently lack the health care
infrastructure to screen for, diagnose, and treat HTN adequately.[7] Inadequate health care access and low health literacy lead to poor disease management,
higher complications, and financial strain in rural families, causing poverty and
catastrophic health expenditures.[8]
HTN in India significantly impacts households, leading to high expenses and productivity
loss. Socioeconomic (SE) inequality contributes to higher medical costs among lower-income
households.[9] Planning treatments and strategies for the prevention and control of HTN requires
understanding the SE disparities in the diagnosis and treatment of HTN, especially
among the rural population.[10] A review study published in 2019 has suggested that the greatest loss of income
among noncommunicable diseases (NCDs) was attributed to HTN, followed by diabetes
and cardiovascular diseases—the NCDs lower gross domestic product, resulting in productivity
losses and significant macroeconomic impact.[11] Another study in Mumbai's Malwani slum revealed that managing HTN and related disorders
costs around ₹7,154 annually, with government and private health care costs averaging
₹6,073 and ₹8,235, respectively.[12] However, rural community-based studies lack information on out-of-pocket expenditure
(OOPE) for treatment and hospitalization among patients with HTN in India. The current
study aimed to assess the monthly expenditures on essential household needs like food,
electricity, and liquefied petroleum gas (LPG) and determine the OOPE among patients
with HTN in a rural community in Karnataka, India.
Methodology
Study Tool
A pretested semistructured questionnaire collected baseline information on household
characteristics, income, and medical history linked to HTN. Moreover, monthly spending
on food-related monthly expenditure, education-related monthly expenditure, electricity/water
amenities, LPG expenditure, and recreation-related expenditure was gathered to track
alterations and tendencies in household spending patterns linked to HTN. Two subject
experts in community medicine did validation and feedback was incorporated into the
questionnaire before the commencement of the pilot study. This study was part of a
larger study involving other NCD conditions like diabetes and both HTN and diabetes.
Data Collection
A longitudinal study was conducted in a rural community under a rural primary health
center (PHC) in a coastal district of Karnataka between 2019 and 2022.
Accredited Social Health Activists workers were contacted in person to identify the
households with HTN patients in the PHC area. The study was focused on households
having at least one member diagnosed with HTN and who was put on treatment for at
least 1 year before the data collection. In case there was more than one individual
with comorbid NCDs of diabetes and both HTN and diabetes, the individuals with HTN
were considered separately for estimating the financial burden and OOPE, especially
if both have different patterns of health care utilization or varying costs associated
with their treatment. These rural residents had a domicile in the study area for at
least 6 months. Consenting adult patients willing to participate in the study and
provide financial data were recruited consecutively till the required sample size
was achieved. The households with HTN patients who were unavailable to the investigator,
even after two informed visits, were excluded. In case monthly visits were not possible
due to coronavirus disease pandemic travel restrictions, telephonic interviews were
employed to collect data, thereby ensuring lower participant attrition.
Additionally, a medical records review was conducted on the study participants to
ascertain medical records, including financial details on medication, frequency of
medical visits to both outpatient departments of health care facilities, and any in-patient
hospitalizations in up to 1 year. Monthly follow-up visits to the households were
conducted to track monthly expenditures for essential household needs (food, electricity,
LPG, and others) and any incidental health care expenditures for patients with HTN
were noted.
Sample Size Calculation
The sample size was calculated based on the study done in Malwani slum, where the
OOPE among HTN patients was estimated to be 34.2%.[12] The estimated minimum sample size of 87 was determined to estimate the expected
proportion with 10% absolute precision and 95% confidence using a Statulator.[13]
Operational Definitions Used in the Study
Complications in HTN: HTN complications, like myocardial infarction, stroke, heart
failure, chronic kidney disease, and peripheral artery disease, result from sustained
high blood pressure.[14]
Health-related OOPE: Health care expenses, including medical consultations, medications,
and hospital stays, that were directly paid by individuals or households, excluding
reimbursable insurance payments or third-party payers, reflecting the financial burden
of health care.[15]
Food-related monthly expenditure: The total monthly spending a household does for
food and beverage items for human consumption, including groceries, dining out, takeout,
and special occasions.[16]
Education-related monthly expenditure: A household's total spending on education-related
goods and services, including tuition fees, school supplies, transportation, extracurricular
activities, tutoring, and other expenses related to formal or informal education.[17]
Electricity/water amenities: The monthly expenditure for electricity/water amenities
includes charges for consumption, water usage, fixed fees, taxes, and other associated
costs, not including installation or repair of infrastructure.
