Prevalence of prehypertension among the adults of

department of health sciences, NCS university

system, Peshawar

Research Project Report

BS (Hons) Medical lab Technology (MLT)

By

Sumaira Niaz

Tariq Khan

Shakir Islam

NCS University System

Peshawar, Khyber Pakhtunkhwa, Pakistan
Session (2014-2018)
Prevalence of prehypertension among the adults of
department of health sciences, NCS university
system, Peshawar

A research project report submitted in the partial fulfillment of the

requirement for the degree of

BS Medical Lab Technology (MLT)

By

Sumaira Niaz 2014/KMU/NCSPMS/28

Tariq Khan 2014/KMU/NCSPMS/39

Shakir Islam 2014/KMU/NCSPMS/29

NCS University System

Peshawar, Khyber Pakhtunkhwa, Pakistan
Session (2014-2018)
 CERTIFICATE

This research project reported by Sumaira Niaz, Tariq Khan, and Shakir Islam is
accepted in its present form, by the department of health sciences, NCS university
system, as satisfying thesis requirements for the award of degree BS in MLT.

Supervisor: ____________________

Khayam ul Haq

Co-Supervisor: ____________________

Dr. Abdul Haq (PT)

External Examiner: ____________________

( )

Executive Director: ____________________

(Mr. Mohkim Ali)

Date: _____________
 DEDICATION
To all paramedics’ students

i
 DECLARATION
We hereby declare that the work accomplished in this thesis is our own research effort
carried out in the department of health Sciences, NCS university system, Peshawar,
KPK. The thesis has been written and composed by us. The material contained in this
thesis is our original work and we have not presented any part of this thesis/work
elsewhere for any other degree. We have tried our best to avoid plagiarism,
falsification and fabrication. We understand that we may be held responsible in case
faulty, non-authentic or plagiarized results found in the dissertation.

Name(s):
Sumaira Niaz: _____________

Tariq Khan: _____________

Shakir Islam: ____________

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 ABSTRACT
Background & objectives: Pre-hypertension is associated with an increased risk of
the development of hypertension and subsequent increased risk of cardiovascular
diseases. The aim of this study was to determine the prevalence of pre-hypertension
among the adults of department of health Sciences, NCS University system.

Materials and methods: In this descriptive cross-sectional study a representative

sample of 176 adults of department of health sciences, NCS university system, were
selected using a systemic random sampling method. A sphygmomanometer device
was used to measure the blood pressure. The measurements and demographics were
recorded on a purposely designed questionnaire. It was followed by data analysis via
SPSS software.

Results: The prevalence of prehypertension was 50.57% (n=89) followed by 31.25%

of normotensive and 18.19% were undiagnosed hypertensives. There was a
statistically significant association of gender with prehypertension (P=0.036). Male
gender was found to be more prehypertensive i.e. 39.8% as compared to female
gender i.e. 10.8%.

Conclusion: Prehypertension was recorded alarmingly high in our study population.

Its occurrence was found statistically significant with male gender and is at increased
risk of developing hypertension.

Key words: Blood pressure, hypertension and prehypertension.

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 ACKNOWLEDGMENT
Praise be to ALLAH, his majesty for his uncountable blessings and best prayers and
peace be upon his messenger Mohammed, his pure descendent and his family and his
noble companions.

First, we would like to thank our families, without their love and support over the
years; none of this would have been possible. They have always been there for our
and we thankful for everything they have helped us achieved.

Then we would like to thank our supervisor Mr. Khayam ul Haq and co-supervisor
Dr Abdul Haq (PT) for help and guidance throughout this thesis work which is
unmeasurable and without it we would not be able to complete our research work

We are particularly grateful to Dr Babar Ali (PT) for his help in measurement of
blood pressure. We are also very grateful to coordinator Allied health sciences Mr.
Amir Waleed for providing us blood pressure measuring instrument.

We are very thankful to Mr. Shahid for his helping us in SPSS for data analysis and
to give guidelines about our research project.

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 TABLE OF CONTENT

DEDICATION ................................................................................................................ i
DECLARATION ...........................................................................................................ii
ABSTRACT ................................................................................................................. iii
ACKNOWLEDGMENT............................................................................................... iv
TABLE OF CONTENT ................................................................................................. v
LIST OF ABBREVIATIONS ......................................................................................vii
LIST OF TABLES ..................................................................................................... viii
LIST OF FIGURES ...................................................................................................... ix
1. INTRODUCTION.................................................................................................... 1
1.1 Blood Pressure ......................................................................................................... 1
1.2 Blood Pressure regulation Mechanism .................................................................... 2
1.2.1 Short-Term Regulation..................................................................................... 2
1.2.2 Long-Term Regulation ..................................................................................... 2
1.2.2.1 By Regulation of Extracellular Fluid Volume .......................................... 3
1.2.2.2 Through renin-angiotensin mechanism .................................................... 3
1.2.3 Hormonal mechanism for regulation of blood pressure ................................... 3
1.2.3.1 Hormones which increase blood pressure................................................ 4
1.2.3.2 Hormones which decrease blood pressure ............................................... 4
1.2.4 Local mechanism for regulation of blood pressure .......................................... 4
1.2.4.1 Local vasoconstrictors .............................................................................. 4
1.2.4.2 Local vasodilators .................................................................................... 5
1.3 Disorders of Blood Pressure .................................................................................... 5
1.3.1 Hypertension: ................................................................................................... 5
1.3.1.1 Types of hypertension ............................................................................... 5
1.3.1.2 Epidemiology of hypertension .................................................................. 6
1.3.1.3 Risk factors of hypertension ..................................................................... 6
1.3.1.4 Sign and Symptoms of hypertension ......................................................... 8
1.3.1.5 Management of hypertension.................................................................... 8
1.3.2 Prehypertension: ............................................................................................... 9
1.4 Literature review: ................................................................................................... 10

