Impact of Some Selected Health Complications on Hypertension in Bangladesh
Hypertension is a silent killer of human life and the numbers of hypertensive patients are increasing globally and nationally. Therefore, the purpose of the study was to investigate age-specific hypertension patterns, alarming age for hypertension, and many determinants of hypertension in Bangladesh, e.g., feminine and nuptial determinants, socio-demographic determinants, health complication determinants, and body composition determinants. The data were collected from Rajshahi district using stratified multistage sampling with technique based on the scheduled questionnaire for this study. To identify the most important determinants, sophisticated statistical tools have been used such as percentage distribution, point bi-serial correlation, phi correlation, Pearson product-moment correlation, path analysis, boot strapping technique, binary backward logistic regression method including Likelihood ratio test, Hosmer-lemeshow test, Nagelkerke R2, Sensitivity and specificity, receiver operating characteristics (ROC) curve etc. From the view of proper critical analysis of impact of some key factors on hypertension, the study was divided into four aspects such as socio-demographic, feminine and nuptial, health complication and body composition aspects.
The study on hypertension is designed to make a broad analysis about the patterns of hypertension in Bangladesh and examine the risk factors of hyper-tension by in-depth assessment. Before beginning the study on hypertension it is important to know about hypertension. Hypertension is nothing but high blood pressure and high blood pressure is higher level of blood pressure. Also, blood pressure is the lateral pressure exerted on the walls of the arteries by blood flowing through the arteries. It reflects the rhythm of the heart beat and is a measure of the volume of blood pressure into the vessels by the heart. The pressure of blood within the arteries is highest whenever the heart contracts and is called systolic pressure. Between beats, when the ven-tricles are at rest, arterial pressure is at its lowest and is called diastolic pressure.
Among leading disease which occur the premature death, hypertension is one of them. Worldwide prevalence estimates for hypertension may be as much as 1 billion individuals, and approximately 7.1 million deaths per year may be attributable to hypertension (WHO, 2002). This study also reports that systolic blood pressure (>115 mm Hg) is responsible for 62% of cerebrovascular disease and 49% of ischemic heart disease, with little variation by sex. In addition, suboptimal blood pressure is the number one attributable risk for death through-out the world (WHO, 2002). Since most blood pressure related deaths or non fatal events occur in middle age or the elderly, the loss of life years comprises a smaller proportion of the global total, but it is nonetheless substantial (64.3 million disease burden, or 4.4 % of the total) (WHO, 2002).
Health is wealth and sound health of Bangladeshi peoples is the primary goal of all development plans. But the poor health of Bangladeshi people is an intractable problem as poverty. Poor health is occurred due to poverty, malnutrition, disease, lack of education, sex discrimination etc. Among the leading diseases hypertension is one which may lead to heart attack, stroke, heart failure, paralysis, kidney disease, eye damage etc. (Chobanian, 2003). Hence, hypertension is a risk factor of premature death and a barrier of sound health. So, it is essential to formulate an appropriate strategy to control hypertension for healthy life.
Bangladesh is familiar as low income and developing country with high mortality (WB, 2007; WHO, 2002). The mortality rate is 9.23 per thousand and the healthy life expectancy in Bangladesh is 56 where the life expectancy/birth is 69.40 (WHO, 2010). A vast portion of total mortality rate is affected by premature deaths. Among the causes of premature or unexpected death hypertension is one which also leads to various diseases of premature deaths. Hypertension is one of top thirteen diseases of deaths in Bangladesh and causes 1.91% of total deaths (WHO, 2010). In the same report, hypertension related coronary heart disease (17.11%) and stroke (8.57%) are the first and third leading causes of total deaths (WHO, 2010). Another report reveals that hypertension related Ischemic heart disease is the first leading causes of deaths in Bangladesh, accounting for 12% of total deaths (WHO, 2006).
