complete thesis of hypertension (2)
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complete thesis of hypertensionTRANSCRIPT
ASSESSMENT OF AWARENESS AND KNOWLDGE OF
HYPERTENSION IN UNIVERSITY OF BALOCHISTAN QUETTA
2014
by
TO FULFILL THE REQUIREMENT OF SUBJECT
CLINICAL PHARMACY II
ABDUL AHAD
UNIVERSITY OF BALOCHISTAN QUETTA
ASSESSMENT OF AWARENESS AND KNOWLDGE OF
HYPERTENSION IN UNIVERSITY OF BALOCHISTAN QUETTA
2014
by
ABDUL AHAD
FACULTY OF PHARMACY
UNIVERSITY OF BALOCHISTAN, QUETTA.
APPROVAL CERTIFICATE
It is certified that thesis entitled “Assessment of Awareness and knowledge of
hypertension in University of Baluchistan Quetta.” Submitted by ABDUL AHAD, to
fulfill the requirement of subject “clinical pharmacy II” as per course of Pharm-D, is his
original work done under my supervision. The matter embodied in this thesis is original
and has not been the submitted or published before.
SUPERVISER
Dr. Noman-Ul-HaqAssistant ProfessorDepartment of pharmacy practiceFaculty of PharmacyUniversity Of Baluchistan, Quetta.
I
II
DECLARATION
The study titled as “Assessment of Awareness and Knowledge of Hypertension in
University of Baluchistan Quetta.” conducted by Abdul Ahad supervised by Dr.
Noman Ul Haq is to fulfill the requirements of subject “Clinical Pharmacy II” as per
Pharm-D course of study. It is declared that, this piece of work has not been published
anywhere or submitted before and it’s my original work and submitted first time.
Internal Examiner:
Dr. Noman-Ul-HaqAssistant ProfessorDepartment of pharmacy practiceFaculty of PharmacyUniversity Of Baluchistan, Quetta.
External Examiner
III
DEDICATION
I dedicate my piece of work to my loving and respectable parents
And to my friends who made this all possible by their support,
Love and motivation.
ACKNOWLEDGEMENT
IV
I would specially thank ALLAH ALMIGHTY who helped me and made this all possible.
This research would never had been completed without Dr. Noman ul Haq, my
supervisor; I would like to thank him for his encouragement, patience and expert
advice. I wish to
Express my thanks to Mr. Aqeel Naseem for his guidance and help. And finally
special thanks go to my friends (Dr.Ashfaq Ahmed, Abdul Hafeez, Abdul Ghaffar, Abdul
Bari, Abdul Rehman, Abdul Ghayas, Qamer Ibrahim, Zaheer Ahmed) and my family
members who have supported me and motivated me throughout my research.
V
ABBREVIATIONS
AHA American Heart Association
AIRE Acute Infarction Ramipril Efficacy
HF Heart failure.
ARB Angiotensin receptor blockers
ACE-I inhibitors Angiotensin converting enzyme
BP Blood Pressure.
BB Beta Blockers.
CVD Cardio vascular diseases.
CCB Calcium channel blocker
HTN Hypertension
DBP Diastolic Blood pressure.
EGFR Estimate Glomerular filtration rate.
BUN Blood urine nitrogen.
BMI Body Mass Index.
ABPM Ambulatory Blood Pressure Monitoring
HBPM Home Blood Pressure Monitoring
CKD Chronic kidney disease.
BHS British Hypertension Society
COX-1 & 2 Cycloxygenase-1 & 2.
VI
DASH Dietary approval to stop hypertension.
DM Diabetes mellitus.
MI Myocardial infarction
IHD Ischemic Heart disease.
JNC-VII Joint National Committee.
NHS National Health Service.
mmHg Millimeter mercury.
NSAIDs Non-steroidal anti-inflammatory drugs.
ISH International Society of Hypertension
PAD Peripheral Arterial Diseases.
SBP Systolic Blood pressure.
SPSS Statistical package for the social sciences.
WHD World Hypertension day.
WHL World Hypertension League.
VII
TABLE OF CONTENT
ApprovalCertificate......................................................................................................I
Declaration....................................................................................................................II
Dedication....................................................................................................................III
Acknowledgement ......................................................................................................IV
Abbreviations…………………………………………………………………………V
ABSTRACT…………………………………………………………….….……........1
CHAPTER 1: INTRODUCTION...............................................................................3
CHSPTER 2: LITRATURE REVIEW…………………………………..……..…..6
2.1: Hypertension………………………………………………….…………….….….7
2.1: Hypertension…………………………………………………………………..…..7
2.3: Classification of blood pressure……………………………………………...……9
2.3.1: Primary (essential) hypertension………………………....................................11
2.3.1.1: Neural hypothesis……………………………………………………….……11
2.3.1.2: Peripheral Auto regulatory Theory…………………………………………..11
2.3.1.3: Renin-Angiotensin-Aldosterone (RAA) hypothesis………………………….12
2.3.1.4: Defective vasopressor mechanisms hypothesis…………………………...…12
2.3.1.5: Defects in membrane permeability theory……………………….…………..12
2.4: Secondary hypertension………………………………………………………….13
2.4.1: Oral contraceptives……………………………………………………………..13
2.4.2: Renal parenchymal disease……………………………….…………………….13
2.4.3: Reno vascular disease…………………………………………………….…….14
2.4.4: Primary aldosteronism…………………………………………………….…….14
VIII
2.4.5: Coarctation of the Thoracic Aorta…………...……………….…………..……14
2.5: Risk factors for hypertension……………………………………………...…….15
2.6: Signs and symptoms of hypertension……………………………………..…......16
2.7: Cardiovascular disease risk…………………………………………………..…..17
2.8: Benefits of lowering blood pressure…………………………………………..…17
2.9: Blood pressure control rates…………………………………………………..…18
2.10: Self-measurement of blood pressure…………………………………….….….18
2.11: Factors that Affect Blood Pressure………………………….……………….….19
2.11.1: Exercise………………………………………………………………….….…19..2.11.2: Nutrition………………………………………………………………….……19
2.11.3: Alcohol………………………………………………………………….……..21
2.11.4: Stress……………………………………………………………………….…..22
2.11.5: Smoking…………………………….……………………………………...…..22
2.12: Causes of Hypertension…………………………………………………….…....22
2.13: Society and culture………………………………………………………………24
2.13.1: Awareness…………………………………………………………………..…24
2.13.2: Economics……………………………………………………….….………....25
2.14: Lifestyle Changes to Treat High Blood Pressure………………..…….….…..…25
2.15: Symptoms of hypertension…………………………………………………...….30
2.16: Diagnoses of hypertension………………………………………………..…..….32
2.16.1: Manual sphygmomanometers………………………………………..…………33
IX
2.16.1: Mercury sphygmomanometers……………………………….…….………..…33
2.16.2: Aneroid……………………………………………….………...….…………...33
2.16.3: Digital………………………………………………..…………………….…...33
2.17: Hypertension Treated……………………………………………….…………….34
2.17.1: Beetroot juice………………………………………………………………..….35
2.17.2: Lead author………………………………………………………..………….…36
2.17.3: Yoga……………………………………………………………………………..36
2.18: Drugs to Treat High Blood Pressure………………………………………………37
2.19:Knowledge needed by hypertensive patients in the prevention and treatment of hypertension…………………………………………………………………………38
2.19.1: Patient education…………………………………………………………..……38
2.19.2: Hypertension speeds up brain aging………………………………….……..….40
2.20: CONCLUSION……………………………………..….…………..……...…….40
CHAPTER 2: METHODOLOGY........…...................................................................42
3.1: Research Design……………………………………………………………..….…43
3.2: Objective………………………………………………………………………..….43
3.3: Study Tool……………………………………………………………...………..…43
3.4: Study design…………………………………………………………………….….43
3.4: Development of questionnaire…………………………………………………...…44
3.5: Study population and sample size…………………………………………………..44
3.6: Inclusion criteria……………………………………………….………………..…..44
3.6.1: Inclusion criteria were as follows…………………………………….….………..45
3.7: Exclusion criteria………………………………………………………………….…45
X
3.8: Data analysis………………………………………………………….……..……...…45
CHAPTER NO: 3 RESULTS...........................................................................................46
4.1: Demographic Characteristics of Respondents……………………………………..…47
4.2: Awareness and knowledge of hypertension……………………………………..……49
4.3: Source group…………………………………………………………………..….…..51
4.4: Source of information………………………………………………………………...53
CHAPTER NO: 4 DISSCUSSION..................................................................................55
CHAPTER NO: 5 CONCULSION ................................................................................59
5.1: Recommendations..........................................................................................................61
REFRENCES.....................................................................................................................62
LIST OF TABLES
S/NO TITLE PAGE NO
2.1 Classification of Hypertension 10
4.1 Demographic Characteristics of Respondents 47
4.2 Awareness and knowledge of hypertension 49
4.3 Source group 51
4.4 : Source of information 53
ABSTRACT
BACKGROUND
Hypertension is a major health problem in Pakistan. And the purpose of this study to find
awareness and knowledge among university students.