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 1.4.1 Prehypertension status world wide ................................................................. 10
1.4.2 Prehypertension in medical students .............................................................. 11
1.4.3 Prehypertension status in Pakistan ................................................................. 12
1.5 Rational and objective of study.............................................................................. 13
2. MATERIALS AND METHODS .......................................................................... 13
2.1 Flow Chart ............................................................................................................. 13
2.2 Study design and duration ...................................................................................... 13
2.3 Study Settings: ....................................................................................................... 14
2.4 Sample Size calculation: ........................................................................................ 14
2.5 Sampling Technique: ............................................................................................. 14
2.6 Sample selection criteria ........................................................................................ 15
2.6.1 Inclusion Criteria: ........................................................................................... 15
2.6.2 Exclusion Criteria:.......................................................................................... 15
2.7 Data collection procedure ...................................................................................... 15
2.7.1 Questionnaire ................................................................................................. 15
2.7. 2 Blood pressure measurement ........................................................................ 16
2.8 Statistical analysis .................................................................................................. 16
3. RESULTS ............................................................................................................... 17
3.1 Population characteristics: ..................................................................................... 17
3.2 Prevalence of prehypertention ............................................................................... 18
3.3 Chi square analysis: ............................................................................................... 19
4. DISCUSSION ......................................................................................................... 21
Limitations ................................................................................................................... 22
5.1 Conclusions ........................................................................................................... 23
5.2 Recommendations ................................................................................................ 23
Annexure-1 ................................................................................................................. 30

vi
 LIST OF ABBREVIATIONS
Blood Presure ( BP)

Prehypertention (PHTN)

Hypertention (HTN)

Systolic blood presure (SBP)

Diastolic blood presure (DBP)

Body Mass Index (BMI)

Pulse pressure (PP)

Mean arterial blood pressure (MABP)

Bachelor of Science (BS)

National college of sciences (NCS)

Khyber-Pakhtunkhwa (KPK)

Dietary Approaches to Stop Hypertension (DASH)

Endothelium-Derived Constricting Factors (EDCF).

Extracellular Fluid (ECF)

Endothelins (ET),

Angiotensin Converting Enzyme (ACE)

vii
 LIST OF TABLES

Table 3.1 Baseline characteristics of study population…………………………….17

Table 3.2 Chi-square analysis……………………………………………………...19

viii
 LIST OF FIGURES
Fig 1.1 Flow chart…………………………………………………………13

Fig.2.1 Sample size determined in Open Epi (version 3) software……..14

Fig 3.1 Blood pressure status in study population…………………………17

Fig 4.1 Recommendation………………………………………………….23

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 1-INTRODUCTION

1. INTRODUCTION
1.1 Blood Pressure

The arterial blood pressure is defined as the lateral pressure exerted by the column of
blood on the wall of arteries. The pressure is exerted when blood flows through the
arteries (1) . Generally, the term blood pressure (BP) refers to arterial blood pressure.
It is further expressed in following four terms.

1.1.1 Systolic blood pressure

1.1.2 Diastolic blood pressure

1.1.3 Pulse pressure

1.1.4. Mean arterial blood pressure.

1.1.1 Systolic blood pressure

The systolic blood pressure (SBP) is defined as the maximum pressure exerted in the
arteries during systole of heart. Normal systolic pressure ranges from 110 mmHg
to140 mm Hg.

1.1.2 Diastolic blood pressure

The diastolic blood pressure (DBP) is defined as the minimum pressure exerted in the
arteries during diastole of heart. Normal diastolic pressure ranges from 60 mmHg to
80 mmHg.

1.1.3 Pulse pressure

The pulse pressure is the difference between the systolic pressure and diastolic
pressure. Normal pulse pressure is 40mmHg.

1.1.4 Mean arterial blood pressure

The mean arterial blood pressure (MABP) is the average pressure existing in the
arteries. It is not the arithmetic mean of systolic and diastolic pressures. It is the
diastolic pressure plus one third of pulse pressure. To determine the mean pressure,
diastolic pressure is considered than the systolic pressure. It is because; the diastolic
period of cardiac cycle is longer (0.53 second) than the systolic period (0.27 second).

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 1-INTRODUCTION

Normal mean arterial pressure is 93 mm Hg (80 + 13 = 93). The formula to calculate

mean arterial blood pressure is given below. Mean arterial blood pressure = Diastolic
pressure + 1/3 of pulse pressure (2, 3).

1.2 Blood Pressure regulation Mechanism

Our body has four regulatory mechanisms to maintain the blood pressure within
normal limits (4).

1.2.1 Nervous mechanism or short-term regulatory mechanism

1.2.2 Renal mechanism or long-term regulatory mechanism

1.2.3 Hormonal mechanism

1.2.4 Local mechanism.

1.2.1 Short-Term Regulation

The nervous regulation is rapid among all the mechanisms involved in the regulation
of arterial blood pressure. When the pressure is altered, nervous system brings the
pressure back to normal within few minutes. Although nervous mechanism is quick in
action, it operates only for a short period and then it adapts to the new pressure.
Hence, it is called short-term regulation. The nervous mechanism regulating the
arterial blood pressure operates through the vasomotor system (5).

