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SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA 
PREVALENCE AND FACTORS ASSOCIATED WITH HYPERTENSION 
AMONG SENIOR HIGH SCHOOL STUDENTS OF SAINT THOMAS AQUINAS 
AND ACCRA HIGH SENIOR HIGH SCHOOL 
BY 
MICHAEL OBU- AFFUL 
(10599607) 
nus THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN 
PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF 
MASTER OF PUBLIC HEALTH DEGREE 
JULY, 1017 
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DECLARATION 
1, Michael Obu- Afful, hereby declare that except for references to literature and other 
people's work, which I have duly acknowledged, this work is my own research . 
....~ ., .•... .... !.~r.~ r~  .~. ................ . 
MICHAEL OBU- AFFUL DATE 
(STUDENT) 
........I. :> J~ .e..-..(. ..!.....~....?.....  . \ 
DRSAMUELSACKEY 
DATE 
(SUPERVISOR) 
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DEDICATION 
I dedicate this work to the Almighty God, the giver of life, for protection and guidance and 
also to my family; my father, Rev Richard Obu- Denyarko, my mother, Hannah Atramah 
Donkoh, my siblings, (Akua and Isaac), (Kwasi Saah and Eunice) and also to the special 
one, Akua Owusu- Amponsah. 
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ACKNOWLEDGEMENT 
My heart felt gratitude to God Almighty. 
Special thanks to Dr Samuel Sackey for his direction. 
I appreciate the School of Public Health, University of Ghana, especially the Epidemiology 
and Disease control department for their tutelage. 
Also to the head master and mistress of Saint Thomas Aquinas and Accra High senior high 
schools and all the students, I say thank you for your cooperation. 
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LIST OF ABBREVIATIONS 
BMI Body Mass Index 
BP Blood Pressure 
CVD Cardiovascular Disease 
HDL High Density Lipoprotein 
LDL Low Density Lipoprotein 
LMIC Low and Middle- Income Country 
PA Physical Activity 
SSA Sub- Saharan Africa 
WHO World Health Organization 
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TABLE OF CONTENTS 
Pages 
~~£::==;::::'::::::::':".' .. '.:::":':::::::.':::.::::::::::::::::::::::.::::::::::.:.:.::::: .. ::::.:.,,:::,~ 
LIST OF ABBREVIA TIONS ......................................................... .. ................................... 1V 
~:~t:~S:::·:··:.·:.:.::::·: ..: ... ·::.··: .. ·:::·::.::::···:.::: ..: ..:  ...: ::.:: ..: .. : :.:.: .. :: ...: .. ::  ....: ... :~;~ 
DEFINITION OF VARIABLES .......................................................................................... x 
ABSTRACT ......................................................................................................................... xi 
CHAPTER ONE ................................................................................................................... 1 
INTRODUCTION ................................................................................................................ 1 
1.1 Background ................................................................................................................. 1 
1.2 Problem Statement ...................................................................................................... 2 
1.3 Justification ................................................................................................................. 4 
1.4 Research Questions ..................................................................................................... 8 
1.5 Objectives .................................................................................................................... 8 
1.5.1 General Objective ................................................................................................. 8 
1.5.2 Specific Objectives ............................................................................................... 8 
CHAPTER TWO .................................................................................................................. 9 
LITERATURE REVIEW ...................................................................................................... 9 
2.0 Introduction ................................................................................................................. 9 
2.1 Diagnosing Adolescent Hypertension ....................................................................... 10  
2.2 Prehypertension ......................................................................................................... 10 
2.3 Causes of Adolescent Hypertension .......................................................................... l1 
2.4 Classification of blood pressure ................................................................................ 12 
2.5 Prevalence of Adolescent Hypertension and prehypertension • Global Perspective 14 
2.6 Prevalence of Adolescent Hypertension and prehypertension • African Perspective 15 
2.7 Prevalence of Adolescent Hypertension and prehypertension - Ghanaian 
Perspective ....................................................................................................................... 15  
2.8 Risk. Factors for Hypertension ................................................................................... 16 
2.8.1 0eIIDI:ie Factors ................................................................................................... 16 
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~~::; ~~~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 
2.8.4 Race .................................................................................................................... 17 
2.8.5 Behavioural Risk factors ..................................................................................... 17 
2.8.6 Nutrition ........................................................................................................ '" '" 17 
2.8.7 Alcohol intake ..................................................................................................... 17 
2.8.8 Tobacco use ........................................................................................................ 18 
2.8.9 Physical inactivity ............................................................................................... 19 
2.8.10 Obesity .............................................................................................................. 19 
2.8.11 Socioeconomic Factors ..................................................................................... 20 
2.8.12 Stress ................................................................................................................. 20 
2.9 Symptoms of Hypertension ....................................................................................... 21 
2.10 Hypertension and Life - Threatening Diseases ....................................................... 21 
2.11 Diagnosing Hypertension in Adolescents ............................................................... 21 
2.12 Interventions for the Prevention of Adolescent Hypertension ................................ 22 
2.12.1 The role of the health worker ............................................................................ 22 
2.12.2 Nutrition ............................................................................................................ 22 
CHAPTER TJlREE ............................................................................................................. 23 
METHODOLOGy .............................................................................................................. 23 
3.1 Study Population ....................................................................................................... 23 
3.2 Study area .................................................................................................................. 23 
3.3 Inclusion and exclusion criteria ................................................................................. 26 
3.4 Study design .............................................................................................................. 26 
3.5 Ethical Consideration ................................................................................................ 26 
3.6 Variables .................................................................................................................... 27 
3.6.1 Dependent variables ............................................................................................ 27 
3.6.2 Independent Variables ........................................................................................ 27 
3.7 Sample Size Calculation ............................................................................................ 27 
3.8 Sampling technique/ procedure ................................................................................. 28 
3.9 Materials and tools .................................................................................................... 28 
3.10 Data collection ......................................................................................................... 28 
3.11 Study Measures ,.~ ..................................................................................................... 29 
~~~~;Jf,~~ and height measurement ............................................................................. 29 
nu.ss.~. (13M!) determination ................................................................... 29 
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3.14 Waist circumference ................................................................................................ 30 
3.15 Blood pressure measurement ................................................................................... 30 
3.12 Data entry ................................................................................................................ 31 
3.13 Data Analysis .......................................................................................................... 31 
3.14 Advice to participants .............................................................................................. 31 
CHAPTER FOUR ............................................................................................................... 32 
ANALYSIS AND RESULTS ............................................................................................. 32 
4.0 Results on demographic/clinical/life style factors distribution of sampled 
participants ...................................................................................................................... 32 
4.1 Prevalence of pre-hypertension and hypertension among the study participants ...... 34 
4.2 Association between Socio-demographic, clinical and lifestyle factors of the study 
participants ...................................................................................................................... 35 
4.3 Effect of demographic, clinical and life style factors on hypertension status ........... 37 
CHAPTER FIVE ................................................................................................................. 39 
DISCUSSION ..................................................................................................................... 39 
5.0 Introduction ............................................................................................................... 39 
5.1lbe prevalence of hypertension ................................................................................ 39 
S.21be prevalence of pre hypertension ........................................................................... 40 
5.3 Factors associated with blood pressure elevation ...................................................... 40 
CHAPTER SIX ................................................................................................................... 42 
CONCLUSION, RECOMMENDATIONS AND LIMITATIONS ................................... .42 
6.1 Conclusion ................................................................................................................. 42 
6.2 Recommendations ..................................................................................................... 42 
6.3 Limitations ................................................................................................................. 43 
REFERENCES .................................................................................................................... 44 
APPENDIX: QUESTIONAIRE ......................................................................................... 47 
PARTICIPANT CONSENT ............................................................................................... 47 
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LIST OF TABLES 
Table 2.1 Classification of blood pressure .......................................................................... 13 
Table 4.0: Socio-demographic, clinical characteristics and lifestyle factors of the study 
participants .......................................................................................................... 33 
Table 4.1 : Association between socio-demographic, clinical and lifestyle factors of the 
study participants ................................................................................................ 36 
Table 4.2: Effect of demographic, clinical and life style factors on hypertension status ... 38 
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LIST OF FIGURES 
Figure 1.1: Conceptual framework ....................................................................................... 6 
Figure: 3.0: Map ofSt. Thomas Aquinas Senior High School ........................................... 24 
Figure: 3.1: Map of Accra High Senior High School ......................................................... 25 
Figure 4.0: Distribution of hypertension status among school children ............................. 34 
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DEFINITION OF VARIABLES 
Population in the study made reference to adolescents in senior high schools aged between 
14-20 years 
Hypertension Systolic BP >/= 140mmHg, diastolic BP >/= 90mmHg for ages IS 
and 19 and a systolic of 120mmHg, diastolic of SOmmHg which 
falls in the 95th percentile for age groups between 13 and 17 years 
old (Flynn et al., 2017). 
