1

INTRODUCTION

Non-communicable diseases (NCDs) are chronic, non-infectious conditions with long durations
and slow progression, including cardiovascular diseases, cancer, respiratory diseases, diabetes,
(1)
mental illnesses, and injuries. Globally, NCDs are a leading cause of illness and death,
(2)
accounting for nearly 71% of all fatalities. In low- and middle-income countries like Pakistan,
NCDs are responsible for approximately 54.9% of health issues, making them the primary cause
(3)
of mortality and morbidity. The rise in NCDs is driven by urbanization, lifestyle changes, and
an aging population, with significant disparities between urban and rural areas. (4)
(5)
Socioeconomic factors heavily influence health behaviors and outcomes. Urban residents
generally have better access to healthcare but often lead sedentary lifestyles due to desk jobs,
(6)
reliance on motorized transportation, and limited access to safe spaces for physical activity. In
contrast, rural residents may lack adequate medical facilities but tend to be more physically
(7)
active due to labor-intensive work. However, rural populations often lack structured
opportunities for exercise, and cultural norms may discourage physical activity, particularly
(8)
among women. Urban areas report higher rates of diabetes, dyslipidemia, and obesity due to
(9)
physical inactivity, processed food consumption, and stress. while rural populations face
higher risks of cardiovascular diseases due to tobacco and alcohol use. (10)
In Pakistan, over 45% of adults do not meet the World Health Organization’s (WHO)
recommended physical activity levels of 150 minutes of moderate-intensity or 75 minutes of
(11)
vigorous-intensity exercise weekly. Sedentary behavior, characterized by low energy
expenditure during waking hours, further exacerbates NCD risks, including obesity,
(12)
hypertension, type 2 diabetes, and cardiovascular diseases. In Hyderabad, Sindh, urbanization
and technological advancements have led to rising rates of obesity, hypertension, and diabetes in
(13)
urban areas. While rural regions face higher burdens of hypertension and cardiovascular
diseases due to agricultural mechanization and limited recreational facilities. (14)
Cardiovascular diseases (CVDs) are a major public health challenge in Pakistan, with urban
(15)
populations exhibiting higher CVD risk factors than rural areas. CVD risk factors are
categorized as modifiable (e.g., obesity, hypertension, diabetes, smoking, stress, sedentary
(16)
lifestyle) and non-modifiable (e.g., aging, genetics). Urbanization has intensified modifiable
risk factors, contributing to the growing prevalence of CVDs. (17)
 2

Diabetes mellitus (DM), a metabolic disorder characterized by high blood sugar levels, has seen
a significant rise in Pakistan due to poor dietary habits, economic growth, and urbanization. (18)
Asia accounts for 60% of global diabetes cases, with urbanization and migration being key
(19)
drivers. In Hyderabad, urban populations are particularly affected by lifestyle changes and
environmental factors, with obesity, sedentary behavior, and unhealthy diets being major
contributors. (20)
Cardiometabolic diseases (CMDs), including coronary heart disease and stroke, are increasing in
low- and middle-income countries like Pakistan due to rapid urbanization, poor urban planning,
(21)
and environmental pollution. Congested road networks, lack of green spaces, and poor
sanitation exacerbate CMD risks, while mental health issues like depression and anxiety further
(22)
contribute to their development. Urban areas like Hyderabad face significant challenges in
managing the growing burden of CMDs due to strained healthcare systems. (23)
Degenerative diseases, such as Alzheimer’s and dementia, are also on the rise in Pakistan.
Dementia, a progressive neurological disorder, affects memory, thinking, and daily functioning,
with 58% of cases occurring among low- and middle-income populations. (24) By 2050, dementia
cases are projected to increase by 71%, driven by aging, genetics, hypertension, smoking, and
lack of mental and physical activity. (25) In Hyderabad, urban residents face lifestyle-related risks,
while rural populations struggle with limited healthcare access and poor nutrition. (26)
Cancer is another growing health concern in Pakistan, with breast cancer (24.1%), oral cancer
(9.6%), colorectal cancer (4.9%), esophageal cancer (4.2%), and liver cancer (3.9%) being the
most common types. (27) Breast cancer remains the leading cause of cancer-related deaths. Urban
populations face lifestyle-related risks, while rural communities are exposed to environmental
(28)
and occupational hazards. Addressing cancer requires improved healthcare access, education,
and preventive measures. (29)
Chronic respiratory illnesses, such as COPD, asthma, and bronchitis, are prevalent in Hyderabad.
(30)
While in urban areas affected by air pollution, smoking, sedentary lifestyles, and rural areas
(31)
exposed to biomass fuel smoke and pesticides. Vehicular emissions, industrial waste, and
(32)
household smoke worsen urban respiratory conditions. while traditional cooking methods and
(33)
agricultural chemicals increase risks in rural areas. Addressing these issues requires improved
air quality, reduced tobacco use, and safer cooking and farming practices. (34)
 3