1.2.2 Long-Term Regulation

The kidneys play an important role in the long-term regulation of arterial blood
pressure. When blood pressure alters slowly in several days/months/years, the nervous
Regulation of blood pressure by baroreceptor mechanism Arterial Blood Pressure
mechanism adapts to the altered pressure and loses the sensitivity for the changes. It
cannot regulate the pressure any more. In such conditions, the renal mechanism
operates efficiently to regulate the blood pressure. Therefore, it is called long-term
regulation. Kidneys regulate arterial blood pressure by two ways:

1. By regulation of extracellular fluid (ECF) volume

2. Through renin angiotensin mechanism (6).

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 1-INTRODUCTION

1.2.2.1 By Regulation of Extracellular Fluid Volume

When the blood pressure increases, kidneys excrete large amounts of water and salt,
particularly sodium, by means of pressure diuresis and pressure natriuresis. Pressure
diuresis is the excretion of large quantity of water in urine because of increased blood
pressure. Even a slight increase in blood pressure doubles the water excretion.
Pressure natriuresis is the excretion of large quantity of sodium in urine. Because of
diuresis and natriuresis, there is a decrease in ECF volume and blood volume, which
in turn brings the arterial blood pressure back to normal level. When blood pressure
decreases, the reabsorption of water from renal tubules is increased. This in turn,
increases ECF volume, blood volume and cardiac output, resulting in restoration of
blood pressure (7).

1.2.2.2 Through renin-angiotensin mechanism

Source of renin secretion, formation of angiotensin and conditions when renin is

secreted (8). When blood pressure and ECF volume decrease, renin secretion from
kidneys is increased. It converts Angiotensinogen into angiotensin I. This is converted
into angiotensin II by ACE (angiotensin converting enzyme). Angiotensin II acts in
two ways to restore the blood pressure (9).

i. It causes constriction of arterioles in the body so that the peripheral resistance is

increased and blood pressure rises. In addition, angiotensin II causes constriction of
afferent arterioles in kidneys, so that glomerular filtration reduces. This results in
retention of water and salts, increases ECF volume to normal level. This

in turn increases the blood pressure to normal level(10).

ii. Simultaneously, angiotensin II stimulates the adrenal cortex to secrete aldosterone.

This hormone increases reabsorption of sodium from renal tubules. Sodium
reabsorption is followed by water reabsorption, resulting in increased

Regulation of blood pressure by renin angiotensin mechanism. ACE = Angiotensin

converting enzyme. Cardiovascular System ECF volume and blood volume. It
increases the blood pressure to normal level (11).

1.2.3 Hormonal mechanism for regulation of blood pressure

Many hormones are involved in the regulation of blood pressure. Hormones, which
increase or decrease the arterial blood pressure are given below (12).

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 1-INTRODUCTION

1.2.3.1 Hormones which increase blood pressure

1. Adrenaline

2. Noradrenaline

3. Thyroxine

4. Aldosterone

5. Vasopressin

6. Angiotensin

7. Serotonin

1.2.3.2 Hormones which decrease blood pressure

1. Vasoactive Intestinal Polypeptide

2. Bradykinin

3. Prostaglandins4.Histamine

4. Acetylcholine

5. Atrial Natriuretic Peptide

6. Brain Natriuretic Peptide

7. C- type Natriuretic Peptide

1.2.4 Local mechanism for regulation of blood pressure

In addition to nervous, renal and hormonal mechanisms, some local substances also
regulate the blood pressure. The local substances regulate the blood pressure by
vasoconstriction or vasodilatation (12).

1.2.4.1 Local vasoconstrictors

The local vasoconstrictor substances are derived from vascular endothelium. These
substances are called endothelium-derived constricting factors (EDCF). Common
EDCF are endothelins (ET), which are peptides with 21 amino acids. Three types of
endothelins ET1, ET2 and ET3 are identified so far. Endothelins are produced by
stretching of blood vessels. These peptides act by activating phospholipase, which in
turn activates prostacyclin and thromboxane A2. These two substances cause
constriction of blood vessels and increase the blood pressure (13).

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 1-INTRODUCTION

1.2.4.2 Local vasodilators

Local vasodilators are of two types; Vasodilators of metabolic origin and Vasodilators
of endothelial origin.

1.3 Disorders of Blood Pressure

Blood pressure is the pressure exerted on walls of the blood vessels by circulating
blood. Along with body temperature, respiratory rate, and pulse rate, blood pressure is
one of the four main vital signs monitored by medical professionals (14). Regulated
by the nervous and endocrine systems, blood pressure fluctuates somewhat
throughout the day depending on factors such as activity level, the body's circadian
rhythm, stress and other emotional reactions, sleep, and digestion (15). The body has
many mechanisms to control blood pressure, including changing the amount of blood
the heart pumps, the diameter of the arteries, and the volume of blood in the
bloodstream. When a disease state causes blood pressure to stay persistently high,
low, or erratic, problems can arise. The most common blood pressure disorders are
high blood pressure (hypertension) and low blood pressure (hypotension). Both have
many causes and can range in severity from mild to dangerous (16).

In the following sections, hypertension and prehypertension has been discussed

separately.

1.3.1 Hypertension:

Hypertension occurs when blood pressure within the arteries puts too much
mechanical stress on the artery walls. This causes the heart to work harder. It also
leads to unhealthy tissue growth within the walls of the arteries, and thickening and
weakening of the heart muscle. A blood pressure reading of 140/90 mm Hg is
generally considered to be hypertensive. Unless long-standing and untreated,
hypertension doesn't usually cause any noticeable symptoms. Fig 1.1 represents the
types of hypertension defined by joint national committee on prevention detection
evaluation and treatment of high blood pressure (17).

1.3.1.1 Types of hypertension

The figure 1.1 contain types of hypertension.

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 1-INTRODUCTION

Fig. 1.1. Types of hypertension.