Discussing the literature reviews (Hoque et al., 2012; Islam et al., 2012; Islam et al., 2012; Rahim et al., 2012; ICDDR, B, 2011; Khanam et al., 2011; Kokiwar, 2011; Zaman et al., 2010; Midha et al., 2009; Agrawal et al., 2008; Chen et al., 2006a; Chen et al.,2006b; Saha et al., 2006; Alamgir et al., 2005; Chen, 2005; Sayeed et al., 2005; Zamudio et al., 2005; Cooper-Dehoff et al., 2004; Chobanian et al., 2003; Sayeed et al., 2003; Sayeed et al., 2002; Hannan et al., 2001; Moula et al., 2001; WHO, 2001; Bond et al., 2000; Rahaman et al., 1999; Zaman and Rouf, 1999;Chowdhury et al., 1998; Hoque et al., 1998; Sayeed et al., 1995; Sayeed 1994; Khandakar, 1993; Islam et al., 1983; Islam et al., 1979; Ullah, 1976), it is clear that many studies about hypertension in nationally and internationally have been conducted in biological aspect through a lot of researchers or institutions. But the mentioned knowledgeable sources (literature reviews) indicate that any expected research about health com-plications aspect aspect has not yet been conducted. Hence, some questions may be asked as following:
i. Are there any age patterns as risk factors of hypertension?
ii. Are there any health complications risk factors of hypertension?
More than one reasons or risk factors are suspected for developing hypertension in the mentioned fields. The suspected risk factors are examined by this study. According to WHO (2001), developing countries are thus likely to face an enormous burden of chronic non-communicable diseases in the near future. Of these diseases, hypertension is the most common of the Cardio-vascular diseases which is the leading cause of morbidity and mortality in the industrial world as well as becoming an increasing common disease in the developing countries (Saha et al., 2006; Islam MM et al., 2022).
Maternal death is an important factor which snatches away at least two life. The causes of maternal death vary by United Nations (UN) region. Hypertension is the first leading cause of maternal mortality in Latin America, accounting for 25.7% of maternal deaths, and also in Developed countries it is second leading cause of maternal health, where it accounts for 14.9% of maternal deaths (Khan et al., 2006). In Asia and Africa, hypertensive disorders, causing 9.10% of maternal deaths. The most important cause of maternal death is “other direct causes” (21%), which includes largely complications during interventions such as those related to caesarean section and anesthesia, followed by hypertensive disorders and embolism (Khan et al., 2006). Also, deaths were occurred by blood pressure are greater in developed countries than developing countries for both sex (WHO, 2002).
From the world-wide information discussed above, it is undoubtedly clear that high blood pressure, other diseases caused by hypertension and blood pressure related diseases plays a vulnerable impact on premature deaths of human life. Since the percentage is small with respect to total world population, but the amount is sustainable. An investigation represents that 27.40% of casus-specific deaths which caused by different causes have been occurred by hypertension related disease such as Ischemic heart disease, rheumatic heart disease, hypertensive heart disease, cerebrovascular diseases, inflammatory heart diseases etc. (WHO, 2011b). The death rates due to hypertension and hypertension related diseases are increasing day by day. Also, 10.51% deaths have been occurred by blood pressure, heart disease as well as stroke and prevalence of morbidity by blood pressure is 6.20% (BBS, 2005; Begum, 1996). In another study, about 4% deaths were due to hypertensive complications in Bangladesh (BHSR, 1998).
The prevalence of hypertensive diabetic is increasing rapidly in Bangladesh (Hoque et al., 2012). A report reveals that the overall prevalence rates of systolic and diastolic hypertension in the Bangladesh population were 14.40% and 9.10%, respectively (Sayeed et al., 2002). The crude prevalence of systolic and diastolic hypertension in Bangladesh is 6.80% and 5.40%, respectively (Sayeed et al., 2005). In an investigation, 11.30% adult people are affected by hypertension (Zaman and Rouf, 1999). Though the number of deaths by hypertension is little, deaths by hypertension related diseases is a major part of total deaths and increasing day by day. Also, the mentioned report proves that the large number of people of Bangladesh living with hypertension and it is increasing day by day.
The data were collected from Rajshahi district using stratified multistage sampling with technique based on the scheduled questionnaire for this study. To identify the most important determinants, sophisticated statistical tools have been used such as percentage distribution, point bi-serial correlation, phi correlation, Pearson product-moment correlation, path analysis, boot strapping technique, binary backward logistic regression method including Likelihood ratio test, Hosmer-lemeshow test, Nagelkerke R2, Sensitivity and specificity, receiver operating characteristics (ROC) curve etc.