The overall discussion shows that non-communicable diseases such as cardiovascular diseases,
diabetes, cancer, and respiratory illnesses are significant health concerns in Pakistan, particularly
in Hyderabad, and Sindh. The rise of these diseases is driven by urbanization, lifestyle changes,
and environmental factors. (1)
In urban areas, residents face risks such as a sedentary lifestyle, poor diets, and pollution, while
rural regions struggle with limited access to healthcare and exposure to biomass fuel. To
effectively prevent NCDs, it is essential to improve healthcare access, enhance education, and
promote healthier lifestyle choices. (35)
 4

LITERATURE REVIEW

1. The cross-sectional study was conducted by Raza et al. in 2023. ‘‘Comparative Analysis
of Non-Communicable Diseases (NCDs) And Their Risk Factors For Rural And Urban
Communities.’’ Of a Total Of 1000 Participants Who Were Interviewed, 450 Belonged
to The Eligible Population (Defined as Those Between The Ages Of 30 And 64) In Rural
Areas And 550 In Urban Areas—Using The Global Physical Activity Questionnaire
(Gpaq) To Assess Biochemical, Behavioral, And Physical Risk Factors For Non-
Communicable Diseases (NCDs). The Study Highlighted Urban Populations' Greater
Vulnerability to Ncds Due to Lifestyle Differences, Emphasizing the Need For Targeted
Prevention Strategies.

2. The cross-sectional study was conducted by Balouch et al. in 2022. ''Prevalence of

cardiovascular disease risk factors in urban and rural areas of Hyderabad, Sindh,
Pakistan." A total of 304 participants lived in the urban and rural areas of Hyderabad,
Pakistan. Out of 304, 161 were men and 143 were women with an age range from 30 to
70 years. Data was collected through an interview-based questionnaire The findings
indicate that men had a higher prevalence of cardiovascular disease (CVD) risk factors.
Furthermore, participants from urban areas exhibited a greater prevalence of CVD risk
factors compared to those from rural areas.

3. A systematic review of this study was conducted by Bull F.C. et al. in 2020. ''World
Health Organization 2020 guidelines on physical activity and sedentary behavior." The
World Health Organization (WHO) reaffirms messages that some physical activity is
better than none, that more physical activity is better for optimal health outcomes, and
provides a new recommendation for reducing sedentary behaviors. These guidelines
highlight the importance of regularly undertaking both aerobic and muscle-strengthening
activities and for the first time, there are specific recommendations for specific
populations including pregnant and postpartum women and people living with chronic
conditions or disability.
 5

4. A prospective (Cohort) study was conducted by Zhao et al in 2020. ‘‘The dose-response

associations of sedentary time with chronic diseases and the risk for all-cause mortality
affected by different health status.’’ A review of 34 high-quality studies involving
1,331,468 participants examined the association between sedentary behavior and chronic
disease outcomes. Independence of physical activity, prolonged sitting, and TV viewing
were linked to increased risks of all-cause mortality, cardiovascular disease (CVD)
mortality, type 2 diabetes (T2D), and cancer mortality. A non-linear relationship was
observed for total sedentary behavior, with risks significantly rising beyond 6–8 hours of
sitting and 3–4 hours of TV viewing per day. While associations with T2D and cancer
mortality were linear, stronger effects were noted for TV viewing time. These findings
highlight the detrimental impact of excessive sedentary behavior on major chronic
diseases.