1.3.1.2 Epidemiology of hypertension

Hypertension is considered as one of the major non communicable disease burden and
effect approximately 37-55% of adult’s population worldwide (3). In the united states
reported an increased in prevalence from 23.9% in 1988-1994 to 28.5% in 1999-
2000.Compared to USH European Countries have higher prevalence of hypertension
(2). In Switzerland the prevalence of hypertension varied with age and gender
between 20% and 50%. Hypertension is a condition that afflicts almost 970 million
people worldwide (18). Hypertension is responsible for 7.5 million death and 12.8%
of all death worldwide in Pakistan 18% adults and 33% of adults above the age of 45
year is hypertensive (19). Only 50% of population in Pakistan is diagnosed and only
half of these are treated while only 12.5% were adequately controlled (19). Some
reports suggest that the prevalence of Hypertension is rapidly increasing in
developing countries and is one of the leading causes of death and disability (20).

1.3.1.3 Risk factors of hypertension

The following mentioned ones are risk factors of hypertension. Each one is discussed
briefly.

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 1-INTRODUCTION

1.3.1.3.1 Advancing age

The older you are the more likely you are to get high blood pressure. As we age, our
blood vessels gradually lose some of their elastic quality, which can contribute to
increased blood pressure. However, children can also develop blood pressure (17).

1.3.1.3.2 Sex
Until age 64, male are more likely to get high blood pressure then women are,
at 65 and older age, women are more likely to get high blood pressure, while
high blood pressure is not directly related to gender, throughout women’s life’s
health issue like pregnancy etc, can increase the risk of high blood pressure
(17).

1.3.1.3.3 Family history

If your parents or other closed blood relatives have high blood pressure, there’s
an increase chance that you will get high blood pressure (21).

1.3.1.3.4 Sedentary life style

A sedentary life style that includes little are no physical activity at all. Someone living
such a life style could experience serious consequences as result, such as increaser in
risk factor of developing type2 diabetes, increase risk of heart diseases, increase risk
of hypertension (high blood pressure in arteries) (22).

1.3.1.3.5 Smoking, high cholesterol diet

Smoke, exposure to other people’s smoke, increased the risk of heart disease for
nonsmokers. Secondhand more than half of our people have high blood pressure
because of high cholesterol level(23).

1.3.1.3.6 Obesity
If the body mass index is more then (30-39.9) these people have more risk to
developed hypertension then the normal(24).

1.3.1.3.7 Diabetes and hyperlipidemia high intake of alcohol

More people with diabetes developed high blood pressure. Secondhand, regularly
heave use of alcohol can cause many health problems, including heart failure, stroke
and an irregular heartbeat. It can cause your blood pressure to increase dramatically
and can also increase risk of cancer, obesity, alcoholism etc. (25).

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 1-INTRODUCTION

1.3.1.4 Sign and Symptoms of hypertension

Hypertension is largely asymptomatic, and over 40% of adults with hypertension are
unaware of their condition (26) . The following mentioned ones are usually found sign
and symptoms in hypertensive patients.

a: No specific complains other than elevated systolic or diastolic blood pressure (27).

b: Morning occipital headache

c: Dizziness; Painless head discomfort with many possible causes included.

Disturbance of vision, the brain, balance system of the inner near hypertension,
gastrointestinal causes (28).

d: Fatigue; weakness and mental or another materials cause by repeated variation of

stress (29).

e: Blurred vision; Blurred is the lose of sharpness of eye site making objects appear
out of focus and hazy(30).

1.3.1.5 Management of hypertension

1.3.1.5.1 Goals of therapy

The ultimate public health goal of antihypertensive therapy is the reduction of

cardiovascular and renal morbidity and mortality. Since most persons with
hypertension, especially those age >50 years, will reach the DBP goal once SBP is at
goal, the primary focus should be on achieving the SBP goal. Treating SBP and DBP
to targets that are <140/90 mmHg is associated with a decrease in CVD
complications. In patients with hypertension and diabetes or renal disease, the BP goal
is <130/80 mmHg (31).

1.3.1.5.2 Lifestyle modification

Adoption of healthy lifestyles by all persons is critical for the prevention of high BP
and is an indispensable part of the management of those with hypertension. Major
lifestyle modifications shown to lower BP include weight reduction in those
individuals who are overweight or obese, adoption of the Dietary Approaches to Stop
Hypertension (DASH) eating plan25 which is rich in potassium and calcium, dietary
sodium reduction, physical activity, 28, 29 and moderation of alcohol consumption.
Lifestyle modifications reduce BP, enhance antihypertensive drug efficacy, and
decrease cardiovascular risk. For example, a 1,600 mg sodium DASH eating plan has

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 1-INTRODUCTION

effects similar to single drug therapy. Combinations of two (or more) lifestyle
modifications can achieve even better results (32).

1.3.1.5.3 Pharmacologic treatment

There are excellent clinical outcome trial data proving that lowering BP with several
classes of drugs, including angiotensin converting enzyme inhibitors (ACEIs),
angiotensin receptor blockers (ARBs), beta-blockers (BBs), calcium channel blockers
(CCBs), and thiazide-type diuretics, will all reduce the complications of
hypertension(33). Thiazide-type diuretics have been the basis of antihypertensive
therapy in most outcome trials. In these trials, including the recently published
Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial,
diuretics have been virtually unsurpassed in preventing the cardiovascular
complications of hypertension. The exception is the Second Australian National
Blood Pressure trial which reported slightly better outcomes in White men with a
regimen that began with an ACEI compared to one starting with a diuretic. Diuretics
enhance the antihypertensive efficacy (34).