LPG expenditure: LPG-related monthly expenditure refers to a household's monthly expenditure
on LPG for cooking and heating, including costs for cylinders, transportation, and
additional charges.[18]
Recreation-related expenditure: It is the monthly spending of the patients on leisure
activities and services, including gym memberships, fitness classes, sports equipment,
hobbies, and entertainment events. This expenditure affects HTN management, considering
both direct and indirect costs.[19]
Ethical Considerations
Before collecting participant data, participants were provided with an information
sheet on the study protocol and the need for follow-up visits to measure trends and
expenditure patterns. Then, each participant was asked to sign a written informed
consent form. All gathered information was kept private and utilized exclusively for
the study. Before statistical analysis, the final data set's identifiable data was
anonymized. The Institution's Central Ethics Committee (CEC) granted study permission
via letter NU/CEC/2019/0241, dated June 13, 2019.
Statistical Analysis
Data thus collected were entered into MS Excel and analyzed using SPSS Version 29.0.
Descriptive statistics of age, gender, income level, and baseline expenditures were
summarized using median and interquartile range (IQR). The monthly expenditure data
on food, electricity, and LPG over the 6 months were analyzed to identify any significant
changes or patterns in nonhealth essential items. Inferential statistics of chi-square
tests were used to determine changes in monthly expenditure patterns and factors significantly
associated with OOPE among HTN patients.
Results
Sociodemographic Description of the Study Population
46 (45.54%) of the 101 adult consenting patients with hypertension were 61 years or
older. The median age of the study population was 59.1 ± 12 years, as seen in [Table 1]. Most participants are married, with a significant proportion of unmarried or widowed
individuals. Most households have two or more earning members and a low frequency
of complications related to HTN, suggesting manageable HTN. Most participants have
not been hospitalized for HTN-related issues, suggesting better access to health care
facilities. The study participants also showed that over half of the participants
have been living with HTN for 5 years or less, with a median of 5 (3–10) years since
the diagnosis of HTN.
Table 1
Sociodemographic data of the study population (N = 101)
|
Socio-characteristics
|
Variables
|
Frequency, n (%)
|
|
Age group (in years)
|
≤ 40
|
7(6.93)
|
|
41–50
|
22 (21.78)
|
|
51–60
|
26 (25.74)
|
|
≥ 61
|
46 (45.54)
|
|
Educational status
|
No formal education
|
25 (24.8)
|
|
Primary to secondary school
|
66 (65.3)
|
|
PUC and above
|
10 (9.9)
|
|
Marital status
|
Married
|
76 (75.24)
|
|
Unmarried/widow/widower
|
25 (24.75)
|
|
Sex
|
Male
|
47 (46.53)
|
|
Female
|
54 (53.46)
|
|
Earning members in the family
|
0–1
|
43 (42.57)
|
|
≥ 2
|
58 (57.42)
|
|
Socioeconomic status as per Modified BG Prasad classification[20]
|
Upper class
|
11 (10.9)
|
|
Upper middle
|
29 (28.7)
|
|
Middle
|
39 (38.6)
|
|
Lower middle
|
20 (19.8)
|
|
Lower
|
2 (2)
|
|
Complications related to hypertension
|
Yes
|
17 (22.66)
|
|
No
|
84 (83.16)
|
|
Admitted to hospital in the past 1 year/for 6 months' follow-up
|
Yes
|
13 (24.52)
|
|
No
|
88 (87.12)
|
|
Duration of hypertension diagnosis (in years)
|
≤ 5
|
53 (52.47)
|
|
≥ 6
|
48 (47.52)
|
|
Health insurance of any type
|
Present
|
39 (38.6)
|
|
Absent
|
62 (61.4)
|
|
Monthly out-of-pocket expenditure on health (INR)
|
≥ 500
|
72 (71.30)
|
|
≤ 499
|
29 (28.7)
|
|
Number of households with more than one comorbidity
|
Present
|
5 (5.0)
|
|
Absent
|
96 (95.0)
|
Abbreviations: INR, Indian rupees; PUC, pre-university course.
Note: Bold represents the highest percentage.
Monthly Expenditure Patterns of the Households in the Study Population (N = 101)
[Table 2] shows the self-reported average monthly expenditure on food was ₹3,187, suggesting
stable spending despite financial pressures from managing HTN. Education expenses
remain constant at ₹1,000 per month, and LPG expenses are fixed at ₹750 per month,
indicating a stable cost. Recreation expenditures show variability, with an average
of ₹683, suggesting discretionary spending adjustments. Essential household expenditures
like food, education, electricity, and LPG remain stable despite financial strain.
Recreation expenses show more variability, suggesting households prioritize these
areas, potentially at the expense of flexibility in other budget categories. Understanding
these patterns can help assess HTN's impact on financial planning and guide interventions
for financially burdened households in rural settings. The monthly expenditure patterns,
however, did not show any significant variations in expenditures related to the nonhealth
essential items of the households with patients with HTN.