Obesity - Body Mass Index (BMI) >/= 30kg/m2. (WHO fact sheet, 2004) 
Overweight Body Mass Index (BMI) > 25kg/m2. (WHO fact sheet, 2004) 
2
Normal weight Body Mass Index (BMI) between IS.5kg/m2 and 25kg/m . 
(WHO fact sheet, 2004) 
Underweight Body Mass Index (BMI) < lS.5kg/m2. (WHO fact sheet, 2004) 
Central Obesity WaistlHip ratio> 0.S5 for girls and 0.90 for boys. 
(WHO, 1999) 
Tobacco use Use of tobacco by smoking, chewing, ingestion of tobacco 
containing Products. (CDC, 2017). 
Alcohol consumption- Intake of more than 16g per day for alcohol users and less than Sg 
per day for insignificant alcohol use. (Keller et aI., 201S). 
Physical activity - Adolescents who involve themselves in moderate to vigorous daily 
activity (60 minutes in a day) will be described as active. 
Adolescents who spend less than 60 minutes in day without 
involvement in any activity will be described as sedentary (WHO. 
Global strategy on diet, physical activity and health, 2017). 
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ABSTRACT 
Introduction: Hypertension is a major risk factor for cardiovascular diseases. Many factors 
contribute to the development of hypertension, which may include nutrition, obesity, lack 
of exercise, alcohol intake, and tobacco use. The prevalence of hypertension in adolescents 
far exceeds the number who have been diagnosed. Early diagnosis of hypertension in 
adolescents will help reduce the prevalence of hypertension and its complications in 
adulthood. The objective of this study was to assess the prevalence of hypertension and its 
associated factors among Senior High School students of Saint Thomas Aquinas and Accra 
High Senior High Schools 
Methods: A descriptive cross·sectional study was performed. A total of 266 senior high 
school students aged between 14· 20 years from Saint Thomas Aquinas Senior High School 
and Accra High Senior High School were recruited from May - July 2017. A self-
administered questionnaire was used to obtain data from the senior high school students. 
The arterial blood pressure, weight, height, and waist circumference were checked by means 
of an electronic sphygmomanometer, a mechanical weighing scale with stadiometer and a 
tailors measuring tape respectively. Data obtained was analysed using Excel 2010 and Stata 
14SE. 
Results: The mean age of respondents was 16.5 years. The overall prevalence of 
prehypertension was 42.2% (95% CI: 36.5 - 48.1%) while that of hypertension was 16% 
(95% CI: 12.1 - 20. 7%).The systolic and diastolic blood pressures were averagely 
123.9mmHg and 68.7mmHg respectively. The estimated average Body Mass Index was 
20.9 kglm2 (range: 14.9·31.9). Gender was significantly associated with hypertension and 
the odds of being hypertensive among the male students was more than three times that of 
'1~es(24.36%vs 5.56%, p=O.OOl). The average body mass index of hypertensive senior 
.~I~'- h;gher !ban tbat of senior high students who had nonna! blood 
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pressure (24.9 kg\m2 vs 20.8 kg\m2, p = 0.0189). High blood pressure was not associated 
with smoking, alcohol intake and physical activity. 
Conclusion: The prevalence of prehypertension and hypertension was high. There was a 
strong association between hypertension and BMI. A link between hypertension and factors 
such as alcohol abuse, tobacco use and physical inactivity could not be established which is 
inconsistent with literature. 
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CHAPTER ONE 
INTRODUCTION 
1.1 Background 
High blood pressure (HBP) is the most prevalent cardiovascular disease risk factor in the 
world and cardiovascular diseases (CVDs) take the lives of 17.7 million people every year, 
representing 31 % of all global deaths (WHO, 2017). Physical inactivity and its associated 
abnormal weight gain as well as certain behaviours such as the use of tobacco and alcohol 
consumption, are the major triggers of these diseases. (WHO fact sheet, 2017). According 
to the WHO, more people die annually from CVDs than from any other cause. Over three 
quarters ofCVD deaths take place in low - and middle income countries (Bowry AD et al., 
201S). Most of these deaths unfortunately occur prematurely, (82%), It has been shown that 
Hypertension seen in children can progress into adulthood thus contributing to the increase 
in the cardiovascular morbidity and mortality in adults. The prevalence of HBP among the 
aged in West Africa is shown to be 33% in some urban communities, however, some studies 
report a prevalence of between 30-40% for rural communities (Essouma et al., 2015). Ghana 
has a high HBP prevalence of 28.7%. A rural-urban study in Ghana suggests a prevalence 
of 27%, each for both rural men and women and 33.4% and 28.9% for urban men and 
women respectively (Afrifa et aI., 201S). 