Once antihypertensive drug therapy is initiated, most patients should return for
follow-up and adjustment of medications at approximately monthly intervals until the
BP goal is reached. More frequent visits will be necessary for patients with stage 2
hypertension or with complicating comorbid conditions(35). Serum potassium and
creatinine should be monitored at least 1–2 times/year.60 After BP is at goal and
stable, follow-up visits can usually be at 3- to 6-month intervals. Comorbidities, such
as heart failure, associated diseases such as diabetes, and the need for laboratory tests
influence the frequency of visits. Other cardiovascular risk factors should be treated to
their respective goals, and tobacco avoidance should be promoted vigorously. Low-
dose aspirin therapy should be considered only when BP is controlled, because the
risk of hemorrhagic stroke is increased in patients with uncontrolled hypertension(36).

1.3.2 Prehypertension:
The seventh report of the joint national committee on prevention detection evaluation
and treatment of high blood pressure (JNC7) defined the prehypertension (pre HTN)
as a blood pressure (BP) of 120-139 mmHg systolic and or 80-89mmHg diastolic
(17), which in the past was called transient hypertension, borderline hypertension, or
high normal BP.

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 1-INTRODUCTION

Hypertension affects approximately 50 million individuals in the United States and

approximately 1 billion worldwide. As the population ages, the prevalence of
hypertension will increase even further unless broad and effective preventive
measures are implemented. Recent data from the Framingham Heart Study suggest
that individuals who are normotensive at age 55 have a 90 percent lifetime risk for
developing hypertension (37) .

The relationship between BP and risk of CVD events is continuous, consistent, and
independent of other risk factors. The higher the BP, the greater is the chance of heart
attack, heart failure, stroke, and kidney disease. For individuals 40–70 years of age,
each increment of 20 mmHg in systolic BP (SBP) or 10 mmHg in diastolic BP (DBP)
doubles the risk of CVD across the entire BP range from 115/75 to 185/115 mmHg
zThe classification “prehypertension,” introduced in this report (table 1), recognizes
this relationship and signals the need for increased education of health care
professionals and the public to reduce BP levels and prevent the development of
hypertension in the general population.

Prehypertension has no clinical symptoms and therapy for it is not recommended for
various reasons (38, 39), but by detecting prehypertension some remedial measures
must be adopted and some changes in life style should be done to prevent
hypertension and its consequences as age advances.

1.4 Literature review:

The following literature review is about the prevalence and risk factors of
prehypertension in different centuries. From this literature review it is estimated that
the prevalence of prehypertension has a different pattern in various countries.

1.4.1 Prehypertension status world wide

Data from the 1999 and 2000 national health and nutrition examination survey
(NHANESIII) estimated that the prevalence of prehypertension among adults in the
United States was 13%. The prevalence of pre hypertension in NHANESIII was
higher among men than women (39% and 23%) respectively (40).

Few data described potential racial difference in the prevalence of pre hypertension or
racial difference in the prevalence with rick factors and other clinical variables (40).

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 1-INTRODUCTION

One study show that the prevalence of pre hypertension differed by region and ranged
between 51% for whites in the stroke buckle to 66% for black individuals living in the
stroke belts (40). The prevalence of pre hypertension was higher in black participants
across all age and gender strata, 58.9% of black males had pre hypertension whereas
47.4% of whites males had pre hypertension (40)

The prevalence of pre hypertension in the conducted by Anand N Shukla et al.,

reported that the prevalence of pre hypertension apparently in healthy western Indian
population was 40% (41). The study conducted by Mohammad Hussein BadaKhash
and his Coworker show that the prevalence of prehypertension in an urban population
in Iran was 30% (42). The study conducted by Dahai yu and his coworker showed that
the overall prevalence of prehypertension among Chinese adults was 21.9%. The
prevalence was 25.7% in men and 18.0% in women (43). The study conducted by
income salmon and his Coworkers show that the prevalence of prehypertension
among adults in the hohoe municipality of Ghana was 25.4% (44).The study
conducted by Mohammad Ibrahimi Ali raza and his co-worker show that the
prevalence of prehypertension in the Mashhad Iran was 12% (45). The study
conducted by Muhammad Syed Esam and Ansari Shamshad Husain on the prevalence
of prehypertension and hype retention and Ruler Bareilly show that the prevalence of
prehypertension and hypertension was (27.2% and 27.4%) respectively (46). The
study conducted by deep Sheikh and co-worker on association of non-commendable
dieses and risk factor and prehypertension and Garhwali region of north India show
that prevalence of prehypertension shoe (33.4%) (47)

1.4.2 Prehypertension in medical students

The study conducted of prehypertension and hypertension and the medical students of
northern border university and Aurar and Saudi Arabia show that (52.1% in female
and 58.8% male) were prehypertensive (48)

The study conducted on the prevalence of prehypertension among the adults and west
Africa show that among the 150 participant adults with prehypertension (41%) of
them at low prehypertension (120-129mmHg and 80-84mmHg) compare to (59%)
who had high prehypertension (130-139mmHg and 95-89mmHg) in term of systolic
blood pressure and diastolic blood pressure respectively (49)

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The study conducted prevalence and risk factor of prehypertension and hypertension
in south china show that the prevalence of prehypertension and hypertension was
(33.2% and 29.0%) respectively (50)

The study conducted on prevalence and incident of prehypertension and hypertension

in the in postmenopausal Hispanic women result from the women health initiative
show that the prevalence of prehypertension and hypertension were (34.7% and
38.3% (51).

