Arterial hypertension and its covariates among nomadic Raute hunter-gatherers of Western Nepal: a mixed-method study

**Background:** Hunter-gatherer populations traditionally exhibit low prevalence of hypertension and other non-communicable diseases due to high physical activity, low-glycemic diets, and limited access to processed foods. However, socioeconomic transitions and acculturation are associated with rising cardiovascular risk in these groups. The Raute are Nepal's last remaining nomadic hunter-gatherers, yet their cardiovascular health has never been systematically studied. This study aimed to determine hypertension prevalence and associated factors among the nomadic Raute of Western Nepal.

**Methods:** An explanatory sequential mixed-method design was employed between May and September 2021 in Surkhet District, Karnali Province. All eligible males and non-pregnant females aged ≥15 years from the nomadic Raute group were included (n=81 of 85 eligible; 2.4% non-response). Quantitative data were collected via structured face-to-face interviews, anthropometric measurements (height, weight, BMI), and blood pressure measurements using a calibrated digital automatic BP monitor (OMRON M6). Three BP readings were taken after 15 minutes of rest; the mean of the second and third readings was used. Hypertension was defined as SBP ≥140 mm Hg and/or DBP ≥90 mm Hg per JNC 7 criteria. Qualitative data came from 15 in-depth interviews with Raute participants (10 males, 5 females; 33.3% hypertensive) and 4 key informant interviews (healthcare worker, two social workers, one expert). Thematic analysis was performed using Dedoose V.8.2.14.

**Key Results:** The median age was 35 years (IQR: 26–51); 53.1% were male; none had formal education. Hypertension prevalence was 30.9% overall (48.8% in males, 10.5% in females). Males had a 4.6-fold higher prevalence than females. Prevalence increased with age: 20.0% among those 15–34, 33.3% among 35–54, and 52.9% among ≥55 years. Current alcohol use was 91.4% (92.1% females, 90.7% males); current tobacco use was 70.4% (57.9% females, 81.4% males). Among 15–24 year-olds, >68% drank alcohol and 42% used tobacco in the past 30 days. Hypertensive participants had higher median drinking days (15 vs 10 days/month) and tobacco use days (25 vs 15 days/month) than non-hypertensives. Median BMI was 21.1 kg/m² (IQR: 19.2–22.9); 17.3% were underweight, 8.6% overweight, and none obese. Only 8% of hypertensive participants were aware of their diagnosis; none had received treatment. Qualitative analysis identified four major themes: (1) socioeconomic transition from a barter-based to a cash-based economy driven by government allowances (5000 NPR/person/month); (2) changing patterns of alcohol and tobacco use with increased commercial product consumption; (3) dietary transition from traditional forest foods to purchased grains, packaged/processed foods; and (4) continued reliance on traditional healing with growing awareness of modern healthcare.

**Clinical Implications:** This study reveals a hypertension burden among nomadic Raute hunter-gatherers (30.9%) that exceeds the general Nepalese population (19.1%–25.2%) and most studied traditional hunter-gatherer groups (e.g., Tsimane 2.9%, Pygmies 3.3%, Hadza 13%). The extremely high rates of alcohol and tobacco use, particularly among youth, combined with dietary transition toward processed foods, signal an emerging cardiovascular disease epidemic in this endangered population. The near-zero awareness and treatment rates highlight critical gaps in healthcare access. Context-specific, culturally sensitive interventions—including health education, screening programs, and policies addressing commercial alcohol/tobacco availability—are urgently needed to prevent hypertension-related morbidity and mortality. The findings also underscore how socioeconomic transitions and market integration can rapidly alter cardiovascular risk profiles in traditional populations, with implications for other indigenous groups undergoing similar changes.