OBJECTIVE
The present study aimed to evaluate the awareness and knowledge of hypertension in
university of Baluchistan Quetta
METHODOLOGY
This was a cross-sectional study covering 321 students, aged 18-30 years, who answered
the hypertension awareness and knowledge questionnaire a written questionnaire was
distributed to students from different departments of university of Baluchistan during the
period from Jun to august 2014. A self-administered questionnaire was used to get
information about demography in a “Yes” and “No” format, and were prepared in English
language. All the students were able to read and write and they filled the questionnaire by
themselves. The collected data were reviewed, coded, verified and statistically analyzed.
Continuous variables were Expressed as mean ±SD, and mean comparison, and categorical
variables are represented in frequency and percentage. Inferential and statistics (Mann
Whitney, Kruskal-Wallis) test were used to differentiate or relate the study variables. P-
value less than 0.05 were considered statistically significant
RESULTS
Three hundred and twenty One students of university of Baluchistan including all
department students were consented to complete the questionnaire. The practices of recent
students from all Departments were better and concomitantly responded the good
1
knowledge near about 85% out of 321. The knowledge about the range of hypertension in
students was about 76%. Eighty three percent student believe that hypertension occurs due
to high salt and fat intake.
CONCLUSION
The findings highlight all students of university of Baluchistan Quetta from different
departments having good knowledge regarding the awareness and knowledgeof
hypertension and needs further more improvement in academic education about the basics
of hypertension. .
2
Chapter 1: Introduction
3
Hypertension is a major contributor to the global disease burden. It poses an important
public health challenge to both economically developing and developed countries,
including Asia. The prevalence and rate of diagnosis of hypertension in children and
adolescents appears to be increasing(Rizwana B. Shaikh)
Hypertension confers the highest attributable risk to deaths from cardiovascular disease
and epidemiological data provide convincing evidence that the risk of cardiovascular
disease related to blood pressure is graded and continuous. This risk is evident even in
childhood; with elevated blood pressure predicting hypertension in adulthood, and adverse
effects of elevated blood pressure in childhood on vascular structure and function,
specifically left ventricular hypertrophy, are already apparent in youth. Reduction of blood
pressure reduces this risk in people with and without hypertension and is a desired goal in
children and adults.(Rizwana B. Shaikh)
Even as most studies describe knowledge of hypertension and its risk factors in older
adults and the elderly, there is a paucity of such data among teenagers and young adults, as
they are considered to be at a lower risk of developing the disease. With a growing
problem of hypertension worldwide, there is a concern that hypertension in young adults
may also be on the rise and that cases are not detected because of inadequate screening in
this age group(Rizwana B. Shaikh).
The epidemiology of demographic transition states that a long-term shift occurs in
mortality and disease patterns, whereby infectious diseases are gradually displaced by
degenerative and man-made diseases as the chief form of morbidity and death.
Furthermore, evidence shows that UAE is a country in transition where people have
adopted western living patterns; risk factors such as sedentary lifestyle; obesity, stress,
4
unhealthy diets; and smoking have all been demonstrated in young adults. The country also
has an increased prevalence of hypertension 19–25%.(Rizwana B. Shaikh)
Knowledge of the predisposing risk factors is vital in the modification of lifestyle
behaviors conducive to optimal cardiovascular health. Measuring and appropriately
disseminating knowledge of the modifiable risk factors at an early age is an essential
preventive educational approach. Strategies to achieve even a modest lowering of the
levels of blood pressure in the population of children and young adults are therefore
important public health goals.(Rizwana B. Shaikh)
5
Chapter 2: Literature review
6
2.1: Hypertension.
Hypertension, also referred to as high blood pressure, is a condition in which the arteries
have persistently elevated blood pressure. Every time the human heart beats, it pumps
blood to the whole body through the arteries. Blood pressure is the force of blood pushing
up against the blood vessel walls. The higher the pressure the harder the heart has to
pump(Collaboration, 2002).
2.2: History
Modern understanding of the cardiovascular system began with the work of
physician William Harvey (1578–1657), who described the circulation of blood in his book
"De motucordis". The English clergyman Stephen Hales made the first published
measurement of blood pressure in 1733. Descriptions of hypertension as a disease came
among others from Thomas Young in 1808 and especially Richard Bright in 1836. The
first report of elevated blood pressure in a person without evidence of kidney disease was
made by Frederick Akbar Mahomed (1849–1884). However hypertension as a clinical
entity came into being in 1896 with the invention of the cuff-based
sphygmomanometer by Scipione Riva-Rocci in 1896.This allowed the measurement
of blood pressure in the clinic. In 1905, Nikolai Korotkoff improved the technique by
describing the Korotkoff sounds that are heard when the artery is auscultated with a
stethoscope while the sphygmomanometer cuff is deflated(Kotchen, 2011).
Historically the treatment for what was called the "hard pulse disease" consisted in
reducing the quantity of blood by bloodletting or the application of leeches. This was
7
advocated by The Yellow Emperor of China, Cornelius Celsius, Galen, and Hippocrates.
In the 19th and 20th centuries, before effective pharmacological treatment for hypertension
became possible, three treatment modalities were used, all with numerous side-effects:
strict sodium restriction (for example the rice diet),sympathectomy (surgical ablation of
parts of the sympathetic nervous system), and pyrogenic therapy (injection of substances
that caused a fever, indirectly reducing blood pressure). The first chemical for
hypertension, sodium thiocyanate, was used in 1900 but had many side effects and was
unpopular. Several other agents were developed after the Second World War, the most
popular and reasonably effective of which were tetra methyl ammonium chloride and its
derivative hexamethonium, hydralazine and reserpine (derived from the medicinal
plant Rauwolfia serpentina). A major breakthrough was achieved with the discovery of the
first well-tolerated orally available agents. The first was chlorothiazide, the
first thiazide diuretic and developed from the antibiotic sulfanilamide, which became
available in 1958. Hypertension can lead to damaged organs, as well as several illnesses,
such as renal failure (kidney failure), aneurysm, heart failure, stroke, or heart attack.