In order to study the background characteristics of different variables, the percentage distribution of the considered variables is conducted. This is applied in the study for health complication related background characteristics. To study the relationship between two binary variables, phi correlation technique is more appropriate to proper investigate the relation. Hence, before find out the risk factors of hypertension it is important to verify the relationship between hypertension and other health complications. Ensuring the existence of relationship between hypertension and other selected health complications, it is important to analyze the causal relationship between hypertension and other selected health complication variables. Hence, we have studied the causal relationship applying binary backward logistic regression method. The fitted model and requisite results are displayed in following:
Now we would like to know how effectively the model we have describes the outcome variable by R square, Hosmer-Lemeshow and classification table. A more complete description of classification accuracy is given by the area under the ROC curve. Bootstrapping is a re-sampling method for estimating the sampling distribution of an estimator by sampling with replacement from the original sample, most often with the purpose of deriving robust estimates of standard errors and confidence intervals of a population parameter like a mean, median, proportion, odds ratio, correlation co-efficient or regression coefficient. The bootstrapping method is used for logistic regression coefficients of health complications factors.
From the view of proper critical analysis of impact of some key factors on hypertension, the study was divided into four aspects such as socio-demo-graphic, feminine and nuptial, health complication and body composition aspects. About 28.10% hypertensive patients were due to socio-demographic aspect. Applying binary logistic regression model in the study of causal relationship, age was found as the most significant variable. i. e. age had positive significant impact on hypertension. Secondly, education had second most significant negative impact on hypertension and its odds ratio focus that for every increase of one year in education, the risk of hypertension increased 0.958 time. It was also found that sedentary life style, working hour (>8 hrs) per day, social stress, occupational stress and mental stress, hereditary hypertension, smoking, taking alcohol and taking excess salt had positive significant impact on raising hypertension where taking regular exercise had negative significant impact on hypertension. Hence, sedentary life style, working hour (>8) per day, social stress, occupational stress, mental stress, hereditary hypertension, smoking, taking alcohol, taking excess salt may be considered as risk factors for raising high blood pressure or hypertension. Though the age was found to be as the highest risk factor, but age increasing is out of human control.
It was found that the number of systolic hypertensive patients (60.40%) were greater than diastolic hypertensive patients (47.90%) in old age group (≥61 years) where diastolic hypertensive patients (7.40%) were greater than systolic hypertensive patients (3.80%) in young age group (≤39 years) and in middle age group (40-60 years) both are same. Hence, young age (≤39 years) was risk period for occurring diastolic hypertension than systolic and old age (≥61years) was risk period for occurring systolic hypertension than diastolic when middle age (40-60 years) was also risk period for occurring both type of hypertension. The differences between two same percentiles of systolic and diastolic blood pressure were varying from 51 mmHg to 93 mmHg for hypertensive respondents where it is same for normotensive. Hence, the abnormality (>40 mmHg) of the differences is an indicator of hypertension or prehypertension. In the health complication aspect, the adult hypertensive patients were 30.60%. In the analysis of causal relationship (applying binary backward logistic regression method) between hypertension and other health complication, kidney disease was found as a significant variable. i. e. kidney disease had positive significant impact on hypertension and its odds ratio 5.428 indicates that the respondents with kidney disease had 5.428 times risk to occur hypertension than the respondent without kidney disease. Also, tumor, diabetes, sleep apnea, hypothyroidism, hyperthyroidism, tachy-cardia and overweight had the positive significant impact for occurring hypertension. After discussing the binary logistic regression it was further found that kidney disease, tumor, diabetes, sleep apnea, hypothyroidism, hyperthyroidism, tachycardia and overweight might be considered as risk factors for raising high blood pressure or hypertension. In selected feminine and nuptial aspect, the active married female hypertensive patients were 28.90%. In the study of causal relationship (applying backward binary logistic regression model) between hypertension and other feminine and nuptial characteristics, first menstruation age was found to be as significant variable. i. e. first menstruation age had negative significant impact on hypertension. Duration of couple life had significant positive significant impact on hypertension. Use of contraceptive method, menopause, pregnancy and miscarriage had positive significant impact for occurring hypertension compared with those who do not possesses the characteristics. Hence, first menstruation age, duration of couple life, use of contraceptive method, menopause, pregnancy and miscarriage might be considered as risk factors or determinants for raising high blood pressure or hypertension. Using path analysis, the total effect of body mass index, abdominal circumference and ratio of waist to hip on systolic blood pressure were 0.207, 0.185 and 0.118 respectively in which their direct effect were respectively 0.146, 0.082 and 0.047. The total effect of body mass index, abdominal circumference and ratio of waist to hip on diastolic blood pressure were 0.289, 0.231 and 0.138 respectively in which their direct effect were respectively 0.231, 0.079 and 0.043.