Individual lifestyle behaviours that come with urbanization contribute to the increasing 
prevalence of HBP among adolescents. Among them are lack of physical activity (pA ), 
alcohol overconsumption, smoking or substance use, unhealthy diets, obesity and 
psychosocial stress (Odunaiya et aI., 2015). These factors are now recorded and gradually 
increasing among the younger population (13-19). However, while it is established in most 
.;~ countries that PA in adolescents and youth reduces risk of obesity and HBP in 
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later life, the association is unclear in most developing countries. For instance, in Nigeria, 
female students in senior secondary schools were more physically inactive compared to their 
male counterparts (39.9% vs 36.0% respectively; p < 0.05) (Ujunwa et aI., 2013). In the 
same study. participants who were inactive were found to have high BMI. Similarly, 
physical inactivity was found to be accompanied by a high prevalence of overweight and 
obesity among youth in South Africa. In Cameroon, it was observed that the BP of 
adolescents 15years and over decreased for high energy expenditure (Sobngwi et aI., 2012). 
In Ghana, the overall prevalence of overweight among women aged 15-49 years has 
increased from 25.5% to 30.5% between 2003 and 2008. Overweight and obesity which 
have been attributed to aging are equally now common among adolescents and children due 
to lifestyle behaviours such as low levels of PA, poor diets and increasing levels of alcohol 
intake. Childhood obesity increased from 0.5% in 1988 to 1.9% in 1993 and to 5% in 2008 
in Ghana (Afrifa-Anane et al., 2015). In this same study, among youths aged 15-19 and 20-
24 in Ghana, there has been an increase from 7.2% to 9.0% and 15.1% to 16.6%, 
respectively in the same period. Childhood and adolescent PA has an effect on adult obesity 
and BP. PA reduces risk of obesity. which are difficult to reverse once established. 
Furthermore, physically active adolescents are at a lower risk of developing other conditions 
such as type II diabetes in future. Hence BMI and P A are significant factors that relate with 
BP. Prevention therefore, should begin early in life to reduce the overall number of cases. 
1.2 Problem Statement 
Hypertension is a complex disease with different features. It is said to be the commonest 
DOll communicable disease. Hypertension in adolescents mostly goes unrecognized. 
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Individual lifestyle behaviours have been said to contribute to the increasing prevalence of 
HBP. Among them are lack of physical activity (PA), alcohol overconsumption, smoking 
or substance use, unhealthy diets, obesity and psychosocial stress. These factors are now 
evident and also high among the younger population 15-24 years (Afrifa-Anane et a!., 
2015). While it is established in most developed countries that PAin adolescents and youth 
reduces risk of obesity and HBP in later life (Jackson et al., 2014), the association is unclear 
in most developing countries. For instance, in Nigeria, female students in Senior Secondary 
Schools were more physically inactive compared to their male counterparts (39.9% vs 
36.0% respectively; p 0.05) (Ujunwa et al., 2013). 
Physical inactivity was found to be accompanied by a high prevalence of overweight and 
obesity among youth in South Africa (Essouma et a!., 2015). In a study that was conducted 
in Cameroon, BP decreased for high energy expenditure among urban and rural respondents 
IS years and older (Sobngwi et al., 2013). Increase in the prevalence of hypertension has 
been associated with increase in the prevalence of childhood obesity (Carvajal et a!., 2014) 
The number of obese children and adolescents have risen from 11 million in 1975 to 124 
million in 2016 (WHO fact sheet, 2017). In Ghana, the overall prevalence of overweight 
among women aged 15-49 years has increased from 25.5% to 30.5% between 2003 and 
2008. Childhood obesity increased from 0.5% in 1988 to 1.9% in 1993 and to 5% in 2008. 
In addition, among the youths aged 15- 19 and 20- 24 years, there has been an increase from 
7.2% to 9.0% and 15% to 16.6%, respectively in the same period (Afrifa- Anane et aI., 
2015). 
In a Global Youth Tobacco Survey (GYTS) that was conducted among Junior High School 
students; 51% of the students had used tobacco, 20% of them lived in homes where others 
smoked and 4()DA, were exposed to' tal b 
enVlronmen to acco smoke (Sarmento et al., 2016). 
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In a meta-analysis that was conducted, the prevalence of adolescent hypertension was 
estimated to be 1-5% in high - income countries and 0-22.3% in some selected African 
countries (Essouma et al., 2015). Similarly, the prevalence of hypertension among urban 
poor youth in Ghana was estimated at 4% (Afrifa- Anane et aI., 2015). 
High blood pressure affects the health of adolescents and result in other health problems in 
later life. It has been shown that hypertension seen in children can progress into adulthood 
thus contributing to the increase in the cardiovascular morbidity and mortality in adults. 
Many studies on hypertension worldwide have been on the middle aged and the elderly 
patients giving the impression that hypertension is a disease meant for only these age groups. 
The true prevalence of hypertension and the link. between the associated factors among 
Senior High School students remain unstudied. The purpose of this study was to estimate 
the prevalence of hypertension and its associated factors among Senior High School 
students. 
1.3 Justification 
The possibility of a permanent disability associated with hypertension and subsequent 
development of other NCDs requires early diagnosis and putting in place necessary 
measures to forestall its occurrence. Hypertension among adults is estimated to be 28.7% in 
Ghana (Afrifa- Anane et al, 2015); an alarming situation indeed. The prevalence of 
hypertension among adolescents has remained between 0-22.3% in Africa (Essouma et al., 
2015), however, the factors that have been recognised as the major risks of hypertension are 
on the ascendancy among adolescents. There has been a tenfold increase in childhood 
obesity from 1975 to 2016 (WHO fact sheet, 2017). There is also the rise in tobacco and 
ateoOOl usage among adolescents (Sarmento et al., 2016). The risk of developing 
h~ 
;. . n as an adolescent is becoming a growing public health concern because of the 
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increased prevalence of the major factors that are associated with hypertension. This has 
necessitated the establishment of Obesity Action Coalition to educate and give support so 
far as obesity is concerned. The WHO has also set up a commission on ending childhood 
obesity. In Ghana, there are school health programs that are targeted on educating Junior 
and Senior High School students on substance use. Little attempt has been made in a bid to 
quantify adolescent hypertension because it is deemed to be a disease meant for the middle 
age and the elderly. Most clinicians accept the news ofa n increased blood pressure in a child 
with a bit of apprehension because it's mostly not expected. With the constant increase of 
the factors that are associated with hypertension among adolescents, it would be an error 
not to find out the prevalence of hypertension among this age group. 
It was therefore appropriate and very important that this study be conducted to fmd out the 
prevalence of hypertension and the factors that are associated with it among Senior High 
School students. Identifying these will give a better picture of the prevalence of hypertension 
among adolescents that will necessitate the implementation of necessary preventive steps to 
reduce the associated factors. This will in the long run reduce the morbidity and mortality 
associated with cardiovascular disease. The quality oflife will generally improve as a result. 
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SOCIa-ECONOMIC 
FACTORS 
__V IOUItAL 
• Stress 
FACTORS • Poor Diet 
ALCQHOlUSE 
•..· .~..·..of \ sympadIe.t.k .. ADOLESCENT \ 
HYPERTENSION I 
TOBACCO USE 
• Arterial GENETIC FACTORS 
sdtfaess 
• impairment of • Family history of 
endothelial Hypertension 
fuRdian 
1----...O BESITY Hyperlipidemia 
• arteriosclerosis 
Figure 1.1: Coneeptual Framework 
Identifying childhood and adolescent hypertension and its associated factors could 
contribute to better prevention of hypertension and cardiovascular disorders in adults. 