Researchers from UC Davis reported in the Journal of the American Academy of
Neurology that high blood pressure during middle age may raise the risk of cognitive
decline later in life. The normal level for blood pressure is below 120/80, where 120
represents the systolic measurement (peak pressure in the arteries) and 80 represents the
diastolic measurement (minimum pressure in the arteries). Blood pressure between 120/80
and 139/89 is called prehypertension and a blood pressure of 140/90 or above is
considered hypertension.(James, 16 October 2014)
8
The concept of essential hypertension was introduced in 1925 by the physiologist Otto
Frank to describe elevated blood pressure for which no cause could be found. In 1928, the
term malignant hypertension was coined by physicians from the Mayo Clinic to describe a
syndrome of very high blood pressure, severe retinopathy and adequate kidney function
which usually resulted in death within a year from strokes, heart failure or kidney failure
(Kotchen, 2011)
2.3: Classification of blood pressure
Provides a classification of BP for adults ages 18 and older. The classification is based on
the average of two or more properly measured seated BP readings on each of two or more
office visits. In contrast to the classification provided in the JNC 6 report, a new category
designated Prehypertension has been added, and stages 2 and 3 hypertension have been
combined. Patients with Prehypertension are at increased risk for progression to
hypertension; those in the 130–139/80–89 mmHg BP range are at twice the risk to develop
hypertension as those with lower values.(Program, 2004) Internationally for persons 18
years and older, a hypertensive person is regarded as a person with multiple blood pressure
readings of 140/90mmHg or higher (Scribante et al., 2004)
According to the Standard Treatment Guidelines and Essential Drugs List for South Africa
(Organization, 1983), which are used in primary health care clinics, levels of hypertension
in adults are classified as follows
9
Table No 2.1: Classification of Hypertension according to JNC VII
LEVELS OF
HYPERTENSION IN
ADULTS Level of
hypertension
Systolic mmHg Diastolic mmHg
Mild 140-159 90-99
Moderate 160-179 100-109
Severe 180 or more 110 or more
10
Hypertension classification can also be based on cause and severity. Classification of
hypertension according to cause is termed primary and secondary hypertension, and
classification of hypertension according to severity is numerically based on systolic and
diastolic pressure like the values reflected above in table 2.1.
2.3.1: Primary (essential) hypertension
Primary hypertension has an unknown cause and accounts for 90% - 95% of all
hypertension cases. Usually these patients do not have many signs or symptoms.
Headaches sometimes occur – but more so with very high pressures and are localized in
the occipital region. According to Woods,(Sarnak et al., 2003) there are several theories to
explain primary hypertension. Five are discussed here namely neural hypothesis, peripheral
auto regulatory, renin-angiotensin-aldosterone, defective vaso-depressor mechanisms and
defects in membrane permeability theories. These theories are briefly summarized below.
2.3.1.1: Neural hypothesis
If there is an increase in systemic vasoconstriction and myocardial reactivity there is an
increase in adrenergic neural activity(Woods et al., 2005)
2.3.1.2: Peripheral Auto regulatory Theory
If there is a defect in sodium excretion at normal arterial pressures it leads to auto
regulation at higher pressure, for what is necessary for resumption of normal sodium and
water secretion (Woods et al., 2005). Hypertension results from impairment in renal
sodium excretory ability when confronted with a sodium load this defect results in sodium
11
and water retention, and blood volume expansion which increases cardiac output and
consequently, arterial pressure. The resulting tissue hyper perfusion leads to an auto
regulatory vasoconstriction resulting in a sustained increase in peripheral vascular
resistance (Woods et al., 2005)
2.3.1.3: Renin-Angiotensin-Aldosterone (RAA) hypothesis
Increased activity of the renin-angiotensin-aldosterone system, results in expansion of
extracellular fluid volume including the intravascular component and systemic vascular
resistance as well(Woods et al., 2005).
2.3.1.4: Defective vasopressor mechanisms hypothesis
According to(Woods et al., 2005) the concentration of vasodilation substances such as
renal prostaglandins is decreased.
2.3.1.5: Defects in membrane permeability theory
In this case interference with the cellular sodium transport caused by the natriuretic
hormone exists because of a defect in reabsorption of sodium from the renal tubules.
Transport of calcium out of the vascular smooth muscle cell is prevented by the increased
intracellular sodium concentration. Systemic resistance and blood pressure then rise
because of the increased muscle contractility that is caused by the increased calcium
concentration(Woods et al., 2005)
12
2.4: Secondary hypertension
Patients with secondary hypertension have a distinct cause and accounts for 5% - 10% of
all hypertension persons. Patients with secondary hypertension are best treated by
controlling or removing the underlying disease or pathology, although they still may
require antihypertensive drugs.
A few identifiable causes of secondary hypertension are as follows:
2.4.1: Oral contraceptives
The estrogen and progestogen in oral contraceptives increase blood pressure in women.
Blood pressure raises with increased amounts of each
Hormone and the severity also increase with time. In contraceptive users, hypertension is
caused by stimulation of the rennin-angiotensin-aldosterone mechanism which creates
volume expansion. Enhanced blood clot formation, increased coronary artery vascular tone
and increased fibroblast deposition are the structural and functional changes associated
with contraceptive users (Urden et al., 2006)
2.4.2: Renal parenchymal disease
A person with renal parenchymal disease that results in hypertension is usually patients
with chronic glomerulonephritis. If untreated it leads to renal damage and inappropriately
stimulates the renin-angiotensin mechanisms. Infections can also alter renal function
(Urden et al., 2006)
13
2.4.3: Reno vascular disease
Reno vascular disease is the result of stenosis caused by atherosclerosis of the renal
arteries. Over-activity of the renin-angiotensin mechanism leads to a decrease in renal flow
resulting in high blood pressure For some people on high blood pressure medication- such
as ACE inhibitors the problem may be discovered if side effects such as kidney failure or
other severe kidney problems appear. As a result of high blood pressure the condition
causes some of the following complications: congestive heart failure, heart attack and
stroke (Urden et al., 2006)
2.4.4: Primary aldosteronism
Because of an overproduction of aldosterone that is caused by an adenoma on the adrenal
gland it leads to Primary aldosteronism. This overproduction creates an excess salt and
water is refrained which is the meganism behind hypertension in this case. Increased
circulating aldosterone causes renal retention of sodium and water, so blood volume and
arterial pressure increase. Plasma renin levels are generally decreased as the body attempts
to suppress the renin-angiotensin system; there is also hypokalemia associated with the
high levels of aldosterone (Urden et al., 2006)
2.4.5: Coarctation of the Thoracic Aorta
Coarctation, or narrowing of the aorta is a congenital defect that obstructs aortic outflow
leading to elevated pressures proximal to the coarctation. This constriction of the Thoracic
Aorta reduces the lumen of the aorta and results in an elevated arterial pressure in the
upper extremities. In the lower extremities the opposite happens where pressures are very
14
low or absent. In hypertension it leads to vasoconstriction and an increase in fluid volume
as well as alterations in renal function.
There are a few more identifiable causes of hypertension like sleep apnea, drug-induced or
related causes, chronic kidney disease, chronic steroid therapy and Cushing’s syndrome,
pheochromocytoma and thyroid or parathyroid disease(Urden et al., 2006).
2.5: Risk factors for hypertension
Certain risk factors appear to increase the like hood of a person to become hypertensive.
These include:
Family history of hypertension
Race (more common in blacks)
Gender
Diabetes mellitus
Stress
Obesity
High dietary intake of satured fats or sodium
Tobacco use
Hormonal contraceptives
Sedentary lifestyle
Aging (Kannel, 1989)
15
2.6: Signs and symptoms of hypertension
Signs and symptoms of hypertension may include the following:
Blood pressure readings of more than 140/90mmHg, on two or more readings,
taken at two or more visits.