Table 2
Median monthly expenditure among the households in the study population over 6 months'
follow-up in the study population (N = 101)
|
Particulars
|
Median and interquartile range (IQR) of variables in months
|
Chi-square table value
|
p-Value
|
|
1st
|
2nd
|
3rd
|
4th
|
5th
|
6th
|
|
Food
|
3,125 (2,500–3,710)
|
3,208 (2,450–3,825)
|
3,200 (2374.5–3,925)
|
3,200 (2,475–3,861.5)
|
3,164 (2,421.5–3,982.5)
|
3,154 (2,423–3,945)
|
6.041
|
0.302
|
|
Education
|
1,000 (625–1,500)
|
1,000 (625–1,500)
|
1,000 (625–1,500)
|
1,000 (625–1,500)
|
1,000 (625–1,500)
|
1,000 (625–1,500)
|
1.000
|
–
|
|
Electricity/water amenities
|
597 (414–794)
|
590 (420–767.5)
|
589 (426.5–765)
|
587 (437.5–766.5)
|
591 (424.5–754)
|
600 (423.5–765)
|
5.695
|
0.337
|
|
LPG
|
750 (700–850
|
750 (700–850)
|
750 (700–850)
|
750 (700–850)
|
750 (700–850)
|
750 (700–850)
|
1.000
|
–
|
|
Recreation
|
700 (500–1,150)
|
700 (500–1,050)
|
500 (500–1,000)
|
600 (500–1,000)
|
750 (500–1,100)
|
800 (500–1,000)
|
0.506
|
0.992
|
|
Medical expenses
|
475 (315–745)
|
475 (315–747.50)
|
475 (315–754)
|
475 (315–749.50)
|
482 (315–754)
|
482 (315–757)
|
59.65
|
0.001[a]
|
Abbreviation: LPG, liquefied petroleum gas.
Note: Bold represents the highest percentage.
a
p-Value < 0.05.
The median food expenditure of ₹2,000, with an IQR ranging from ₹1,000 to ₹3,000,
indicates that households spend a significant portion of their budget on food. The
wide range suggests that household food costs vary considerably, potentially influenced
by family size, dietary needs, and local food prices. This expenditure is a substantial
component of the household budget, reflecting a relatively stable necessity despite
other financial pressures. The time series plot, as seen in [Fig. 1], analyzed the variations in the population's health expenditure and nonhealth expenditures.
As seen in [Fig. 1], stable categories like education, LPG, and electricity/water showed minimal changes
over time, while variable categories like food showed small fluctuations, indicating
external factors influencing household spending.
Fig. 1 Median monthly expenditures of households over a 6-month period (N = 101).
Factors Associated with Monthly OOPE
[Table 3] shows the factors associated with monthly OOPE in the study population. The higher
OOPE was significantly associated with visits to private health care facilities and
SE status. Lower OOPE was significantly associated with visits to government facilities
like the nearby PHCs.
Table 3
Factors associated with monthly out-of-pocket expenditure in the study population
(n = 101)
|
Characteristic
|
Variables
|
Monthly out-of-pocket expenditure in INR
n (%)
|
Chi-square value
|
p-Value
|
|
≤ 499
|
≥ 500
|
|
Age group (in years)
|
< 50
|
7 (24.1)
|
22 (75.9)
|
0.416
|
0.63
|
|
≥ 51
|
22 (30.6)
|
50 (69.4)
|
|
Highest level of education
|
Up to primary
|
22 (29.3)
|
53 (70.7)
|
0.055
|
0.815
|
|
Above primary
|
7 (26.9)
|
19 (73.1)
|
|
Marital status
|
Married
|
20 (26.3)
|
56 (73.7)
|
0.862
|
0.445
|
|
Others
|
9 (36.0)
|
16 (64.4)
|
|
Earning members in the family
|
0–1
|
12 (27.3)
|
32 (72.7)
|
0.079
|
0.779
|
|
≥ 2
|
17 (29.8)
|
40 (70.2)
|
|
Socioeconomic status[b]
|
Higher (class I and II)
|
6 (15.0)
|
34 (85.0)
|
6.08
|
0.015[a]
|
|
Lower (class III, IV, and V)
|
23 (37.7)
|
38 (62.3)
|
|
Health insurance (any type)
|
Present
|
9 (31.0)
|
30 (41.7)
|
0.986
|
0.321
|
|
Absent
|
20 (69.0)
|
42 (58.3)
|
|
More than one comorbidity in the household
|
Present
|
2 (6.9)
|
3 (4.2)
|
0.327
|
0.567
|
|
Absent
|
27 (93.1)
|
69 (95.8)
|
|
Years since being diagnosed with hypertension
|
≤ 5
|
20 (37.7)
|
33 (62.3)
|
4.43
|
0.035[a]
|
|
≥ 6
|
9 (18.8)
|
39 (81.3)
|
|
Medicines purchased from
|
Government health facilities/primary health centers
|
24 (54.5)
|
20 (45.5)
|
25.4[c]
|
< 0.001[a]
|
|
Others
|
5 (8.8)
|
52 (91.2)
|
|
Private health facilities
|
14 (17.5)
|
66 (82.5)
|
23.63
|
< 0.001[a]
|
|
Others
|
15 (71.4)
|
6 (28.6)
|
|
Generic medicine stores
|
10 (40.0)
|
15 (60.0)
|
2.068
|
0.202
|
|
Others
|
19 (25.0)
|
57 (75.0)
|
Abbreviation: INR, Indian rupees.