High blood pressure can run in a family, the risk for high blood pressure can increase based 
on age, race or ethnicity. Members of a family pass traits from one generation to another 
through genes. Genetic factors likely play some role in high blood pressure, heart disease 
and other related conditions. However, it is also likely that people with a family history of 
high blood pressure share common environments and other potential factors that increase 
their risk. The risk of high blood pressure can increase even more when heredity combines 
with \Ulhealtby lifestyle choices, such as smoking cigarette, abusing alcohol and eating an 
UDhealthy diet (CDC, 2014). 
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Obesity and its associated cardiovascular, metabolic, and renal disorders have rapidly 
become a major threat to global health. Worldwide obesity has nearly tripled since 1975 
(WHO. Fact sheet, 2017). The Framingham Heart Study, suggests that 78% of primary 
hypertension in men and 65% in women can be ascribed to excess weight gain. Poor dietary 
habit such as excess intake of high energy diet has a direct link to excess weight gain. 
Obesity in a way ensures an increased activity of the renin- angiotensin aldosterone and 
insulin resistance which predisposes to hypertension (Sadoh W. E et al., 2016). It is well 
recognised that regular physical exercise is cardio protective. On the other hand, sedentary 
living is an established risk factor for cardiovascular diseases. There is mostly accumulation 
of plaques in the blood vessels that increases blood pressure (Crisafulli A. et al., 2015). 
Epidemiological, preclinical, and clinical studies have established association between high 
alcohol consumption and hypertension. Alcohol causes an imbalance of the central nervous 
system, impairment of the baroreceptors, enhanced sympathetic activity, stimulation of the 
renin-angiotensin aldosterone system, increased cortisol levels, increased vascular reactivity 
due to increase in intracellular calcium levels, and the stimulation of the endothelium to 
release vasoconstrictors (Husain K. et al., 2014). 
Tobacco use causes an impairment of endothelial function, arterial stiffness, inflammation, 
lipid modification and also alteration of antithrombotic and prothrombotic process. It also 
causes a stimulation of the sympathetic nervous system. All these physiological activities 
link up with each other and finally give rise to an increased blood pressure, hence adolescent 
hypertension. 
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1.4 Research Questions 
1. What is the prevalence of hypertension among Senior High School students? 
2. What are the factors associated with hypertension among Senior High School 
students? 
1.5 Objectives 
1.5.1 General Objective 
The general objective was to determine the prevalence and factors associated with 
hypertension among Senior High School students of Saint Thomas Aquinas and Accra High 
Senior High School from May- July 2017. 
1.5.2 Specific Objectives 
The specific objectives were: 
• To determine the prevalence of hypertension among Senior High School students. 
• To determine the factors associated with hypertension among Senior High School 
students 
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CHAPTER TWO 
LITERATURE REVIEW 
2.0 Introduction 
Hypertension, also known as high or raised blood pressure, is a condition in which the blood 
vessels have persistently raised pressure. Blood is transported from the heart to all parts of 
the body in the vessels. The heart beats, to supply certain amount of blood into the vessels. 
Blood pressure is created by the force of blood pushing against the walls of the blood vessels 
as it is pumped by the heart. The higher the pressure, the harder the heart has to pump (WHO, 
2013). Hypertension is mostly unaccompanied by symptoms. One of the key risk factors for 
cardiovascular disease is hypertension. Hypertension already affects one billion people 
worldwide, leading to heart attacks and strokes (WHO. Fact sheet, 2017). Most dangerously, 
hypertension is silent, invincible killer and rarely causes symptoms. Raised blood pressure 
is a serious warning sign that significant lifestyle changes are urgently needed (WHO, 
2013). The steep rise in the prevalence of hypertension is attributed to population growth, 
and behavioural risk factors such as unhealthy diet, harmful use of alcohol, lack of physical 
activity, excess weight and exposure to persistent stress (Afrifa-Anane et aI., 2015). Blood 
pressure (BP) is measured in millimetres of mercury (mmHg) and is recorded as two 
numbers usually written one above the other. The upper number is the systolic blood 
pressure - the highest pressure in blood vessels and happens when the heart contracts, or 
beats. The lower number is the diastolic blood pressure - the lowest pressure in blood 
vessels in between heartbeats when the heart muscles relaxes (CDC, 2017). Normal adult 
blood pressure is defined as systolic blood pressure of 120mmHg and a diastolic blood 
pressure of 80mmHg. Hypertension is defmed as a systolic BP equal to or above 140nunHg 
andlor diastolic BP equal to or above 90mmHg. In adolescents, their age, sex, and height 
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are taken into consideration in defining whether they are hypertensive or not (Christensen, 
2014). 
2.1 Diagnosing Adolescent Hypertension 
Untreated paediatric hypertension has long-term serious health consequences. Sustained 
hypertension in children is often caused by a serious underlying health problem affecting 
the heart, kidneys, or endocrine system. This type of hypertension is known as secondary 
hypertension, because it develops due to a medical condition. Mild to moderate hypertension 
with no known underlying disease process is classified as primary or essential hypertension. 
This is the type of hypertension that many older children and most adults have (American 
Heart Association, 2016). In children with hypertension, 30% to 60% have secondary 
hypertension, while 40% to 70% have primary hypertension (Luma et al., 2014). 
In children, prehypertension is persistent BP that equals or exceeds the 90th percentile for a 
normotensive child of the same age, sex, and height, or is below the 95th percentile but 
exceeds 120/80 mm Hg (either SBP exceeds 120 mm Hg, or DBP exceeds 80 mm Hg, or 
both). Hypertension is persistent BP that equals or exceeds the 95th percentile for a 
normotensive child of the same age, sex, and height (Ujunwa et al., 2013). 
2.2 Prebypertension 
Prehypertension is defined as blood pressure between 120-139/80-89 mmHg. It is a major 
public health concern. Prehypertension is very prevalent. It is often associated with other 
cardiovascular risk factors and independently increases the risk of hypertension and 
subsequent cardiovascular events (papadopoulos et aI., 2008). 
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Early recognition of prehypertension provides important opportunities to prevent 
hypertension and cardiovascular diseases. Stage 1 prehypertension is blood pressure 120-
129/80-84 mmHg and stage 2 as blood pressure 130-139/85-89 mmHg. Stage 2 
prehypertensive individuals have a threefold greater risk for developing hypertension and 
twofold higher risk for cardiovascular events compared to normotensives (Egan & Julius, 
2008). 