Throbbing occipital headaches upon waking
Drowsiness
Confusion
Vision problems
Nausea (Tuck and Corry, 1989)
Other clinical effects only appear until complications develop as a result of vascular
changes in target organs. These include:
Left ventricular hypertrophy
Angina
Myocardial infarction
Heart failure
Stroke
Transient ischemic attack
Nephropathy
Peripheral arterial disease
Retinopathy (Tuck and Corry, 1989)
16
2.7: Cardiovascular disease risk
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.
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.
The 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. Hypertension prevention strategies are available to achieve this goal.
2.8: Benefits of lowering Blood pressure.
In clinical trials, antihypertensive therapy has been associated with reductions in stroke
incidence averaging 35–40 percent; myocardial infarction, 20–25 percent; and heart
failure, more than 50 percent. It is estimated that in patients with stage 1 hypertension
(SBP 140–159 mmHg and/or DBP 90–99 mmHg) and additional cardiovascular risk
factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1
17
death for every 11 patients treated. In the presence of CVD or target organ damage, only 9
patients would require such BP reduction to prevent a death.
2.9: Blood pressure control rates
Hypertension is the most common primary diagnosis in America (35 million office visits
as the primary diagnosis). Current control rates (SBP <140 mmHg and DBP <90 mmHg),
though improved, are still far below the Healthy People 2010 goal of 50 percent; 30
percent are still unaware they have hypertension. (See table 2.) In the majority of patients,
controlling systolic hypertension, which is a more important CVD risk factor than DBP
except in patients younger than age 50 and occurs much more commonly in older persons,
has been considerably more difficult than controlling diastolic hypertension. Recent
clinical trials have demonstrated that effective BP control can be achieved in most patients
who are hypertensive, but the majority will require two or more antihypertensive drugs. ,
when clinicians fail to prescribe lifestyle modifications, adequate antihypertensive drug
doses, or appropriate drug combinations, inadequate BP control may result.
2.10: Self-measurement of blood pressure
BP self-measurements may benefit patients by providing information on response to
antihypertensive medication, improving patient adherence with therapy, and in evaluating
white-coat hypertension. Persons with an average BP more than 135/85 mmHg measured
at home are generally considered to be hypertensive. Home measurement devices should
be checked regularly for accuracy.
18
2.11: Factors that Affect Blood Pressure
Blood pressure is the force of blood against the walls of the arteries as the heart pumps
blood throughout the body. Many factors affect blood pressure, causing it to change from
day to day and throughout the day. We are unable to control some of the factors that
increase the risk of developing high blood pressure like being African American, over the
age of 35, family history of high blood pressure, or having diabetes, gout or kidney
disease, but the good news is that there are some that we can change! Check out the list
below.
2.11.1: Exercise
Regular exercise, along with an active lifestyle, may decrease blood pressure. To
significantly reduce the risk of developing high blood pressure, it is recommended that
adults participate in 150 minutes a week of cardiovascular exercise such as walking,
cycling and swimming. Increasing daily activity by walking to and from class and work
(rather than taking the bus) and walking up and down stairs (versus riding the elevator),
will also contribute to an active, healthy lifestyle(Kaplan et al., 1999). Make an
appointment with the McKinley Fitness Specialist at Sport Well Center if you have
questions about blood pressure and exercise.
2.11.2: Nutrition
Research has shown that diet affects the development of high blood pressure
(hypertension). The DASH (Dietary Approaches to Stop Hypertension) eating plan is
recommended if your blood pressure is high or if you are at risk for high blood pressure.
19
DASH is a combination diet that is low in fat and rich in fruits and vegetables. It is low in
cholesterol and saturated fat, high in dietary fiber, potassium, calcium and magnesium and
moderately high in protein.
DASH includes more than eight servings of fruits and vegetables daily. Fruits and
vegetables that are particularly high in potassium and magnesium are recommended
including:
Apricots
Artichokes
Bananas
Broccoli
Carrots
Dates
Greens
green and lima beans
green peas
grapefruit
grapes
mangoes
melons
oranges
peaches
pineapple
potatoes
20
prunes
raisins
squash
strawberries
sweet potatoes
tangerines
tomatoes(Kaplan et al., 1999)
Two to three servings of low fat dairy products per day contribute calcium and protein to
DASH. Whole grains from cereals, breads and crackers contribute fiber and energy. Lean
meat, poultry and fish (less than six ounces per day) provide more potassium and protein.
To boost potassium, fiber, protein and energy intake even more, DASH recommends nuts,
seeds or cooked dried beans 4-5 times per week.
Healthy weight management and appropriate intake of salt (sodium) are both very
important in blood pressure control. Try to limit the amount of processed and fast food you
eat and take the salt shaker off the table - don't add salt to food after it is cooked. DASH
helps you eat a healthful diet and can also help manage weight.
2.11.3: Alcohol
Alcohol is a drug, and regular over-consumption can raise blood pressure dramatically, as
well as cause an elevation upon withdrawal. Try to limit alcohol to twice a week and drink
only 1-2 servings (equivalent to two four-ounce glasses of wine, two eight-ounce glasses
of beer or two shots of spirits).
21
Also, remember that alcohol intake can be a factor in weight gain. The current
recommendation is to limit alcohol intake to no more than two drinks per day for most men
and no more than one drink per day for women and lighter-weight persons(HIGH).
2.11.4: Stress
The effects of stress can vary, but long-term, chronic stress appears to raise blood pressure.
Various relaxation techniques such as deep breathing, progressive relaxation, massage and
psychological therapy can help to manage stress and help lower stress-induced blood
pressure elevations(Devereux et al., 1983).
2.11.5: Smoking
Smoking is the third leading cause of death in the United States. Smoking causes
peripheral vascular disease (narrowing of the vessels that carry blood to the legs and arms),
as well as hardening of the arteries. These conditions clearly can lead to heart disease and
stroke and are contributing factors in high blood pressure. Don't start smoking and if you
do smoke, seek assistance with quitting(Kaplan et al., 1999).
2.12: Causes of Hypertension.
Though the exact causes of hypertension are usually unknown, there are several factors
that have been highly associated with the condition. These include:
Smoking
Obesity or being overweight
During adulthood.
22
Diabetes
Sedentary lifestyle
Lack of physical activity
High levels of salt intake (sodium sensitivity). According to the American Heart
Association (AHA), sodium consumption should be limited to 1,500 milligrams per day,
and that includes everybody, even healthy people without high blood pressure, diabetes or
cardiovascular diseases. AHA's chief executive officer, Nancy Brown said "Our
recommendation is simple in the sense that it applies to the entire U.S population, not just
at-risk groups. Americans of all ages, regardless of individual risk factors, can improve the
heart health and reduce their risk of cardiovascular disease by restricting their daily
consumption of sodium to less those 1,500 milligrams." The recommendation was
published in the journal Circulation (November 5th, 2012 issue)
Insufficient calcium, potassium, and magnesium consumption
Vitamin D deficiency
High levels of alcohol consumption
Stress
Aging
Medicines such as birth control pills
Genetics and a family history of hypertension - In May 2011, scientists from the
University of Leicester, England, reported in the journal Hypertension that some
genes in the kidneys may contribute to hypertension.
23
Chronic kidney disease
Adrenal and thyroid problems or tumors.