Health Complication determinants of hyper-tension
In medicine, complication is an unfavorable evolution of a disease, a health condition or a therapy. Hence, this sub section is devoted for health complications aspect. In the context of health complication, the study is conducted on 2010 respondents of above 18 years old that are separated from total data 2250. For health complication aspects we consider the adult people who are above 18 years old. Because before 18 years old the people are known as child and the children are consider as immature in physically and mentally.
Health complication related background characteristics
To develop any basic concept about the study, background characteristics of the respondents or target population or nature of the data have to study. This assessment leads to the interpretation of results and to examine any cause-effect relationship among the study variables. The percentages of selected health complication related background charac-teristics among the adult people (above and 18 years old) are displayed in Table 1. Among adult total respondents 4.8% are patients with kidney disease. Our study shows that 13.60% respondents have tumor when 8.2% are diabetic patients. Sleep apnea disease affect 25.10% respondent. The percentages of hypothyroidism and hyperthyroidism disease are 32.40% and 31.70% respectively. The pulse rate per minute above 100 times is known as tachycardia disease and the people affected by tachycardia disease are 5.60%. Among the adult respondents 24.3% are fatty. Finally, the adult hypertensive patients are 30.60%.
Table 1: Percentage distribution of health complication characteristics.
Characteristics |
Percent (%) |
Characteristics |
Percent (%) |
Characteristics |
Percent (%) |
Kidney Disease |
Sleep Apnea |
Tachycardia |
|||
No |
95.2 |
No |
74.9 |
No |
94.4 |
Yes |
4.8 |
Yes |
25.1 |
Yes |
5.6 |
Total |
100 |
Total |
100.0 |
Total |
100.0 |
Tumor |
|
Hypothyroidism |
|
Over Weight |
|
No |
86.4 |
No |
67.60 |
No |
75.7 |
Yes |
13.6 |
Yes |
32.4 |
Yes |
24.3 |
Total |
100 |
Total |
100.0 |
Total |
100.0 |
Diabetes |
|
Hyperthyroidism |
|
Hypertension |
|
No |
91.8 |
No |
68.3 |
No |
69.4 |
Yes |
8.2 |
Yes |
31.7 |
Yes |
30.6 |
Total |
100 |
Total |
100.0 |
Total |
100.0 |
Association between hypertension and health complications
To study the relationship between two binary variables, phi correlation technique is more appropriate to proper investigate the relation. Hence, before find out the risk factors of hypertension it is important to verify the relationship between hypertension and other health complications. Also, the results are represented in Table 2. This table depicts that the relationships between hypertension and other variables such as kidney disease, tumor, diabetes, sleep apnea, hypothyroidism, hyperthy roidism, tachycardia and overweight are highly significant at 1% level of significance. These relationships have been studied by phi correlation because all variables are binary.
Table 2: Association between hypertension and health complications.
Impact of health complication determinants on hypertension
Ensuring the existence of relationship between hypertension and other selected health complications, it is important to analyze the causal relationship between hypertension and other selected health complication variables. Hence, we have studied the causal relationship applying binary backward logistic regression method. The fitted model and requisite results are displayed in following:
To study the causal relationship between hypertension and other health complication, kidney disease is found as a significant variable. i. e. kidney disease has positive significant impact on hypertension and its odds ratio 5.428 indicates that the respondents with kidney disease have 5.428 times risk to occur hypertension than the respondent without kidney disease. Secondly, tumor has positive significant impact on hypertension and the odd ratio 1.643 indicates that the respondents with tumor have 1.643 times odds or risk of occurring hypertension compared with those who do not have tumor. Thirdly, diabetes has positive significant impact on hypertension and its odd ratio indicates that the respondents with diabetes have 3.452 times odds or risk of occurring hypertension compared with those who do not have diabetes disease. Sleep apnea has positive significant impact on hypertension and the odds ratio indicates that the respondents who possess the sleep apnea have 15.795 times risk for occurring hypertension compared with those who do not possess. Also, hypothyroidism, hyperthyroidism and tachycardia disease have positive significant impact on hypertension and the odds ratios estimate that the respondents who possess hypothyroidism, hyperthyroidism and tachycardia disease have 1.662, 8.096 and 1.771 times risk respectively for occurring hypertension compared with those who do not possess.