The relationship between prehypertension and hypertension and periodontal dieses of

prospective cohort study in janpan by Yuya Kawabata and co-worker shoe that
prevalence of prehypertension and hypertension were (34.1% AND 4.2%)
respectively (52)

The study conducted the prevalence of prehypertension and hypertension among

secondary school students by Jamal Qaddimi shoe that prevalence of hypertension
and prehypertension were (18.7% and 40.5%) respectively (53)

The study conducted on prehypertension among young adults (22-30 years) and costal
village of Udupi district and southern India by Sanjja Kani show that the prevalence
of prehypertension was (45.2%) (54)

Prehypertension by Kyoung-Soon HongMD in division of cardiology department of

internal medicine, Chunchon Sakared hot hospital collage of medicine Hallym
university Chan chino Korea show that in US show that the prevalence of
prehypertension , Hypertension , Normotention were (31%,29%and39%) respectively.
Thus (60%) of US adults have prehypertension. Aged adjusted the overall prevalence
of prehypertension among Chan chino city resident age over (45 and was 32%) in the
Keelung community based integrated screening study of Taiwan the prevalence rate
(31.2%) for prehypertension and (29.4%) for hypertension (55)

1.4.3 Prehypertension status in Pakistan

In Pakistan, numerous studies are available regarding hypertension prevalence and its
associated risk factors. It has been speculated that of number of patients suffering
from hypertension in Pakistan is increasing rapidly nowadays (56). Despite that, very
few private organizations focus on CVD prevention and health promotion in
collaboration with international organizations(57). To the authors knowledge, data
regarding prehypertension prevalence, its associated risk factors and its awareness is
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 1-INTRODUCTION

lacking. Awareness studies are strictly needed about prehypertension as it has been
strongly associated with hypertension and subsequent cardio related diseases.

1.5 Rational and objective of study

In 2003, JNC- 7 published its updated report regarding management and prevention of
hypertension for worldwide clinical settings. This report came up with more rigorous
control of hypertension by defining a new term i.e. prehypertension. Patients with
prehypertension are at increased risk for progression to hypertension and to
subsequent cardiovascular diseases (17). Soon after this publication, worldwide
studies were conducted to estimate the true prevalence of prehypertension (40-42).
However, scenario in Pakistan regarding prehypertension is gruesome due to paucity
of information about its prevalence and awareness. Therefore, the purpose of this
study was to determine the prevalence of prehypertension by focusing on the adults of
department of health sciences, NCS university system, Peshawar, KPK.

13
 2. MATERIALS AND METHODS

2. MATERIALS AND METHODS

2.1 Flow Chart

Internal review committee (IRC)

approval

Systemic sampling

Selected participants

Questionnaire distribution Measurements

(close-ended)

Socio-demographics & Blood Pressure

related risk factors (avg. of 2 readings)

Data analysis (via

SPSS)

Fig. 2.1 Working flow chart

2.2 Study design and duration

A single centred, descriptive cross-sectional study was designed to determine the

prevalence of prehypertension among adults of department of health sciences, NCS
university system. This sort of design aim for estimating the prevalence of a
disease/phenomenon by taking a cross-section of the target population It measure
exposure (risk factors) and outcome at a same time but no causal relationship can be

13
 2. MATERIALS AND METHODS

made between them (58). The duration of study was from February 2018 to May
2018.

2.3 Study Settings:

This study was conducted in department of Health Sciences, NCS University system,
Peshawar, KPK. This institute was established in 2008 in Peshawar and currently
consist of four different disciplines of health sciences. These are as follows; a) BS
Medical lab Technology (MLT), b) BS Dental Technology (DT), c) BS Doctor of
physical therapy (DPT), and d) BS Medical imaging technology (MIT).

2.4 Sample Size calculation:

For sample size calculation, Open Source Epidemiologic Statistics for Public Health
(OpenEpi) software, version 3 was used. This software is free and open source for
epidemiologic statistics (www.OpenEpi.com).

Sample size calculated was 188 (Fig.2.2).

Fig 2.2 Sample size determined in OpenEpi (version 3) software.

2.5 Sampling Technique:

For the selection of sample, mixed sampling technique i.e. systemic sampling
technique was adopted. This technique was used to provide known chance of
selection to all the adults at the institute. For this purpose, sampling frame (complete

14
 2. MATERIALS AND METHODS

list of information of target population, acquired officially) was generated. Sampling

interval (k) was calculated by dividing total no of data (i.e. N=651) by sample size
calculated (i.e. n=180);

Sampling interval (k) = 651/180 = 3.61 (or app. 4)

The starting point selected by simple random sampling (SRS) technique was 03 from
first interval (i.e. 4). From the rest of the intervals every third participant was selected
then which constituted the calculated sample size.

2.6 Sample selection criteria

2.6.1 Inclusion Criteria:

All the Adults, irrespective of gender, of department of health sciences, NCS

University system, Peshawar were included.

2.6.2 Exclusion Criteria:

Adults with already diagnosed hypertension and other than the included ones were
excluded.

2.7 Data collection procedure

All the ethical issues related to the study were thoroughly discussed with internal
review committee (IRC), NCS University system. After ensuring to take all the
measures and ethical considerations, the institute granted us the permission to carry
out the study.

The primary objective of this study was achieved by measuring the blood pressure of
all the respondents with the help of sphygmomanometer device by a trained person.
This and along with other useful data (socio-demographics and related risk factors)
was recorded on a close-ended questionnaire.

2.7.1 Questionnaire

A close-ended and anonymous questionnaire (annexure-I) was designed after

reviewing the relevant and published literatures. It included demographic variables
(like name, age, ethnicity etc.), measurement (Blood pressure) and questions about
some relevant risk factors (like family history of hypertension, daily exercise status,
marital status etc.). Verbal consent was obtained from all the respondents before their
participation in this study.