Statistics in the USA indicate that African Americans have a higher incidence of
hypertension than other ethnicities(Chobanian et al., 2003)
2.13: Society and culture
2.13.1: Awareness
The World Health Organization has identified hypertension, or high blood pressure,
as the leading cause of cardiovascular mortality. The World Hypertension
League(WHL), an umbrella organization of 85 national hypertension societies and
leagues, recognized that more than 50% of the hypertensive population worldwide
is unaware of their condition(Chockalingam, 2007). To address this problem, the
WHL initiated a global awareness campaign on hypertension in 2005 and dedicated
May 17 of each year as World Hypertension Day (WHD) Over the past three years,
more national societies have been engaging in WHD and have been innovative in
their activities to get the message to the public. In 2007, there was record
participation from 47 member countries of the WHL. During the week of WHD, all
these countries – in partnership with their local governments, professional societies,
nongovernmental organizations and private industries – promoted hypertension
awareness among the public through several media and public rallies. Using mass
media such as Internet and television, the message reached more than 250 million
people. As the momentum picks up year after year, the WHL is confident that
almost all the estimated 1.5 billion people affected by elevated blood pressure can
24
be reached.
2.13.2:Economics
High blood pressure is the most common chronic medical problem prompting visits
to primary health care providers in USA. The American Heart Association
estimated the direct and indirect costs of high blood pressure in 2010 as $76.6
billion. In the US 80% of people with hypertension are aware of their condition,
71% take some antihypertensive medication, but only 48% of people aware that
they have hypertension are adequately controlled(Lloyd-Jones et al.,
2010). Adequate management of hypertension can be hampered by inadequacies in
the diagnosis, treatment, and/or control of high blood pressure. Health care
providers face many obstacles to achieving blood pressure control, including
resistance to taking multiple medications to reach blood pressure goals. People also
face the challenges of adhering to medicine schedules and making lifestyle changes.
Nonetheless, the achievement of blood pressure goals is possible, and most
importantly, lowering blood pressure significantly reduces the risk of death due to
heart disease and stroke, the development of other debilitating conditions, and the
cost associated with advanced medical care.(Elliott, 2003)
2.14: Lifestyle Changes to Treat High Blood Pressure
A critical step in preventing and treating high blood pressure is a healthy lifestyle.
You can lower your blood pressure with the following lifestyle changes:
Losing weight if you are overweight or obese.
25
Quitting smoking.
Eating a healthy diet, including the DASH diet (eating more fruits, vegetables, and
low fat dairy products, less saturated and total fat).
Reducing the amount of sodium in your diet to less than 1,500 milligrams a day if
you have high blood pressure. Healthy adults should try to limit their sodium intake
to no more 2,300 milligrams a day (about 1 teaspoon of salt).
Getting regular aerobic exercise (such as brisk walking at least 30 minutes a day,
several days a week).
Limiting alcohol to two drinks a day for men, one drink a day for women(Cohen,
2013).
Ascertain patients’ diet and exercise patterns because a healthy diet and regular
exercise can reduce blood pressure. Offer appropriate guidance and written or
audiovisual materials to promote lifestyle changes.
Education about lifestyle on its own is unlikely to be effective.
Healthy, low-calorie diets had a modest effect on blood pressure in
overweight individuals with raised blood pressure, reducing systolic and
diastolic blood pressure on average by about 5−6 mmHg in trials. However,
there is variation in the reduction in blood pressure achieved in trials and it
is unclear why. About 40% of patients were estimated to achieve a
reduction in systolic blood pressure of 10 mmHg systolic or more in the
short term, up to 1 year.
Taking aerobic exercise (brisk walking, jogging or cycling) for 30–60
26
minutes, three to five times each week, had a small effect on blood pressure,
reducing systolic and diastolic blood pressure on average by about 2–3
mmHg in trials. However, there is variation in the reduction in blood
pressure achieved in trials and it is unclear why. About 30% of patients
were estimated to achieve a reduction in systolic blood pressure of 10
mmHg or more in the short term, up to 1 year.
Interventions actively combining exercise and diet were shown to reduce
both systolic and diastolic blood pressure by about 4–5 mmHg in trials.
About one-quarter of patients receiving multiple lifestyle interventions were
estimated to achieve a reduction in systolic blood pressure of 10 mmHg
systolic or more in the short term, up to 1 year.
A healthier lifestyle, by lowering blood pressure and cardiovascular risk,
may reduce, delay or remove the need for long-term drug therapy in some
patients. Relaxation therapies can reduce blood pressure and individual
patients may wish to pursue these as part of their treatment. However,
routine provision by primary care teams is not currently recommended.
Examples include: stress management, meditation, cognitive therapies,
muscle relaxation and biofeedback.
Overall, structured interventions to reduce stress and promote relaxation
had a modest effect on blood pressure, reducing systolic and diastolic blood
pressure on average by about 3–4 mmHg in trials. There is variation in the
reduction in blood pressure achieved in trials and it is unclear why. About
one-third of patients receiving relaxation therapies were estimated to
27
achieve a reduction in systolic blood pressure of 10 mmHg systolic or more
in the short term, up to 1 year.
The current cost and feasibility of providing these interventions in primary
care has not been assessed and they are unlikely to be routinely provided.
Ascertain patients’ alcohol consumption and encourage a reduced intake if a patient
drinks excessively, because this can reduce blood pressure and has broader health
benefits.
Excessive alcohol consumption (men: more than 21 units/week; women:
more than 14 units/week) is associated with raised blood pressure and
poorer cardiovascular and hepatic health.
Structured interventions to reduce alcohol consumption, or substitute low
alcohol alternatives, had a modest effect on blood pressure, reducing
systolic and diastolic blood pressure on average by about 3–4 mmHg in
trials. Thirty percent of patients were estimated to achieve a reduction in
systolic blood pressure of 10 mmHg systolic or more in the short term, up to
1 year.
Brief interventions by clinicians of 10–15 minutes, assessing intake and providing
information and advice as appropriate, have been reported to reduce alcohol
consumption by one-quarter in excessive drinkers with or without raised blood
pressure, and to be as effective as more specialist interventions.
Brief interventions have been estimated to cost between £40 and £60 per
28
patient receiving intervention. The structured interventions used in trials of
patients with hypertension have not been costed.
Discourage excessive consumption of coffee and other caffeine-rich products.
Excessive consumption of coffee (five or more cups per day) is associated
with a small increase in blood pressure (2/1 mmHg) in participants with or
without raised blood pressure in studies of several months duration.
Encourage patients to keep their dietary sodium intake low, either by reducing or
substituting sodium salt, as this can reduce blood pressure.
Advice to reduce dietary salt intake to less than 6.0 g/day (equivalent to 2.4
g/day dietary sodium) was shown to achieve a modest reduction in systolic
and diastolic blood pressure of 2–3 mmHg in patients with hypertension, at
up to 1 year in trials. About one-quarters of patients were estimated to
achieve a reduction in systolic blood pressure of 10 mmHg systolic or more
in the short term, up to 1 year.
Long-term evidence over 2–3 years from studies of normotensive patients
shows that reductions in blood pressure tend to diminish over time.
One trial suggests that reduced sodium salt, when used as a replacement in
both cooking and seasoning, is as effective in reducing blood pressure as
restricting the use of table salt.
29
Do not offer calcium, magnesium or potassium supplements as a method for
reducing blood pressure.
The best current evidence does not show that calcium, magnesium or
potassium supplements produce sustained reductions in blood pressure.
The best current evidence does not show that combinations of potassium,
magnesium and calcium supplements reduce blood pressure.
Offer advice and help to smokers to stop smoking.
There is no strong direct link between smoking and blood pressure.
However, there is overwhelming evidence of the relationship between
smoking and cardiovascular and pulmonary diseases, and evidence that
smoking cessation strategies are cost effective.
A common aspect of studies for motivating lifestyle change is the use of group
working. Inform patients about local initiatives by, for example, healthcare teams or
patient organizations that provide support and promote healthy lifestyle change.