5. A descriptive cross-sectional study was conducted by Khan, U.I. et al. in 2025. ‘‘focusing
on the burden of cardiometabolic diseases and depression in a low-income urban
community in Pakistan.’’ The researchers approached 4,933 families, of which 1,513
(30%) agreed to participate. In these families, 4,656 of 6,180 (75%) family members
consented to take part, including 3,051 adults (aged 18 years and older). Participation
rates varied among census circles, ranging from 3.63% to 59%. Data was collected
through screening and assessments by using the Patient Health Questionnaire-2 (PHQ-2)
and Patient Health Questionnaire-9 (PHQ-9). This study highlights the significant burden
of cardiometabolic diseases (CMDs), multimorbidity, and depression in this low-income
urban community in Pakistan. The findings suggest that a cardiometabolic
multimorbidity (CMM) epidemic is emerging in urban areas, emphasizing the need for
integrated interventions that address physical, mental, economic, and environmental
factors in the management of CMDs.

6. A cross-sectional study was conducted by Shahid F. et al. in 2022. ‘‘to investigate the
factors and consequences of dementia among older adults in Karachi, Pakistan.’’ A total
of 383 participants, all caretakers of dementia patients, were selected for the study.
Among them, 52% were between the ages of 20 and 30, and most had been caring for the
patients for around five years or less; 39.8% of the participants were children of dementia
 6

patients. Data was collected using a questionnaire that included the Clinical Dementia
Rating (CDR) scale to determine the severity of dementia and the Zarit Burden Interview
to assess the burden on caregivers. The findings indicated that the quality of life of
caregivers was significantly impacted by the demands of caring for dementia patients,
resulting in both financial and mental strain. The study included participants from various
genders and socioeconomic backgrounds, with most caregivers experiencing mild to
moderate levels of burden. The results suggested that the most common factors leading to
dementia, as reported by the caregivers, were a family history of the condition and
unhealthy eating habits.

7. A cross-sectional study conducted by Shah, S.Q. et al. in 2021. ‘‘examined the frequency
of different types of diabetes among patients attending Isra University Welfare Hospital,
comparing urban and rural populations in Sindh, Pakistan.’’ A total of 166 patients
visited the clinic from August 1 to August 31, 2019. Among these, 62.65% were from
urban areas and 37.35% from rural areas. In the urban group, 28% of the patients were
male and 72% were female, while in the rural group, the percentages were 35% male and
65% female. The patients represented various age groups, with approximately 46% aged
between 50 and 69 years and about 39% aged between 30 and 49 years. The study
concluded that diabetes mellitus (DM) is more prevalent in urban areas compared to rural
areas, with a higher incidence in females than in males. Additionally, the frequency of the
disease increases with age. Contrary to the common belief that diabetes primarily affects
wealthier individuals, this study found that it is more prevalent among those in lower
socioeconomic groups.

8. A cross-sectional study conducted by Hayder et al. in 2023. examined the occurrence and
responsiveness level of common non-communicable diseases (NCDs) and their
associated risks among non-medical undergraduate students in Karachi. The study
involved interviewing 500 participants using a comprehensive structured questionnaire,
which consisted of 71 questions designed to evaluate awareness, risk factors, and the
prevalence of NCDs. The findings revealed that the participants had insufficient
awareness and knowledge regarding the prevention of NCDs. Additionally, the study
 7

identified a high prevalence of NCD vulnerability among the undergraduate population,

attributed to unhealthy lifestyles and behaviors.