15
 2. MATERIALS AND METHODS

2.7. 2 Blood pressure measurement

BP was measured by trained person using sphygmomanometer device. The subject

had rested for at least 5 mints in a chair. The arm was placed at the heart level. The
measurement was taken from right arm. Two measurements were taken with the help
of mercury sphygmomanometer with at least 3 mints between successive
measurements. The means of two measurements were used for SBP and DBP values.

Before the BP measurement, the subjects were directed to avoid cigarette smoking,
coffee tea, any food and exercise for at least 30 mints.

The subjects were divided into three categories based on their BP readings as per JNC
VII guidelines (59).

i. Normotensive (NT); If SBP is < 120 mmHg and DBP is < 80mmHg.
ii. Prehypertensive (PHT); If either SBP is between 120 to 139 mmHg or DBP is
between 80-89 mmHg but not qualifying for hypertension.
iii. Hypertensive (HTN); if either SBP ≥ 140 mmHg or DBP ≥ 90mmHg

2.8 Statistical analysis

Statistical Package for Social Sciences (SPSS) Version 22.0 was used for the
statistical analysis of the data collected from a representative sample of the students of
department of Health sciences, NCS university system, Peshawar. For the socio
demographic variables, descriptive statistics were computed which is stated (in
tabulated and bar chart forms) as suitably in mean, frequencies and standard
deviation. The associations between each of the socio-demographic variables and the
prevalence of prehypertension among the study participants were also computed by
using chi square tests. The p-values less than or equal to 0.05 were taken as
statisticaly significant for all statistical tests.

16
 3. RESULTS

3. RESULTS
3.1 Population characteristics:

The sample size calculated was 188 for this study. However, our final sample size was
176 as non-respondent rate was 12 (6.38%). All the selected participants were adults
of department of health sciences, NCS university system, Peshawar, KPK. Table 3.1
represents the characteristics of studied participants. Minimum and maximum age
observed was 18 and 66 years, respectively.

Variables

Gender n (%)

Male 124 (70.5%)

Female 52 (29.5%)

Age (mean ± SD) years 22.26 ± 4.79

History of Hypertension in family n (%)

Male 44 (25.0%)

Female 21 (11.9%)

Discipline Status n (%)

Medical lab technology (MLT) 42 (23.9 %)

Doctor of physical therapy (DPT) 87 (49.4%)

Dental technology (DT) 27 (15.3%)

Medical imaging technology (MIT) 10 (5.7 %)

Supporting Staff 5 (2.8%)

Administration staff 5 (2.8%)

Ethnicity n (%)

Pathan 172 (97.7%)

Punjabi 1 (0.6%)

Christian 3 (1.7 %)

Marital Status n (%)

Married 16 (9.1 %)

Un married 155 (88.1%)

Widowed 0 (0%)

Other 5 (2.8%)

17
 3. RESULTS
Daily Exercise status

Yes 47 (26.7%)

No 129 (73.2%)

Living Status n (%)

Home 78 (44.3%)

Hostel 97 (55.1%)
Table 3.1 Baseline characteristics of study population.
Others 1 (0.6%)

3.2 Prevalence of prehypertention

Fig 3.1 illustrates the blood pressure status of studied participants. The prevalence of
prehypertension, indicated in pink bar, was 50.57% (n=89) followed by normotensive,
indicated in green bar, was 31.25% and undiagnosed hypertensive, indicate in red bar,
was 18.19%.

Fig 3.1 blood pressure status in study population

18
 3. RESULTS

3.3 Chi square analysis:

The table 3.2 illustrates some potential risk factors of prehypertension in study
population. The independent variables like gender, daily exercise status, family
history of hypertension and living status or accommodation status of students, were
cross-tabulated with our dependent variable i.e. blood pressure status. It was followed
by chi-square test to check any statistically significant association between them.

There was a statistically significant association of gender with prehypertension

(P=0.036). Male gender was found to be more prehypertensive i.e. 39.8% as
compared to female gender i.e. 10.8%. Proportion of male students is high in this
institute as compared to females. This factor may act as a confounding variable to
infer that male gender is at more risk towards prehypertension in our studied
population.

Blood pressure status

Normotensive Prehypertensive Hypertensive P

Variables Total X2
value
N % N % N %

Male 124 36 20.5% 70 39.8% 18 10.2%

Gender* 6.635 .036
Female 52 19 10.8% 19 10.8% 14 8.0%

Yes 47 15 8.5% 25 14.2% 7 4.0%

Daily
.478 0.788
exercise No 129 40 22.7% 64 36.4% 25 14.2%

Married 16 4 2.3% 10 5.7% 2 1.1%

Marital Unmarrie 155 48 27.3% 77 43.8% 30 17.0%

4.072 0.396
status d
Other 5 3 1.7% 2 1.1% 0 0.0%

Home 78 23 13.1% 43 24.4% 12 6.8%

Living status Hostel 97 32 18.2% 45 25.6% 20 11.4% 2.849 0.583

Other 1 0 0.0% 1 0.6% 0 0.0%

Family Yes 65 25 14.2% 33 18.8% 7 4.0%

history of HT 4.831 .089
No 111 30 17.0% 56 31.8% 25 14.2%

Table 3.2. Potential risk factors of prehypertension in study population

statistical association, HT; hypertension

19
 3. RESULTS

For the rest of independent variables, we could not find any statistically significant
association with prehypertension (table 3.2). However, high percentages of unmarried
i.e. 43.8% individuals (vs 5.7% married) and individuals with no daily exercise status
i.e. 36.4% (vs 14.2% individuals with daily exercise) were observed more in
prehypertensive group as compared to normotensive group.

Moreover, It was alos observed that major portion of prehypertensive individuals i.e.
31.8% belonged to the family with no history of hypertension (table 3.2).