2.15: Symptoms of hypertension.
There is no guarantee that a person with hypertension will present any symptoms of the
condition. About 33% of people actually do not know that they have high blood pressure,
and this ignorance can last for years. For this reason, it is advisable to undergo periodic
blood pressure screenings even when no symptoms are present. Hypertension is rarely
accompanied by any symptoms, and its identification is usually through screening, or when
seeking healthcare for an unrelated problem. A proportion of people with high blood
30
pressure reports headaches (particularly at the back of the head and in the morning), as
well as lightheadedness, vertigo tinnitus (buzzing or hissing in the ears), altered vision
or fainting episodes These symptoms however are more likely to be related to
associate anxiety than the high blood pressure itself (Marshall et al., 2012).
On physical examination, hypertension may be suspected on the basis of the presence of
hypertensive detected by examination of the optic fundus found in the back of the eye
using ophthalmoscopy(Wong and Mitchell, 2007) .Classically, the severity of the
hypertensive retinopathy changes is graded from grade I–IV, although the milder types
may be difficult to distinguish from each other(Wong and Mitchell,
2007).Ophthalmoscopy findings may also give some indication as to how long a person
has been hypertensive
Extremely high blood pressure may lead to some symptoms, however, and these include:
Severe headaches
Fatigue or confusion
Dizziness
Nausea
Problems with vision
Chest pains
Breathing problems
Irregular heartbeat
Blood in the urine.
31
2.16: Diagnoses of hypertension.
Hypertension may be diagnosed by a health professional who measures blood pressure
with a device called a sphygmomanometer - the device with the arm cuff, dial, pump, and
valve. The systolic and diastolic numbers will be recorded and compared to a chart of
values. If the pressure is greater than 140/90, you will be considered to have hypertension.
Manual sphygmomanometers are used in conjunction with a stethoscope.. The device was
invented by Samuel siegfriedKarl Ritter von baschin 1881(Booth, 1977). Scipione Riva-
Rocci introduced more easily used version in 1896. In 1901, Harvey Cushing modernized
the device and popularized it within the medical community.
A high blood pressure measurement, however, may be spurious or the result of stress at the
time of the exam. In order to perform a more thorough diagnosis, physicians usually
conduct a physical exam and ask for the medical history of you and your family. Doctors
will need to know if you have any of the risk factors for hypertension, such as smoking,
high cholesterol, or diabetes.
If hypertension seems reasonable, tests such as electrocardiograms (EKG) and
echocardiograms will be used in order to measure electrical activity of the heart and to
assess the physical structure of the heart. Additional blood tests will also be required to
identify possible causes of secondary hypertension and to measure renal function,
electrolyte levels, sugar levels, and cholesterol levels.
2.16.1: Manual sphygmomanometers.
32
Require a stethoscope for auscultation (see below). They are used by trained practitioners.
It is possible to obtain a basic reading through palpation alone, but this only yields the
systolic pressure.
2.16.2: Mercury sphygmomanometers.
Are considered to be the gold standard They measure blood pressure by observing the
height of a column of mercury; once made, errors of calibration cannot occur Due to their
accuracy, they are often required in clinical trials of pharmaceuticals and for clinical
evaluations of determining blood pressure for high-risk patients including pregnant
women.
2.16.3: Aneroid.
Sphygmomanometers (mechanical types with a dial) are in common use; they require
calibration checks, unlike mercury manometers. Aneroid sphygmomanometers are
considered safer than mercury based, although inexpensive ones are less accurate. [2] A
major cause of departure from calibration is mechanical jarring. Aneroid mounted on walls
or stands are not susceptible to this particular problem.
2.16.4: Digital.
Using oscillometric measurements and electronic calculations rather than auscultation.
They may use manual or automatic inflation. These are electronic, easy to operate without
training, and can be used in noisy environments. They measure systolic and diastolic
pressures by oscillometric detection, using a piezoelectric pressure sensor and electronic
33
components including a microprocessor. They do not measure systolic and diastolic
pressures directly, per se, but calculate them from the mean pressure
and empirical statistical oscillometricparameters. Calibration is also a concern for these
instruments. Most instruments also display pulse rate. Digital oscillometric monitors are
also confronted with several "special conditions" for which they are not designed to be
used, such as: arteriosclerosis; arrhythmia; preeclampsia; Such people should use analog
sphygmomanometers, as they are more accurate when used by a trained person. Digital
instruments may use a cuff placed, in order of accuracy and inverse order of portability and
convenience, around the upper arm, the wrist, or a finger. The oscillometric method of
detection used gives blood pressure readings that differ from those determined by
auscultation, and vary subject to many factors, for example pulse pressure, heart
rate and arterial stiffness. Some instruments claim also to measure arterial stiffness(Van
Montfrans, 2001). However such machines are not recommended for regular users as
machines that claim to have 3% accuracy rate, are usually inaccurate to over 7%, and even
provided two different readings when checked at the same time. Some of these monitors
also detect irregular heartbeats(Van Montfrans, 2001).
2.17: Hypertension Treated.
The main goal of treatment for hypertension is to lower blood pressure to less than 140/90
- or even lower in some groups such as people with diabetes, and people with chronic
kidney diseases. Treating hypertension is important for reducing the risk of stroke, heart
attack, and heart failure.
34
High blood pressure may be treated medically, by changing lifestyle factors, or a
combination of the two. Important lifestyle changes include losing weight, quitting
smoking, eating a healthful diet, reducing sodium intake, exercising regularly, and limiting
alcohol consumption.
Medical options to treat hypertension include several classes of drugs. ACE inhibitors,
ARB drugs, beta-blockers, diuretics, calcium channel blockers, alpha-blockers, and
peripheral vasodilators are the primary drugs used in treatment. These medications may be
used alone or in combination, and some are only used in combination. In addition, some of
these drugs are preferred to others depending on the characteristics of the patient (diabetic,
pregnant, etc.).
Calcium-channel blockers and cancer risk - postmenopausal females who took calcium-
channel blockers for 10 years were found to be 2.5 times more likely to develop breast
cancer compared to women who never took them or those on other hypertension
medications. If blood pressure is successfully lowered, it is wise to have frequent checkups
and to take preventive measures to avoid a relapse of hypertension.
2.17.1: Beetroot juice.
A research team from Queen Mary, University of London, wrote in the journal
Hypertension that a cup of beetroot juice each day can reduce blood pressure in
hypertensive patients.
35
The researchers started off examining what the impact of consuming nitrates might be on
laboratory rats, and then confirmed their findings with 15 volunteer humans, all with
hypertension.
The following foods are high in nitrates:
Beetroot
Fennel
Cabbage
Lettuce
Radishes
Carrots.
2.17.2: Lead author.
Amrita Ahluwalia, Ph.D., said "Our hope is that increasing one's intake of vegetables with
high dietary nitrate content, such as green leafy vegetables or beetroot, might be a lifestyle
approach that one could easily employ to improve cardiovascular health."
2.17.3: Yoga.
Dr. Debbie Cohen and colleagues from the University of Pennsylvania reported at the
"28th Annual Scientific Meeting" that yoga is effective in reducing blood pressure.
Telemonitoring improves uncontrolled hypertension - researchers reported significant
improvements in the health of hypertensive patients who used telemonitoring, which can
36
be used at home. Patients use a portable system allowing them to record and send their
blood pressure readings straight to the doctor's office in real time.
"Switching off" high blood pressure in the body - scientists from University of California
San Diego have designed molecules that could eventually be used in medications that
"switch off" high blood.