Table 3: Stepwise logistic regression of hypertension on health complications.
Characteristics |
Regressor Coefficient (β) |
Standard Error of β |
Wald Test |
d. f |
P - Value |
Odds Ratio |
95% Confidence Interval |
|||
Lower |
Upper |
|||||||||
Kidney
Disease |
|
|
|
|||||||
No (r) |
- |
- |
|
|
- |
- |
|
|
||
Yes |
1.692 |
.376 |
20.236 |
1 |
.000 |
5.428 |
2.597 |
11.342 |
||
Tumor |
|
|
|
|||||||
No (r) |
- |
- |
|
|
- |
- |
|
|
||
Yes |
.496 |
.273 |
3.315 |
1 |
.069 |
1.643 |
.963 |
2.803 |
||
Diabetes |
|
|
|
|||||||
No (r) |
- |
- |
|
|
- |
- |
|
|
||
Yes |
1.239 |
.285 |
18.845 |
1 |
.000 |
3.452 |
1.973 |
6.039 |
||
Sleep
Apnea |
|
|
|
|||||||
No (r) |
- |
- |
|
|
- |
- |
|
|
||
Yes |
2.760 |
.191 |
207.804 |
1 |
.000 |
15.795 |
10.853 |
22.986 |
||
Hypothyroidism |
|
|
|
|||||||
No (r) |
- |
- |
|
|
- |
- |
|
|
||
Yes |
.508 |
.184 |
7.658 |
1 |
.006 |
1.662 |
1.160 |
2.382 |
||
Hyperthyroidism |
|
|
|
|||||||
No (r) |
- |
- |
|
|
- |
- |
|
|
||
Yes |
2.091 |
.172 |
147.608 |
1 |
.000 |
8.096 |
5.778 |
11.345 |
||
Tachycardia |
|
|
|
|||||||
No (r) |
- |
- |
|
|
- |
- |
|
|
||
Yes |
.572 |
.314 |
3.322 |
1 |
.068 |
1.771 |
.958 |
3.275 |
||
Over Weight |
|
|
|
|||||||
No (r) |
- |
- |
|
|
- |
- |
|
|
||
Yes |
.939 |
.169 |
30.782 |
1 |
.000 |
2.558 |
1.836 |
3.564 |
||
Constant |
-3.266 |
.141 |
535.066 |
1 |
.000 |
.038 |
|
|
Note: r represents the reference category.
Finally, over weighted or fatty respondents are in risk of 2.558 times for occurring hypertension than normal normal respondents. After discussing the binary logistics regression it is established that kidney disease, tumor, diabetes, sleep apnea, hypothyroidism, hyperthyroidism, tachycardia and over weight may be considered as risk factors for raising high blood pressure or hypertension.
Assessing the fit of the logistic regression model
Now we would like to know how effectively the model we have describes the outcome variable by R square, Hosmer-Lemeshow and classification table. Also, the results of assessment are displayed in Table 4.
Table 4: Results of assessment of fitted logistic regression model.
-2 Log likelihood |
Cox & Snell R Square |
Nagelkerke R Square |
||
1134.885 |
0.487 |
0.70 |
||
Hosmer and Lemeshow Statistic |
df |
P - Value |
||
2.985 |
5 |
0.71 |
||
Classification Table |
Predicted Hypertension |
% |
||
No |
Yes |
|||
Observed Hypertension |
No |
1327 |
68 |
95 (specificity) |
Yes |
148 |
467 |
76 (sensitivity) |
|
|
90 |
|||
Area Under ROC Curve = 0.93 |
The Table 4 depicts the value of Negelkerke R square is 0.70 which implies that all selected variables of logistic regression model have explained 70% of outcome variable. Also, the value of the Hosmer-Lemeshow goodness-of-fit statistic is 2.985 and the corresponding p-value is 0.75 with 5 degree of freedom which indicates that the model seems to fit quite well. The results of classifying the observations of hypertension using fitted logistic regression model are presented in same table. The overall rate of correct classification is estimated as 90% with 95% of the hypertension free group (specificity) and only 75% of the hypertensive group (sensitivity) being correctly classified.