2.3 Causes of Adolescent Hypertension 
The degree of persistent hypertension, the age of the child, the symptoms found during 
physical examination, and the risk factors documented in a thorough patient history will 
detennine the next steps taken by the physician. For example, a child with low birth weight, 
family history of hypertension, and/or obesity has an increased probability of developing 
paediatric hypertension. Undiagnosed hypertension results in measurable organ damage in 
children, and overweight and obese children have a significantly increased risk of 
developing hypertension as adults. Risk factors for hypertension that cannot be modified 
include a family history of hypertension or CVD, low birth weight, gender, race, genetic 
inheritance, socioeconomic status (SES), premature birth, and use of umbilical artery 
catheters. Risk factors that can be modified include decongestants, nose/eye drops, oral 
contraceptives, bronchodilators, dietary habits, salt intake, excess adiposity, physical 
activity level, second-hand smoke, and poor sleep quality and/or short sleep duration. Sleep-
disordered breathing (SOB) and obstructive sleep apnoea (OSA) have both been associated 
with paediatric hypertension and should be ruled out or treated. The prevalence of OSA in 
all children is estimated at less than 3%, but estimates in obese youth range from 5.7% to 
36%, with prevalence and severity positively correlated with the degree of obesity. The risk 
ofS~B in general increases by 12% for every I kglm2 above mean body mass index (BMI), 
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and for each standard deviation above mean BMI, the risk of OSA is 3.5-fold greater. 
Typically, older children and adolescents are more likely to present with primary 
hypertension, while younger children are most likely to have secondary hypertension. Low 
renin and abnormal sodium transport in the kidneys are characteristics of secondary 
hypertension with an underlying genetic basis, which should be further investigated. For all 
children with persistent elevated BP, a baseline evaluation to exclude secondary causes 
should include certain blood and urine tests, a kidney ultrasound, and an echocardiogram. 
If these are found to be abnormal, the child should be referred to a paediatric nephrologist 
or paediatric cardiologist for further evaluation; if the baseline evaluation is normal and no 
medical condition has been found, primary hypertension is diagnosed (Lurna et aI., 2014). 
2.4 Classification of blood pressure 
Optimal blood pressure is defined as a systolic blood pressure of 90-119 mmHg and a 
diastolic blood pressure 60-79 mmHg. Systolic blood pressure of 120-139 mmHg and or 
diastolic blood pressure 80-89 mmHg is defined as prehypertension. Systolic blood pressure 
of 140 mmHg or greater and or a diastolic blood pressure 90 mmHg or greater is defined as 
hypertension. Hypertension is further divided into three stages. Stage 1 hypertension is a 
systolic blood pressure of 140-159 mmHg and or a diastolic blood pressure 90-99 mmHg, 
stage 2 hypertension is a systolic blood pressure of 160-179 mmHg and or a diastolic blood 
pressure 100·109 mmHg and stage 3 hypertension is defined as a systolic blood pressure 
greater than or equal to 180 mmHg and or a diastolic blood pressure greater than or equal 
to 110 mmHg. Blood pressure can be classified as follows (Table 2.1 below): 
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Table 1.1 Classification of blood pressure 
Category Systolic (mmHg) Diastolic (mmHg) 
Optimal BP 90-119 60-79 
Prehypertension 120-139 80-89 
Stage 1 hypertension 140-159 90-99 
Stage 2 hypertension 160-179 100-109 
Stage 3 hypertension ~180 ~110 
(Source: Rashid et al., 2011). 
Interventions 
The single most effective way to prevent or reduce hypertension in adolescents is to measure 
height, weight, BP, and we, and calculate BMI %, for every child, every year, in every 
school grade, so that early signs can be followed up and corrective measures can be taken 
before organ damage occurs. As the literature has shown, conventional practices are not all-
inclusive; many health care screenings do not include BP measurements for children, and 
BMI is rarely calculated or used unless the child is already obese. These simple screening 
measurements could be incorporated into existing school or community programs, and 
should include children who have little or no access to regular health care, such as low 
income, immigrant, and minority youth, who are most at risk for and most affected by 
hypertension and obesity. Early intervention and preventive measures would reduce the 
number of children and adolescents who reach adulthood before they are diagnosed with 
hypertension. Prevention is also the best strategy for reducing the incidence of overweight 
and obesity, and exercise for personal fitness should be emphasized in physical education 
programs. Obese children should be evaluated for hypertension before beginning any 
exemse regimen. Interventions focused on preventing or minimizing further weight gain 
~~'ieeded, which combine the expertise of professionals in the fields of exercise 
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physiology, physical therapy, behavioural health, and nutrition as appropriate. Nutritional 
counselling to achieve weight loss is an important part of managing hypertension and 
obesity and should include family. Dietary interventions need to emphasize reduced intake 
of fruit-flavoured drinks, and other foods containing high-fructose com syrup, promote 
increased consumption of low-fat milk or 100% fruit juice, and provide calcium-rich 
alternatives for lactose-intolerant children. The sale of energy-dense, nutrient-poor drinks 
and snacks through school-based stores, vending machines, and snack bars should be 
reduced or eliminated. Intervention strategies should focus on replacing unhealthy 
selections with better-quality options in the home, school, and child care environments, 
modelling of healthy behaviours by parents and educators, and reducing children's exposure 
to marketing that promotes unhealthy choices. (Luma et al., 2014). 
1.5 Prevalence of Adolescent Hypertension and prehypertension - Global Perspective 
Hypertension in children is often caused by a secondary factor (an already existing health 
problem). The problem may be emanating from the heart, kidneys or the endocrine system 
(Saragih et aI., 2015). Hypertension without an underlying cause is considered as primary 
or essential hypertension. In children, secondary hypertension is estimated to be around 30% 
to 60% and 40% to 70% is estimated for essential hypertension (Ewald and Haldeman, 
2015). The prevalence of hypertension in children is estimated to be between 2% and 5% 
and prevalence of prehypertension is estimated between 4% and 15% (Ewald and 
Haldeman, 2015). Studies in the United States of America and Europe have found that only 
13% to 26% of childhood hypertension is properly diagnosed (Ewald and Haldeman, 2015). 
In a study that was conducted in Kerala, India, among 2,438 students aged between 13- 17 
years the prevalence of hypertension and prehypertension was found to be 21.4 % (Tony L 
ctaLi~t6). 
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2.6 Prevalence of Adolescent Hypertension and prehypertension - African 
Perspective 
Hypertension is gradually graduating into an epidemic among African adults. As part of 
measures to control this menace, accurate epidemiological data on hypertension in African 
children and adolescents should be obtained to institute preventive policies. Rise in non-
communicable diseases (NCDs) is a major concern in Low- and - middle income countries 
«(LMIC). Hypertension which was not too common has become a major public health 
problem because of its high prevalence. Children who present with high BP are at a high 
risk of becoming hypertensive at an adult age. Many epidemiological studies have attempted 
to estimate the prevalence of adolescent hypertension. In high income countries, there is an 
increasing burden of hypertension in children and adolescents with prevalence rate of 1- 5% 
and this also applies to African countries where there is a considerable variability of the 
estimated prevalence in South Africa and certain West African countries being 0-22.3%. 
(Essouma et al., 2015). In a similar study conducted in Enugu, South Eastern Nigeria the 
prevalence of hypertension was estimated to be 5.4%, 6.9% in females and 3.8% in males 
(Ujunwa et aI., 2013). 