2.18: Drugs to Treat High Blood Pressure
There are several types of drugs used to treat high blood pressure, including:
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin II receptor blockers (ARBs)
Diuretics
Beta-blockers
Calcium channel blockers
Alpha-blockers
Alpha-agonists
Renin inhibitors
Combination medications
Diuretics are often recommended as the first line of therapy for most people who have high
blood pressure.
However, your doctor may start a medicine other than a diuretic as the first line of therapy
if you have certain medical problems. For example, ACE inhibitors are often a choice for a
people with diabetes. If one drug doesn't work or is disagreeable, additional medications or
37
alternative medications may be recommended. If your blood pressure is more than 20/10
points higher than it should be, your doctor may consider starting you on two drugs or
placing you on a combination drug.(Cohen, 2013)
2.19: Knowledge needed by hypertensive patients in the prevention and treatment of
hypertension.
2.19.1: Patient education.
Patient education is essential because patients want information and because recovery
appears to be accelerated in patients who are well informed. The aim is to improve quality
and quantity of life by identifying and modifying risk factors and optimize medical
treatment, in order to achieve this goals patients need to be educated about their condition.
The following is important:
Discuss the importance of regular medical examinations and stress the importance
of compliance.
Smoking - explain that nicotine causes vasoconstriction and an increase in the
heart rate, blood pressure and the force of contraction of the heart and therefore
increased workload and oxygen demand.
Stress - advise patients to avoid upsetting situations and an accumulation of stress
factors by spacing activities, setting aside time for relaxation and be prepared for
boredom, depression and weakness which may be experienced.
38
Diet - explain that salt restriction prevents accumulation of fluid and the resulting
increased cardiac work load. If dietary changes are necessary the help of a
dietician can be enlisted.
Family education - inform families to overcome fears and misconceptions about
the disease, to promote an understanding of drug therapy and diet, to foster an
awareness of signs and symptoms which could be manifestations of trouble and to
help families to identify and deal with stress-provoking situations and learn
methods to support.
The major objective is that hypertensive patients must be involved in their treatment and
management of hypertension. They need to have the necessary information about their
condition to empower them to participate in
Their health condition. It is very important to have an open two- way communication
system between the patient and the care giver. One of the important causes of uncontrolled
blood pressure is poor adherence to therapy. If the patient knows about the following
obstacles it will improve adherence to therapy:
Long duration of therapy.
Educate patients about their disease, let them measure blood pressure at home and involve
the family in treatment.
Side-effects of medication, adjust therapy to prevent and minimize side-effects.
Expensive medications, important to keep care inexpensive and simple.
Maintain contact with patients and encourage a positive attitude about the disease
and to achieve their goals.
39
Encourage lifestyle modifications.
Patients must carry on with their daily living and pill-taking must be integrated in their
routine activities (Seedat and Rayner, 2012)
2.19.2: Hypertension speeds up brain aging.
Young and middle aged people with high blood pressure have a higher risk of accelerated
brain aging,
The risk appears to be there even for those whose elevated blood pressure is not considered
enough for medical intervention.
The authors say their findings should encourage doctors to control patients' blood pressure
early on, even the prehypertensive ones.
The team, led by Professor Charles DeCarli, said they found evidence of structural damage
in white matter, and also volume of gray matter among people with high blood pressure,
including prehypertensive patients in their 30s and 40s. They wrote that "(brain injury)
develops insidiously over the lifetime with discernible effects".(Nordqvist, 26 September
2014)
2.20: CONCLUSION
The hypertensive patient need to know what is their risk factors to prevent any further
developing of illnesses or heart disease. It is very important to increase their awareness of
risk factors so that prevention strategies can be implemented early
. According to the (Atkinson and Veriava, 2006) the following can be seen as major risk
factors:
40
Levels of systolic and diastolic blood pressure
Smoking
Diabetes mellitus
Men >55 years
Women > 65 years
Family history of early onset of cardiovascular disease, Men aged < 55 years and Women
aged < 65 years
Waist circumference abdominal obesity: Men > 102 cm and Women > 88 cm
The literature review of hypertension, its causes, predisposing problems, management and lifestyle
modifications, as well as knowledge needed by hypertensive patients in the prevention and
treatment of hypertension, served as basis to compile a measuring instrument. It was used
to test the knowledge of people with hypertension regarding cardiovascular risk factors.
The survey or test results would be used to make recommendations and to develop
strategies to help them with risk factor modification and to improve their knowledge. The
end goal would be to decrease the mortality and morbidity rates of hypertensive patients
associated with cardiovascular disease.
Chapter 3: Methodology
41
3.1: Research Design
42
The purpose of the present study was to determine the awareness and knowledge of
hypertension among university students, to examine whether age, gender and profession
associated with different knowledge about hypertension. The following methods are used.
3.2: Objective.
Present study is aim to examine the awareness and knowledge of hypertension towards
the students of Baluchistan university Quetta.
3.3: Study Tool
Questionnaires are a less time consuming way of obtaining data from a large group of
people and are less expensive in terms of time and money. The format of the questionnaire
is standard for all respondents or subjects and is not dependent on the mood of the
interviewer or interviewee. The respondents feel a greater sense of anonymity than with an
interviewer and are more likely to provide honest answers or just do not answer a question
which is knowledge related if the answer is not known. These aspects could all contribute
to the validity and reliability of a study.
3.4: Study design.
A cross section study was conducted this method is beneficial to reduce the errors and bias
among the participants.
3.4: Development of questionnaire.
43
Self-administration hand over to the respondents. They took an average of 20-25 min to
complete the questionnaire. The final questionnaire included 12 items. The questionnaire
was developed in English, it was a multiple choice question type and only one response
was correct for each item and also source of information (academic learning, newspaper,
internet, broachers, pictures and printed materials, health workers) was included in
questions. Four questions dealt with the demography of participants, four questions dealt
with the target awareness, two questions with measurement and apparatus, two questions
with the Diagnosis and with the basis of therapy,
3.5: Study population and sample size.
The target sample for this study is the undergraduates’ of university of Baluchistan Quetta
who are under study in their academic session. According to the record, there are around
36 departments and in each department the average number of students are about 500.
3.6: Inclusion criteria.
Convenience sampling was used in this study due to limited patient numbers and the
inclusion criteria. The distributed questionnaires to the first 50 informed. Those participant
are included who are students of UOB and from different departments, age of 18 years or
over and who agreed to participate in the study. The volunteers signed an informed consent
form prior to entering the study, which was approved by the experts of faculty of
pharmacy.
3.6.1: Inclusion criteria were as follows:
44
Students should be able to understand English
Students should have been diagnosed by the doctor as hypertensive
Students should currently receive treatment for hypertension
3.7: Exclusion criteria.
Those who did not agree to participate in the study are excluded from the study
3.8: Data analysis.
The collected data were reviewed, coded, verified and statistically analyzed using the IBM
Statistical package for social sciences (SPSS) software version 20. Variables were
Expressed as mean +SD, and mean comparison.
45
Chapter 4: Results
46
4.1: Demographic Characteristics of Respondents
On 1st June 2014, 321 questionnaires were distributed to the University of Baluchistan
Quetta who are successfully doing their study in University. Out of 321 questionnaires
distributed, a total of 321 students had participated in the study (response rate of 100%).
According to the summary of demographic characteristics of respondents in Table 1, two-
third of the respondents were male (62.9%; n =202) and the rest were female (37.1%;
n=19). As all the respondents came from different batch, so most participant’s aged
between 18 to 24 years old (79.8%; n=203).The total no of 2nd year students are more as
compare to other academic year.