20
 4. DISCUSSION

4. DISCUSSION
This study was designed to assess the prevalence of prehypertension in adults of
department of health sciences, NCS university system, Peshawar. Majority of the
adults were Pushtoon students belonging to various areas of Khyber Pakhtunkhwa
(KPK), Pakistan. To the authors’ knowledge, this is the first study conducted in this
region with major emphasis on prehypertension prevalence and its awareness.

This study revealed that half of our study population (i.e. 50.57%) were
prehypertensive, a serious health concern. Moreover, 18.8% were found to be
hypertensive which is comparable to other studies done in Peshawar, about prevalence
of hypertension (19, 60). A study of 100 medical students in Davangere, India,
showed that the prevalence of prehypertension was 64% (61) while another study of
500 medical students in a Mangalore College, India, showed a point prevalence of
55.4% (62). High prevalence of prehypertension (i.e.56.07%) was also observed in
medical students of Northern Border University in Arar city, Saudi Arabia (63). Our
study follows all these studies.

Population based studies about prehypertension prevalence reflects data with

relatively low prevalence of prehypertension. The National Health and Nutrition
Examination Survey (NHANES) reported that the overall prevalence of
prehypertension in disease free adults from 1999 to 2006 was 36.3%(64). Another
study reported prevalence of prehypertension to be 33.7% in an adult population in
south of Iran (65). A cross-sectional survey in a nationally representative large sample
of Chinese adults reported 21.9% prevalence of prehypertension (43). Nearly similar
rates have been reported from Japan (66), Korea (67), Jamaica (68), and India (69).

The discrepancies observed locally and globally with reference to prehypertension

prevalence seems multifactorial. The likely reasons may include social and cultural
differences, target population and its size, sample collecting method, geographical and
racial differences.

In our study, chi-square test of independence was used to examine the dependence of
dependent variable (blood pressure status) with independent variables like gender,
daily exercise, family history of hypertension, marital status and living status. There
was a statistically significant association of gender with blood pressure status
(P=0.036). Males were found to be more prehypertensive i.e. 39.8% as compared to

21
 4. DISCUSSION

females i.e. 10.8%. This pattern is consistent with many other studies (40, 48). For
the rest of independent variables, we could not find any statistically significant
association with prehypertension (table 3.2). Moreover, unlike other studies (63, 69)
family history of hypertension was not associated significantly with prehypertension
in our respondents (P=0.089).

Our findings about prehypertension prevalence are of crucial importance because it

has been estimated that prehypertensive individuals are at more risk to become
hypertensive patients as compared to normotensive individuals (70, 71). If this high
prevalence of prehypertension remains unchecked, it may lead to even higher rates of
clinical hypertension and, subsequently, higher prevalence of CVD mortality (72).

Limitations
The major limitation of this study lies with in the design of this study (i.e. descriptive
cross-sectional study). This design permitted us only one time contact with all the
respondents for measuring of blood pressure. Multiple measurements at regular
intervals are considered more reliable. Moreover, we were unable to asses various
globally reported risk factors (like glucose, cholesterol levels in blood, and body mass
index, life style etc.) related to prehypertension in our study population. Time and
financial constraints were two major reasons for the above-said limitations.

22
 5. CONCLUSION AND RECOMMENDATIONS

5.1 Conclusions

Prehypertension was recorded alarmingly high and occurrence of it was found

statistically significant with male gender. The nature of this study permits us to
extrapolate our finding on the whole population of department of the health sciences,
NCS university system. So, it is inferred that half of the population (esp. males) of the
institute are prehypertensive and are at increased risk of developing hypertension.

5.2 Recommendations
As the half of the study population is found to be prehypertensive, they are strictly
advised to follow the life style modification ,adopted from JNC-7 report (17)
presented in fig. 5.1.

Moreover, prehypertension awareness programmes (with aim of providing free blood

pressure screening and clinical guidance for prehypertensive and hypertensive
individuals) in community and educational institutes should be initiated. This could be
achieved by mutual collaboration of universities, health care professionals and govt.
health agencies.

Fig. 5.1. Recommended life style modifications for prehypertensive individuals 23

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al. Prevalence and determinants of prehypertension in a Japanese general population:
the Jichi Medical School Cohort Study. Hypertension Research. 2008;31(7):1323.
67. Choi KM, Park HS, Han JH, Lee JS, Lee J, Ryu OH, et al. Prevalence of
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68. Ferguson TS, Younger NO, Tulloch-Reid MK, Wright MBL, Ward EM,
Ashley DE, et al. Prevalence of prehypertension and its relationship to risk factors for
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 Annexure-1

NCS UNIVERSITY SYSTEM

DEPARTMENT OF HEALTH SCIENCES

091-9331105, 091-9331205 091-9331305, 091-9331205

QUESTIONNAIRE
Dear participant, this questionnaire has been designed to determine the “prevalence of prehypertension
and its associated risk factors among the adults of department of Health sciences, NCS university
system,”. Being a part of NCS university, you have been selected as a result of systemic random
sampling. The information obtained will be only use for the research purpose and kept highly
confidential.
Note: Tick only the relevant box.

PART-A

1. Subject ID: _______ 2. Age: ______ 3. Gender:  Male  Female

4. Ethnicity:  Pathan  Punjabi  Other (please specify): _______
5. Discipline: DT MLT MIT Faculty staff Admin. Staff Other (please specify): _______

PART-B
1. Blood pressure measurements
Systolic BP: __________ Diastolic BP: ________
2. Marital Status
Married Widowed
Unmarried  Other (specify): ______

3. Living status:
Home Other (specify): _____
Hostel

4. Do you exercise daily (not less than 30 mins)?

Yes  No

5. Family history of hypertension?

Yes No

Thank you for your participation.

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