2.7 Prevalence of Adolescent Hypertension and prehypertension _ Ghanaian 
Perspective 
High BP among adolescents affect their health and results in other health problems in later 
life. Most studies in Ghana have focussed on adult hypertension. The proportion of pre 
hypertension and hypertension among youth (15- 25 years) is said to be 32.3% and 4% 
respectively. The rates of pre hypertension (42.0 vs 24.80) and hypertension (6.8 vs 1.80) 
are said to be high . mal 
er m es than in females. These are according to a study which was 
conduc:ted by Afrifa... Anane et aI., 2015. In the above statistics, females were more inactive 
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bl 'th that of men of similar ages or even higher. This is attributed to however compara e WI 
postmenopausal hormonal changes in women (Reckelhoff. 200 I). 
2.8.4 Race 
Various studies report a higher prevalence of hypertension in people of African descent and 
other minority racial groups than in Caucasians living in the United States of America 
(Lackland, 2.014). The higher prevalence of hypertension in people of African origin in the 
United States of America than in Africa demonstrates that environmental and behavioural 
characteristics are likely to account for the higher prevalence of hypertension in Afro· 
Americans (Fuchs, 2011). 
2.8.5 Behavioural Risk factors 
Many behavioural risk factors have been associated with the development of hypertension, 
they include; alcohol abuse, tobacco use and physical inactivity. 
2.8.6 Nutrition 
Diet has an influence on the development of hypertension. Consumption of high fat diet 
causes a blockade in the blood vessels. The heart exerts more pressure in pumping blood 
which results in increased BP. Increased sodium intake also causes an increase in the total 
blood volume. The consumption of fibre on the other hand helps to speed up the transit time 
ofall materials through the colon (Berz, 2.012). 
2.8.7 Alcohol intake 
The effect of alcohol on cardiovascular diseases is a controversial issue. There is 
considerable amount of evidence that a modest intake of alcohol, especially red wine has a 
ptOtedive effect against coronary heart disease because of the presence of antioxidants 
(s.i~ et al., 2.0 I .0). However, the sharp increase in mortality associated with more than 
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two drinks per day suggests that public health recommendations that emphasized the 
positive health effects of alcohol would likely do more harm than good. Research suggests 
that moderate alcohol intake raises High Density Lipoprotein (HDL) cholesterol and 
therefore reduces the risk of heart diseases, however, consumption in high doses is 
associated with hypertension (Husain et al., 2014). 
One of the harmful effects of excessive alcohol intake is its association with hypertension. 
The positive relationship between the amount of alcohol consumed and blood pressure is 
one of the strongest associations of potentially modifiable risk factors for hypertension. 
Many studies show progressively higher blood pressure levels with increasing levels of 
alcohol intake and decreases in blood pressure over time when alcohol intake decreases 
(Husain et aI., 2014). Alcohol intake has also been associated with resistance to 
antihypertensive therapy. These could be due to poor compliance among heavy drinkers or 
interaction of alcohol with medications (O"Keefe et al., 2007). 
According to Ghana Demograhpic and Health survey, alcohol consumption is highest 
among young people between the ages of 15-39 years than other groups. In a study that was 
conducted in Ghana, the prevalence of alcohol among the youths was estimated at 43% 
(Osci- Bonsu et aI., 2017). Similarly, the prevalence of alcohol use among Senior High 
School students in the Ga Central Municipality of Ghana was 35% (Annor, 2016). 
2.8.8 Tobacco use 
Addiction to tobacco products has adverse effect on the cardiovascular system. Studies have 
demonstrated that tobacco in all forms greatly increases the risk of premature death from 
~c disease including hypertension (Kaplan, 2015). Cigarette smoking acutely exerts a 
::,~~\........we effect. mainly via the stimulation oft he sympathetic nervous system. Cigarette 
RI.~·· '.j~aP9~ oatdiovascular risk factor 
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Stoppage of smoking is the single most effective lifestyle measure for the prevention of a 
large nwnber of cardiovascular diseases. Impairment of endothelial function, arterial 
stiffness, inflammation, lipid modification as well as an alteration of anti thrombotic and 
prothrombotic factors are smoking-related major determinants of initiation, and acceleration 
of the atherothrombotic process, leading to cardiovascular events. Regarding the effect of 
chronic smoking on blood pressure, available data do not indicate a direct causal relationship 
between chronic smoking and hypertension. Hypertensive smokers however, are more 
likely to develop severe forms of hypertension such as malignant and renovascular 
hypertension, due to accelerated atherosclerosis (Virws et a!., 2010). 
In a study that was conducted in Botswana, 10% of students were current smokers with 29% 
reporting to have tried smoking (Mbongwe et a!., 2017). In a similar study that was 
conducted among 1,174 students, 140 were current smokers giving a smoking prevalence 
of 12.5% (Adeyeye, 2011). 
2.B.9 Physical inactivity 
Activities such as walking help to maintain normal body weight. Frequent exercise has been 
identified to control cholesterol levels and hence the prevention of atherosclerosis. This 
conflmlS findings of a cross- sectional study among a Japanese population that revealed that 
high HDL cholesterol levels were associated with high frequencies of physical activity 
(Hedge et al., 2015). 
2.B.I0 Obesity 
This is the excess or abnormal accumulation offat. Obesity is seen as one oft he most serious 
st 
public health challenges in the 21 century. The prevalence of overweight and obesity in 
adolescents is defined accordin t th WHO 
. g 0 e growth reference for school- aged children 
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and adolescents (overweight=one standard deviation body mass index for age and sex, and 
obese: two standard deviations body mass index for age and sex). 
It is estimated that at least 75 % of the incidence of hypertension is related directly to obesity 
(Landsberg et al., 2013). Obesity is associated with numerous comorbidities including 
hypertension. Blood pressure is usually increased in overweight people. Overweight and 
hypertension interact with cardiac function. A key determinant of the weight-induced 
increases in blood pressure is a disproportional increase in cardiac output that cannot be 
fully accounted for by the hemodynamic contribution of new tissue. The hypertension 
among overweight people seems strongly related to altered sympathetic activity (Gray, 
2009). 
The prevalence of obesity among Senior High School students has been found to be 47.06% 
in a study that was conducted in Ghana (Amoh et a!., 2017). According to a WHO report, 
18% of children and adolescents aged 5-19 were overweight or obese in 2016 (WHO fact 
sheet, 2016). 
2.S.11 Socioeconomic Factors 
Social determinants ofhea1th e.g. income, education and housing, have an adverse impact 
on behavioural risk factors and in this way influence the development of hypertension. For 
instance, rapid unplanned urbanization encourages the development of hypertension as a 
result of unhealthy environments that encourage the consumption of fast food, sedentary 
behaviour, tobacco use and harmful use of alcohol (Cuschieri et al., 2017). 