47
Demographic characteristics of respondents (n=321)
Descriptive Frequency percentageAGE GROUP18-24 203 79.825-30 65 20.2ACADEMIC YEAR1st 79 24.62nd 110 34.33rd 75 23.44th 26 8.15th 30 9.3GENDER Male 202 62.9Female 119 37.1
48
4.2: Awareness and knowledge of hypertension
The questions are about awareness and knowledge of hypertension. Total questions are 12
only two questions are about 90% and above the students have knowledge. The two
questions are 80% and above. Four questions have a knowledge of 70% and above. The
remaining 4 questions are about 50% and less than.
49
Awareness and knowledge of hypertension
S/N Questions Yes
No
Don’t know
1 Have you ever heard the disease called Hypertension?
300(93.5)
18(5.6) 3(0.9)
2 Do you agree that Hypertension is high blood pressure?
280(87.2)
28(8.7) 13(4.0)
3 Do you know the normal range of Hypertension? 288(71.0)
71(22.1)
22(6.9)
4 Is the normal range of blood pressure 120/80 mmHg?
246(76.6)
53(16.5)
22(6.9)
5 Are stethoscope and sphygmomanometer used for blood pressure measurement?
233(72.6)
54(16.8)
34(10.6)
6 Do you agree that high blood pressure is dangerous for health?
303(94.4)
14(4.4) 4(1.2)
7 Is blood pressure of a patient measured in sitting position?
246(76.6)
44(13.7)
31(9.7)
8 Is high blood pressure risk factor for cardiovascular disease?
222(66.2)
50(15.6)
49(15.3)
9 Is high blood pressure a curable disease? 185(57.6)
84(26.2)
52(16.2)
10 Does high salt and fat intake leads to high blood pressure?
268(83.5)
35(10.9)
18(5.6)
11 Can we control the hypertension by antihypertensive drugs?
190(59.2)
69(21.5)
62(19.3)
12 Can hypertension be controlled by lifestyle changes?
213(66.4)
46(14.3)
62(19.3)
50
4.3: SCORE GROUP
The students involve in good knowledge having a frequency of 273 with percentage of
85.0 and the students having the poor knowledge with a frequency of 48 and percentage is
15.0. The table is as follow.
51
Poor and good knowledge of hypertension in students
SCORE GROUP
Good Knowledge 273 85.0
Poor Knowledge 48 15.0
52
4.4: SOURCE OF INFORMATION
The response rate of academic learning is (50.5%; n=162) newspaper is (22.7;n=73)
internet is (18.7;n=60) bluchers, pictures and printed material is (3.7;n=12) health worker
is (26.2;n=84) so the academic learning knowledge is good students are attached with
academies
53
Table 4.4: Source of information
Academic learning 162 50.5
News paper 73 22.7
Internet 60 18.7
Brochure pictures & printed material 12 3.7
Health worker 84 26.2
54
Chapter 5: Discussion
55
This study conducts the descriptive survey to understand the current status of knowledge
and awareness of hypertension in university of Baluchistan Quetta. Our results suggest that
the students are aware of HTN in general, but are less aware of HTN about specific factors
related to their condition, which is also reported by oliveria et al according to which
majority of correspondents are aware about hypertension but are not aware about the
factors related to it (Oliveria et al., 2005).
The study also indicates that a quarter of study correspondents are not aware that life style
changes can also effect hypertension which in line to finding by oliveria et (Oliveria et al.,
2005) according to findings by oliveria et al large number of people are not aware that
changing their life style can affect their hypertension. Efforts to educate the public that
lifestyle modifications can prevent hypertension (Viera et al., 2008).
More than 50% of the correspondents knew that hypertension could lead to cardio vascular
problems which is according to research findings by aliinger et al (Ailinger, 1982)Aliinger
et al reported that half of his study subjects were aware of the cardiovascular sequel of
hypertension.
56
Ninety percent of people agree that high blood pressure is dangerous to health which is in
line to the established facts (BPA, 2008) according to Blood pressure association UK over
a period of years, the blood pressure remains high and starts to damage the blood vessels.
This is when the damage to the blood vessels can lead to a heart attack, stroke, heart failure
or kidney disease.
Some twenty percent of the people responded negatively when asked if antihypertensive
drugs could control hypertension. This might be due to their past experiences or
inefficiency of the medication they or their relatives are using. If a person is having
hypertension and he is using medicine of an in effective brand or company (which may be
due to less amount of active ingredient then specified) or counterfeit then such patients
don’t get cured as a consequence the relatives or people around these patients start having
a disbelief in medicines and they start believing that hypertension cannot be cured using
anti-hypertensive drugs.
The dietary factors were also addressed in the questionnaire two quarter of the people
agreed that increasing salt intake can elevate hypertension. The raised blood pressure
caused by eating too much salt may damage the arteries leading to the brain (BPA, 2008).
At first, it may cause a slight reduction in the amount of blood reaching the brain. This
may lead to dementia (known as vascular dementia) (BPA, 2008).
Study correspondent’s response show that a considerable number of people know about the
sphygmomanometer and stethoscope which may imply that the amount of hypertensive
patients in our society is exceedingly increasing.
57
Even though, the rate of awareness towards hypertension is quite prominent from 62% in
Australia to 72% in US, the control rates are quite discouraging as with to 24% and 35%
respectively. In the South Asian region, the scenario is more threatening as China reported
only 8% control rates and India with 6% in management of hypertension. At present, it is
estimated that about 1 billion people worldwide have hypertension (>140/90 mmHg), and
this number is expected to increase to 1.56 billion by 2025 (Saleem et al., 2010).
The correspondents were also asked if the Blood pressure of a person is measured in sitting
position. More than seventy percent people said yes. However Different arm positions
below heart level have significant effects on blood pressure readings (Adiyaman et al.,
2006). Adiyamanet all also reported that he leading guidelines about arm position during
blood pressure measurement are not in accordance with the arm position used in the
Framingham study, the most frequently used study for risk estimations.
When asked is hypertension a curable disease, almost a quarter of study correspondents
disagreed. This might be due to the de centralized cause of hypertension as there is no one
known cause or causative agent the treatment normally includes a wide variety of
medication life style changes and diet changes In most cases, it’s impossible to pinpoint an
exact cause of high blood pressure. There are, however, a number of factors that have been
linked to high blood pressure (Vascular cures, 2013). this implies that treating homeopathy
(alternative medicines) requires a wide range of issues to be addressed both
pharmacologically and non-pharmacologically.
58
The potential feature study of awareness and knowledge of hypertension is that it chooses
a very important part of the society which had been neglected before. Therefore the above
mention study has been conducted.
Chapter6: Conclusion
59
Result and discussion shows that enormous proportions of students have knowledge and
awareness regarding hypertension without necessarily preceding its updated knowledge in
provided recommendations. Extent of knowledge regarding hypertension the variables of
B.P range and diagnosis of hypertension mentioned as patients B.P range and devices used
for measurement, was calculated partially,
Rest of participants from science faculty. The participants from Arts faculty has poor
knowledge which may represent their inappropriate knowledge due to their academic
courses and lake of information provided them regarding science or disease, as the
hypertension known to be a silent killer which needs awareness among the population.
As the poor knowledge of Arts faculty participants is concerned represent the lake of
facility of sources, awareness programs in Quetta city and conducting / attending any
seminar regarding health care problems etc.
60
Recommendation.
The method of collecting data must be improved to get more respondents, so that the
results will be more reliable. Web based survey might be applied by email the
questionnaires to all graduates and they will reply the answer. In addition, respondents will
not answer the questions in hurry. There should be conduction of seminar or such
programs regarding awareness and knowledge to all students of University of Baluchistan
regarding hypertension or any other life threatening disease etc.so that all the youngsters
are aware of hypertension a silent killer disease of mankind to be prevented and treated.
61
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