9. A retrospective (cohort) study was conducted by Khowaja, P.A. et al. in 2022. "The
Burden of Non-Communicable Diseases in the Middle-Aged Population of Karachi,
Pakistan." The study registered a total of 318 Type II diabetic patients, comprised of 91
males (28.6%) and 227 females (71.4%). A complete medical history and physical
examination were performed for all registered patients. A questionnaire consisting of 22
variables was developed and administered to identify the burden of diabetes and
dyslipidemia. This study aimed to determine the burden of diabetes mellitus in the
middle-aged group (ages 36 to 56) and established its association with obesity, sedentary
lifestyles, and high HbA1c levels.

10. A cross-sectional study was conducted by Seema, S et al 2021. Prevalence and

contributing factors for adolescent obesity in the present era. Involving a total of 385
adolescents from the district of Rohtak, Haryana. The study employed a cluster sampling
technique, randomly selecting five schools from a total of 15 schools in the district using
a lottery method. Data collection was performed using standardized questionnaires, along
with validated and calibrated height meters and weighing devices. The results of this
study indicate that healthcare practitioners and policymakers need to be aware of the
prevalence of and contributing factors to teenage obesity. Adolescents need to adopt
practices such as healthy eating habits, avoiding smoking, and engaging in regular
physical activity. Failure to address obesity may increase their risk of developing chronic
non-communicable diseases in adulthood and later life stages.
 8

Methods
Study Design:

It will be an observational cross-sectional survey-based study.

Study Setting:

It will be conducted in urban and rural areas of Hyderabad, Sindh.

Sample Size:

The sample size will be collected according to WHO data with an expected prevalence of non-
communicable disease (52%), confidence interval (95%), and margin of error (5%), the
calculated sample size will be 384 Data Collection:

Sample Technique:

Stratified random sampling ensures equal representation of urban and rural participants by first
dividing the population into two groups: urban and rural. Within each group, cluster sampling is
employed to select specific urban neighborhoods and rural villages. Finally, simple random
sampling is used within these clusters, selecting participants from household lists or
hospital/clinic records to achieve a representative sample.

Inclusion Criteria:

Urban and rural populations of Hyderabad Sindh Pakistan.

Ages above 30 years to 64 years are also included.
Both male and female.

Exclusion Criteria:

Individuals who have moved to urban or rural areas within the last year.
Pregnant Woman.
Individuals with severe conditions of comorbidity.
 9

Households where eligible participants refuse to participate.

Data Collection Procedure:

Informed consent forms will be signed by each (for ethical participant) gloves and sanitizers (for
hygiene and safety during the data collection).

Data Collection Tool:

Data will be collected through face-to-face interviews using a modified WHO STEPS
questionnaire for (behavioral and demographic data), stadiometer for (height measurement),
digital weighing scale for (weight measurement), measuring tape for (waist circumference
measurement) and digital sphygmomanometer for (blood pressure measuring). Missing data will
be completed through follow-ups.

Statistical Analysis Procedure:

Data will be analyzed through SPSS version 22. Descriptive Statistics For continuous variables
(e.g., age, blood pressure, blood sugar), calculate the mean, median, and standard deviation. For
categorical variables (e.g., gender, type of non-communicable disease), summarize the data using
frequency counts and percentages.
Comparative Analysis To compare categorical variables, such as the prevalence of diabetes
between urban and rural areas, use the chi-square test (χ²). For continuous variables, such as
mean blood pressure levels, apply the independent t-test for normally distributed data or the
Mann-Whitney U test for non-normally distributed data when comparing urban and rural
populations.

Ethical Considerations:

This study will be adhere to ethical guidelines outlined by the Declaration of Helsinki. Before
participation, all individuals will provide written informed consent. Participants' confidentiality
and anonymity will be maintained, and all data will be securely stored with restricted access.
Ethical approval will be obtained from the relevant institutional review board. Additionally,
participants will have the right to withdraw at any stage without any consequences.
 10

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