2.S.12 Stress 
Stress can cause hypertension thr ugh 
. 0 repeated blood pressure elevations as well as by 
~on oftbe nervous syst to d 
i.< . em pro uce large amounts of vasoconstricting hormones 
20 
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that increase blood pressure. Overall, studies show that stress does not directly cause 
hypertension. but can have an effect on its development. Although stress may not directly 
cause hypertension, it can lead to repeated blood pressure elevations, which eventually may 
lead to hypertension (Virdis et al., 2010). Stress also leads to the production of excessive 
amount of cholesterol which can occlude blood vessels and lead to hypertension (Garbarino 
& Magnavita, 2015). 
2.9 Symptoms of Hypertension. 
Most hypertensive people have no symptoms at all. However, increase in blood pressure 
may result in headaches, shortness of breath, dizziness, chest pain, palpitations and bleeding 
from the nose. It can be dangerous to ignore such symptoms but they can also not be relied 
upon to signify hypertension. 
2.10 Hypertension and Life - Threatening Diseases 
High blood pressure increases the chances of life threatening complications. Untreated 
hypertension results in harmful consequences to the heart and blood vessels in major organs 
such as the brain, and kidneys. A list of complications of hypertension may include the 
following; kidney failure, heart failure, stroke, eye complications etc. 
2.11 Diagnosing Hypertension in Adolescents 
Normal blood pressure values for children and adolescents are based on age, sex, and height. 
and are available in standardized tables. Prehypertension is defmed as a blood pressure in at 
least the 9()Ib percentile, but less than the 95th percentile for age, sex, and height. or a 
measurement of 120/S0mmHg or greater. Hypertension is defined as blood pressure in the 
a 
9S percentile or greater based on at least three separate readings. 
21 
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2.12 Interventions for the Prevention of Adolescent Hypertension 
The single most important way to reduce or prevent adolescent hypertension is the ability 
to identify early signs. This can be achieved by frequently checking BMI. Regular exercise 
and physical fitness should be emphasized. Dietary interventions such as the reduction of 
foods with excess fats and salt will be an important measure. Policies regarding harmful use 
of alcohol and tobacco must also be instituted. 
2.12.1 The role of the health worker 
Skilled health professionals have a role to play in designing hypertension control 
programmes among adolescents. This is by creating awareness that hypertension does only 
affect adults but adolescents as well. Activities such as regular BP measurements and 
education about hypertension can be carried out in senior high schools. 
2.12.2 Nutrition 
Scientific studies have demonstrated that a modest intake of sodium helps to reduce BP. 
WHO recommends the intake of Sg of sodium per day. Processed foods are said to contain 
bigh amount of sodium. Adolescents need to be educated to cut down on the intake of 
processed foods. 
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CHAPTER THREE 
METHODOLOGY 
3.1 Study Population 
The study population comprised of senior high school students of Saint Thomas Aquinas 
Senior High School and Accra High Senior High school. They are adolescents of different 
ages and gender. 
Saint Thomas Aquinas Senior high school is a public Senior High day school. It is a boys' 
school with about 1500 students who read different courses ranging from Science, General 
Arts, Agricultural Science, Business and Visual Arts. 
Accra High Senior High school is also a public Senior High day school with a population 
of 1300 students. It is a mix school comprising of 500 boys and 700 girls. The following 
courses are offered in the school; Science, Business, Home Economics, and Visual arts. 
3.2 Study area 
Saint Thomas Aquinas Senior High school is a public senior high day school (6.663<N, 
1.645° W) and is located on the cantonment street, Osu in the Greater Accra Region of 
Ghana. 
Accra High Senior High school is also a public Senior High day school located at North 
Ridge, Accra Ghana. 
Figure 3.0 and 3.1 show maps of Saint Thomas Aquinas and Accra High Senior High School 
respectively. 
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SWS&loCl __ a ,Ii  ",_til 
-.ta. ....d ~ II I ", t SWSthf1t _6thS. 
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Figure: 3.0: Map sowing St. Thomas Aquinas Senior High School 
24 
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, ~ 
~* .! . I CemIan~ Eft'blssy I ../ Visa Se•ction  Q , I OF irst Atlantic Bark· HFC 8anl North RIdge atar eh Vi 
{, GN~ank ·tfeadOffl~ q Embas&} of Switzt>rland ~ 
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f ..... ! 0V ....0.  W. A. E. C. Head Office ..- .j National Health ~ 
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Figure: 3.1: Map showing Acera High Senior High Sehool 
25 
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3.3 Inclusion and exclusion criteria 
The study took into consideration mainly Senior High School students between the ages of 
14- 20years and excluded Senior High School students of the same age bracket who have a 
history of hypertension due to existing disease conditions such as kidney conditions. This 
information was obtained by interviewing the subjects about their past medical history. 
3.4 Study design 
It was an institution based descriptive cross- sectional quantitative study. Data was obtained 
by the use of questionnaire, measurement of blood pressure, weight and height of 
participants. 
3.5 Ethical Consideration 
Ethical clearance was obtained from the Ghana Health Service Ethical Review (protocol 
number; GHS- ERC: 154/02/17). Permission was obtained from the Head Master and Head 
Mistress of Saint Thomas Aquinas and Accra Girls Senior High School respectively. 
Consent was sought from the parents/guardian of the respondents through the head of the 
various institutions. The participants were given a brief introduction about the study and 
their consent were sought for before enrolment. Each participant was told about the non -
invasive nature of the procedure except for a minor discomfort that may come with BP cuff 
inflation. 
26 
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3.6 Variables 
3.6.1 Dependent variables 
• Presence of hypertension 
3.6.2 Independent Variables 
• Obesity 
• Physical inactivity 
• Consumption of alcohol 
• Tobacco use 
3.7 Sample Size Calculation 
A total number of 266 students, aged between 14-20years was studied. All the 266 agreed 
to participate fully after appropriate explanation was given that they could opt out. 
Calculation was based on the Cochrane formula below: 
where no =E stimated sample size 
Z = Level of confidence interval= 1.96 
p~ prevalence (estimated proportion) = 22.3% (0.223). The prevalence was obtained from 
a meta-analysis study of childhood hypertension conducted by Esouma et al., 2015. 
q = 1 - P (the probability of not having hypertension) = 0.777. 
d =a cceptable margin of error= So/o{O.OS) . 
. ,.~ no = LL26f<0.223) (Q.77D 
(O.os)2 
27 
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no = 266.14 
no = 266. 
3.8 Sampling technique! procedure 
Participants were selected using the simple random sampling. Teachers of the various 
classes were made to pick pieces of papers with the inscriptions YES or NO. The classes of 
teachers who picked YES were selected. Within the chosen classes, students were made to 
pick pieces of papers with similar inscription YES or NO. Those who picked the paper with 
the YES inscription were recruited into the study. 