Receiver operating characteristics (ROC) curve for health complication factors
The area under the ROC curve in the present study for socio-demographic aspects is 0.93 which indicates that the models ability is excellent to discriminate between those respondents who have hypertension than who do not have.
Fig. 1: ROC curve for health complications.
Receiver operating characteristics (ROC) curve for health complication factors
The area under the ROC curve in the present study for socio-demographic aspects is 0.93 which indicates that the models ability is excellent to discriminate between those respondents who have hypertension than who do not have.
Logistic regression for health complications by bootstrapping
Using bootstrapping method, regression coefficients of health complications factors have been found approximately same with comparing the logistic regression coefficients. The small amount of bias may be ignored. These results are shown in the Table 5.
Table 5: Logistic regression for health complications by bootstrapping.
Bootstrap |
Logistic Regressor Coefficient (β) |
Bootstrapping
Regressor Coefficient (β) |
Bias |
Standard Error of β |
P-value |
95% Confidence Interval |
|
Lower |
Upper |
||||||
Kidney Disease |
1.692 |
1.695 |
.000 |
.464 |
.001 |
.694 |
2.625 |
Tumor |
.496 |
.504 |
.009 |
.262 |
.056 |
.002 |
1.046 |
Diabetes |
1.239 |
1.244 |
.023 |
.300 |
.001 |
.688 |
1.885 |
Sleep Apnea |
2.760 |
2.760 |
.024 |
.195 |
.001 |
2.402 |
3.168 |
Hypothyroidism |
.508 |
.510 |
-.005 |
.204 |
.009 |
.091 |
.889 |
Hyperthyroidism |
2.091 |
2.091 |
.028 |
.193 |
.001 |
1.742 |
2.495 |
Tachycardia |
.572 |
.570 |
-.005 |
.316 |
.065 |
-.114 |
1.138 |
Over Weight |
.939 |
.940 |
.015 |
.173 |
.001 |
.592 |
1.277 |
Constant |
-3.266 |
-3.259 |
-.024 |
.141 |
.001 |
-3.585 |
-3.021 |
Though with increasing age the rate of both type hypertension is increasing but young age (<40years) is more risk period for occurring diastolic hyper-tension than systolic and old age (>60years) is more risk period for occurring systolic hypertension than diastolic when middle age (40-60 years) is also risk period for occurring both type of hypertension. The differences between two same percentiles of systolic and diastolic blood pressure are increasing with increasing percentiles cut-offs for hypertensive respondents and the differences are almost same with increasing percentiles for normotensive. Age, educational level, sedentary lifestyle, working hour (>8hrs) per day, taking regular exercise, social stress, occupational stress, mental stress, hereditary hypertension, smoking, taking alcohol, taking excess salt are statistically highly related with hypertension at one percent level of significant except taking regular exercise. Also, sedentary lifestyle, working hour (>8hrs) per day, taking regular exercise, social stress, occupational stress, mental stress, hereditary hypertension, smoking, taking alcohol, taking excess salt have statistically highly impact on hypertension. Though age may be considered as risk factor, but age increasing is out of human control. Health complications kidney disease, tumor, diabetes, sleep apnea, hypothyroidism, hyperthyroidism, tachycardia and overweight are statistically highly related with hypertension at one percent level of significance. The feminine and nuptial variables first menstruation age, duration of couple life, use of contraceptive method, pregnancy, miscarriage, and menopause have significant impact on hypertension. Body mass index, abdominal circumference and ratio of waist to hip are statistically highly correlated with systolic and diastolic blood pressure at one percent level of significance.
Not Applicable
All the authors contributed to conceptualize and design the study. M.I. contributed in report writing, A.A.M. contributed in data collection and A.N. contributed in data analysis of the study. M.A.U. prepared journal article from the research report.
First and foremost, the authors are grateful to Almighty Allah. The authors are also thankful to anonymous reviewers and editors for their helpful comments and suggestions.
The author declares no conflict of interest.
Academic Editor
Dr. Abduleziz Jemal Hamido, Deputy Managing Editor (Health Sciences), Universe Publishing Group (UniversePG), Haramaya, Ethiopia.
Islam M, Mamun MAA, Uddin MA, and Nahian A. (2024). Impact of some selected health complications on hypertension in Bangladesh. Eur. J. Med. Health Sci., 6(6), 177-188. https://doi.org/10.34104/ejmhs.024.01770188