Introduction
Hypertension is
one of the major risk factors for global mortality and is estimated to have
caused 9.4 million deaths, according to the WHO Global Status Report on
Non-communicable Diseases in 2014 1.
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The National High Blood Pressure
Education Program Coordinating Committee of the National Heart, Lung, and Blood
Institute in United States released the Seventh Report of the Joint National
Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (the JNC 7 report), on May 14th, 2003 2.
According to this report, a systolic blood pressure (SBP) less than 120 mm Hg
and diastolic blood pressure (DBP) less than 80 mm Hg was considered as normal
blood pressure and a systolic BP of 120 to 139 mm Hg and/or a diastolic BP of
80 to 89 mm Hg was considered as pre-hypertension. The definition of
pre-hypertension remains the same in the latest JNC-8 report published in 2014 3.The
objective of defining this classification of blood pressure was to draw the
attention of clinicians and public in the prevention of hypertension in healthy
people in the pre-hypertensive range of blood pressure. Various studies
conducted in India have shown the prevalence of pre-hypertension in the age
group 20–30 years to be ranging from 24.6 to 65% 4-9.Although pre-hypertension is an asymptomatic condition, it
chronically evolves into a major risk factor for cardiovascular,
cerebrovascular, and renal diseases that, in turn, represent crucial causes of
morbidity and mortality.
Stress can cause hypertension through repeated blood pressure
elevations as well as by stimulation of the nervous system to produce large
amounts of vasoconstricting hormones that increase blood pressure. In
these days, stress has become a
prevalent part of people’s lives in very early stage of life; therefore the
effect of stress on blood pressure is of
increasing relevance and importance in young adults.
Objectives
Primary Objective:
To find prevalence of pre-hypertension among University Students
(18-30 years).
Secondary Objective:
To find out association between pre-hypertension and stress
among University Students (18-30 years).
Methodology
Study design:
Cross sectional study.
Study
period: Two months (April-May 2018).
Study
population: University Students of Central India (18-30 years).
Sample size: Sample size has been estimated by
OpenEpi software Version 3 using following assumptions-
1.
Two
sided significance level (1-alpha): 95%
The
estimated sample size is 200.
Sampling strategy: University
students (Undergraduate, Postgraduate, and PhD) from different colleges of
Central India (18-30 years) will be potential participants of the study. We will offer participation till
desired number of participants is recruited.
Inclusion
Criteria: University Students
between 18-30 years (Undergraduate, Postgraduate and PhD).
Exclusion
Criteria: Known hypertensive (both primary and secondary) already on
treatment for hypertension and those not consenting for voluntary participation.
Data collection: Data will be collected by individually
interviewing the participant maintaining confidentiality and privacy. A
structured questionnaire will be prepared. Questionnaire will have socio demographic
variables, blood pressure readings, perceived stress scale. We will be using
the 10 point Perceived Stress Scale that has already been extensively used and
validated in India.
Operational definitions:
Pre Hypertension: Systolic Blood Pressure of 120 to 139 mm Hg and/or
a diastolic Blood Pressure of 80 to 89 mm Hg is considered as pre-hypertension 10.
Stress: Psychological stress has been defined
as the extent to which persons perceive (appraise) that their demands
exceed their ability to cope.
Measurement Tools:
1. A
pre-tested questionnaire will be administered to the subjects after obtaining
their consent. The questionnaire will comprise socio demographic variables like
name, age, gender, profession, category of study, marital status, whether
living with family or not and family history of hypertension and psychiatric
disorder.
2. Three
consecutive measurements of systolic and diastolic blood pressure will be
measured by appropriately sized cuff and the bell of a standard stethoscope,
with at least 1 min between assessments after the participant has rested
for 5 min in a sitting position. Average blood pressure will be calculated
arithmetically for the 3 measurements of each systolic and diastolic blood
pressure. Missing values will be excluded from being included in the study. Blood
pressure classification will be done using JNC 7 algorithm 11. Pre hypertension is defined as
systolic blood pressure (SBP) measurement of 120–139?mmHg or diastolic blood
pressure (DBP) of 80–89?mmHg in people who are not taking antihypertensive
medication. Hypertension is defined as SBP ?140 mmHg and/or DBP
?90 mmHg and/or current use of antihypertensive medication. Normotension
is defined as BP values <120/80 mmHg in students who are not taking
antihypertensive medication 12. All
respondents will be asked if they have ever been diagnosed with hypertension
and if they did, whether or not they have been taking any kind of drugs or
other treatment for the last 2 weeks and last 12 months.
3. 10 point Perceived Stress
Scale will be used which has already been extensively used and validated in
India. The Perceived Stress Scale (PSS)
is a classic stress assessment instrument. The tool, while originally developed
in 1983, remains a popular choice for helping understand how different
situations affect feelings and perceived stress. The questions in this scale
ask about the feelings and thoughts during the last month. In each case, they
will be asked to indicate how often they felt or thought a certain way.
4.
For
each item 0=never; 1=almost never; 2=sometimes; 3=fairly often; 4=very often
Interpretation will be done as follows: First, reversing the scores for questions 4, 5, 7, and 8. On these
4 questions, the score will be changed as-
0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0.
Addition of the scores for each item will be done to get a total.
Individual scores
on the PSS can range from 0 to 40 with higher scores indicating higher
perceived stress.
?Scores ranging from 0-13 would be considered low
stress.
?Scores ranging from 14-26 would be considered moderate
stress.
?Scores ranging from 27-40 would be considered
high perceived stress.
Plan of analysis: Analysis will be done using Epi-info software.
Descriptive analysis using frequency and proportion will be carried out. Odds
ratio with 95% confidence intervals will be estimated for studying
associations.
Ethical considerations: This study will be initiated only after
approval from the institutional ethical committee. A written informed consent
will be taken from the Young Adults participating in this study. The young
adults detected with pre-hypertension will be referred to the physician for
counseling and treatment. Those found with high scores of stress will also be counseled
regarding management of stress.
Implications
Pre-hypertension
elevates the risk of Cardiovascular Diseases, and that of end-stage renal
disease. Cardiovascular morbidities are increasing among
pre-hypertensive individuals compared to normal. Pre-hypertension may also be
associated with on-going Cardiovascular changes. It is
necessary to screen the pre-hypertensive individuals in early age so as to
prevent them from progressing towards full blown hypertension. As pre
hypertensive stage is asymptomatic, there should be screening strategies for
pre-hypertension at an early age and National programs should be initiated for Young
Adults in the country. This study will also focus on counseling for
psychological stress management and lifestyle modification which can help to
prevent significant mortalities and morbidities among the Youth. It is necessary
to identify risks associated with pre-hypertension in young adults, and
improving our prevention strategies at both the individual and population
levels.
Given the high incidence of stress and
pre-hypertension among Young Adults, this intervention may have the potential
to result in substantial savings for the nation.