Risk Factors for Hypertension in Indonesian Hajj Pilgrims: A Systematic Review and Meta-Analysis

Background

Hypertension is a leading cause of morbidity and mortality among Indonesian Hajj pilgrims, a large and high-risk population with many elderly individuals. This study aims to quantitatively synthesize evidence on risk factors for hypertension in this specific population.

Methods

Following a pre-registered protocol (PROSPERO: CRD420251084054), a systematic literature search was conducted in major international and national databases up to June 2025. This review included analytical observational studies. Two reviewers independently performed study selection, data extraction, and risk of bias assessment (JBI checklist). A random-effects meta-analysis was performed, and the certainty of evidence was assessed using the GRADE framework.

Results

Five cross-sectional studies involving 286,987 pilgrims were included. The meta-analysis identified several significant risk factors for hypertension: advanced age, a history of Diabetes Mellitus (pooled OR: 1.86; 95% CI [1.72, 2.01]; I ² =0%), obesity/excess BMI (pooled OR: 1.39; 95% CI [1.26, 1.53]; I ² =34%), and a family history of hypertension (pooled OR: 1.70; 95% CI [1.29, 2.23]; I ² =92%). Dyslipidemia was not found to be a statistically significant risk factor (pooled OR: 1.18; 95% CI [0.99, 1.40]; I ² =94%). The certainty of evidence was rated low to moderate.

Conclusion

Advanced age, Diabetes Mellitus, obesity, and family history are major risk factors for hypertension in Indonesian Hajj pilgrims. These findings support a policy shift towards long-term health coaching and proactive screening during the extensive Hajj waiting period to improve pilgrim health outcomes.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• This is the first systematic review and meta-analysis to quantitatively synthesize evidence on hypertension risk factors specifically for the large and unique population of Indonesian Hajj pilgrims.

• The review methodology was robust, following a pre-registered PROSPERO protocol and PRISMA 2020 guidelines, with two independent reviewers involved in all stages of study selection, data extraction, and quality assessment to minimize bias.

• The evidence base consists solely of observational, primarily cross-sectional studies, which limits the ability to establish causality between the identified risk factors and hypertension.

• The included studies exhibited significant heterogeneity in the definitions of some exposures (e.g., dyslipidemia) and population characteristics, which impacted the consistency and certainty of some pooled estimates.

• The analysis relies on data from published studies and may be limited by potential residual confounding from variables not consistently reported in the primary articles, such as specific lifestyle factors (diet, physical activity).