Note: Bold represents highest percentage.
a
p-Value < 0.05.
b Modified BG Prasad classification.
c Fischer's exact test.
Discussion
The current study findings reveal that health-related expenditures are significantly
higher for hospitalization and medicine purchases from the pharmacy. Monthly expenditures
are highest for food among households with patients with HTN when compared with other
amenities like electricity, LPG, and recreation purposes. Household financial management
is influenced by fixed expenses like education and utility costs, but discretionary
spending can be adjusted to cope with unforeseen medical or essential costs. Households
with HTN patients experience significant OOPEs associated with visits to private health
care facilities and the SE status of the households of the patients with HTN irrespective
of the age group, level of education, marital status, and the number of earning members
in the family. Lower OOPEs were associated with visits to government health facilities
like the nearby PHCs.
Financial Impact on Essential Expenditures
The high cost of essential items such as food, electricity, and LPG exacerbates this
financial burden with almost similar spending patterns in the population on medicines
among households with HTN. This finding aligns with previous research that highlights
how chronic illnesses like HTN disproportionately affect low-income households, as
seen in the study by Patel et al, which found households with chronic illnesses in
rural India often experience reduced spending on necessities due to high medical expenses.[21]
The study contrasts with a study conducted on the National Sample Survey in India
in 2018, which showed that elderly adults from higher SE status and financially independent
individuals incurred higher OOPE compared with those who were partially or fully economically
dependent as there were no association found with OOPE of more than 500 INR with gender,
age, marital status, and educational level.[22]
Health Care Expenditures and Its Implications
The average monthly expenditure on HTN-related health care was found to be at par
with nonhealth care essentials. The findings align with the study using the National
Sample Survey estimates of 2017–18 in India, where the outpatient consultation charges
for HTN related to outpatient visits in public facilities ranged from INR 277 (standard
deviation [SD] 571) to INR 695 (SD 1,431) depending on the type of private hospital/clinic,
similar to our study.[23] The study findings contrast the study conducted by Ramanna et al, where the mean
expenditure among households with patients with HTN was 1,464, which was much higher
compared with the current study.[24] The study contrasts the high expenditure seen in the average annual basic household
expenditure in the Philippines, which is $12,255.59, with the HTN-attributable OOPE
of $147.75, which was seen in approximately 23.7% of the households, primarily for
nonmedical expenses like dietary requirements and transportation to health care consultations,
which were significantly lower with a median expenditure of 100 to 1,500 INR and more
than 72 (71.30%) of the households with HTN patients spending more than INR 500 per
month on medicines as seen in [Tables 2] and [3].[25]
Other studies conducted in Nigeria also showed higher expenditure patterns among those
with HTN, that is, 
36,814 (INR 1,900). These costs included the average monthly cost of controlling HTN,
where laboratory tests and medications accounted for the largest portion of this expense.
A similar study conducted among those who attended the outpatient departments for
treatment of HTN in Egypt incurred a direct OOPE of 682.4 ± 283.8 Egyptian pounds
(∼1,175.58 INR), which was higher when compared with the present study finding.
Impact on Nonessential Expenditures
Research suggests that managing HTN in households reduces spending on nonessential
items due to substantial out-of-pocket costs and economic strain. In the current study,
the households with HTN patients' variable spending on recreation reflect the prioritization
of medical expenses over quality-of-life enhancements. The current study findings
align with a research in Sri Lanka, which found that households with chronic NCD patients
face higher OOPEs for medicines, pharmaceutical products, medical laboratory tests,
and ancillary services.[26]
Limitations
The study on HTN's financial burden has limitations due to its focus on a single rural
community, suggesting that future research should include a diverse sample and additional
variables for a more comprehensive understanding. Future research should explore these
issues and provide evidence-based recommendations for mitigating chronic diseases'
financial impact.
Conclusion
Monthly expenditure among households with patients with HTN in the rural community
shows no significant variation for nonhealth essential items. Higher OOPE was associated
with households with higher SE status and visits to private health facilities for
treatment of HTN.