3.9 Materials and tools 
Tools and equipment: 
1. Digital sphygmomanometer; PhysioLogic (AMG Medical Inc., New York USA) 
2. Mechanical weighing scale; ADE scale with adjustable stadiometer for measuring 
height (GmbH & Co, Humburg Germany) 
3. Tape measure; TM170 Cloth Tape Measure (Amazon). 
4. Questionnaire; WHO stepwise approach. 
3.10 Data collection 
Data collection was carried out from 8th May 2017 to 22nd May 2017 Part" t 
' " lClpan S were 
gathered in a room early in the moming before classes begun and their blood pressure, 
weight, height and waist circumference measured, 
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3.11 Study Measures 
Questionnaire was developed using WHO stepwise approach and the international physical 
activity questionnaire (lPAQ). The questionnaire considered the following profile 
(demographics, smoking, alcohol, physical activity and nutrition). Alcohol and tobacco use 
requires financial commitment. Though the population under study were only students and 
therefore had no or little fmancial assess to acquire the substance, considerations were made 
based on the fact that they could purchase the substance using their pocket money. 
After completing the survey, objective measurements of blood pressure (BP) and 
anthropometrics were taken by the principal researcher and three qualified nurses. 
3.12 Weight and height measurement 
Weight was measured with a mechanical ADE scale, with a capacity of up to 150kg and a 
50g interval variation. Height was measured using the stadiometer attached to the scale, 
with a lmm resolution and a measuring capacity of up to 230cm. The scale (ADE) was 
placed on a level floor. The scale was zeroed before each participant stepped onto it. 
Subjects were made to wear light clothing without shoes. Participants emptied their pockets 
of all heavy substances. Participants were made to stand upright with arms resting by them, 
head up and eyes looking straight up before reading were taken. Weight was recorded to 
the nearest kilogram and height in centimetres. Height was further converted to meters by 
dividing the figure by 100. 
3.13 Body mass index (BMI) determination. 
13MI of each participant was calculated by dividing the weight in kilograms by the square 
of the height in meters. The participants were then grouped, based on their BMI into: 
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underweight; BMI less than 18.5kglm2, nonnal weight; BMI IS.5- 24.9kglm2  ,overwel•g h t·,  
BMI 25.0- 29.9kglm2 and obese; BMI 30.0 kglm2 and above. 
3.14 Waist circumference 
Waist circumference was measured using cloth tape measure which was 150 centimetres 
long on one side and 60 inches on the other side. Waist circumference was measured at the 
approximate midpoint between the lower margin of the last palpable rip and the top of the 
iliac crest, while hip circumference was measured at the widest point of the buttocks (both 
in centimetres) using a tape measure. The tape measure was tight enough and the 
respondents positioned appropriately (i.e. parallel to the floor at the level at which 
measurement is made) Waist-hip ratio was calculated as waist measurement divided by hip 
measurement (WHO, 200Sb). 
3.15 Blood pressure measurement 
BP was measured using a pre- calibrated digital monitor (PhysioLogic). Each participant 
was made to rest for at least 5 minutes before the blood pressure measurement was taken. 
Pulse rate of respondents was recorded to rule out any emotional interference. An 
appropriate cuff size (depending on the arm size of respondents) was wrapped around the 
left upper arm approximately 2 centimetres above the cubital fossa with participants seated 
with both feet on the floor and arms resting on a flat surface at the level of the heart. If BP 
fell out of the norrnallimits it was recorded again after 10-minute rest and the average value 
used. This was to address any anxiety introduced by participating in the study. Participants 
were grouped based on their blood pressure into, Optimal blood pressure; systolic blood 
pressure of less than 120mmHg and a diastolic blood pressure of less 80mmHg, 
ptehypertension; systolic blood pressure of 129-139mmHg and a diastolic blood pressure 
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· f th 140mmHg and diastolic 
80-90mmHg, hypertension; systohc blood pressure 0 more an 
blood pressure of more than 90mmHg. 
3.12 Data entry 
Data was entered into Excel 2010 worksheet in batches on a daily basis. Each participant 
was given a specific identification number. The data of each participant was entered in a 
row. 
3.13 Data Analysis 
Data analysis was done using Microsoft Excel 2010 and Stata SE version 14 statistical 
software (StataCorp, 2014). The data were inspected and sorted. There were no missing 
valu~s. Data were descriptively reported using means and standard deviations, or 
percentages and 95% confidence intervals (CIs) as appropriate. 
Chl square was used to test the association between hypertension and the various variables 
with p- value less than 0.05 as significant. Bivariate logistic regression model was fitted to 
test the strength of the association between hypertension and the individual variables. 
Multivariate logistic regression analysis was done to show the effect of demographic, 
clinical and life style factors on hypertension. 
3.14 Adviee to participants 
Participants were encouraged to maintain healthy lifestyle by exercising regularly and eating 
healthy diet by reducing excess fat and confectionary intake and ensuring that their meals 
have large portions of fruits and vegetables. They were also advised on the dangers of 
alcohol and tobacco abuse. 
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CHAPTER FOUR 
ANALYSIS AND RESULTS 
4.0 Results on demographiC/clinicalllife style factors distribution of sampled 
participants 
A total of 266 senior high school students were recruited as the participants for the study. 
The characteristics of these 266 students are shown in Table 4.0. The participants were aged 
from 14 to 20 years with a mean age of 16.5 years. More than half (55.3%) of the study 
participants were males. Most (69.7%) of the participants were in their first year (SHS 1). 
General Arts was the program offered by majority (48.9%) of the study participants. The 
estimated mean height and weight of the participants were 165.6 centimeters and 58.0 
kilogram respectively. The shortest of the study participant was 114 centimeters tall while 
the tallest was 189.1 centimeters long. 30 kilogram was the weight oft he lightest participant 
whilst the heaviest was 101 kilograms. The estimated average Body Mass Index was 20.9 
kg/m2 (range: 14.9 - 31.9). The study participants had a mean waist circumference of 
90.1cm. The systolic and diastolic blood pressure were averagely 123.9mmHg and 
68.7mmHg respectively. 14.7% of the participants reported to have had family members 
who were hypertensive. Majority (91.5%) of the participants reported to be active with a 
third (34.9%) of the participants exercising only once a week. 3.2% of the participants have 
ever smoked with less than I % of them still smoking. About one of every ten selected study 
participant drinks alcohol. Some of the eating habit of the participants were in these fonns: 
most (42.6%) of them occasionally or do not eat fruit whilst half or more (> 50%) of them 
eat roughage or vegetables foods every day. Details of characteristics of the study 
participants can be found in table 4.0 
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Table 4.0: Socio-demographic, clinical characteristics and lifestyle factors of the 
study participants 
Frequency(n. 1(6) Percentage(% ) 
Sex 
Female 118 44.68 
Male 148 55.32 
age(mean ± SO) 16.49 ± 0.97 
Class 
SHS 1 183 69.86 
SHS2 82 29.79 
SHS3 1 0.35 
Program offered 
OenScience 66 24.64 
OenArts 126 48.93 
Business 10 3.57 
Visual Arts! Home 
Econs 64 22.78 
Weigbt(mean ± SO) 165.59 ± 11.03 
Height(mean ± SO) 57.80 ± 9.98 
BMI (mean ± SO) 20.90± 3.00 
Waist circumference 
(mean± SO) 90.13 ± 9.81 
family history of 
hypertension 
No 116 
Yes 85.29 20 
Central Obesity 14.71 
No 
88 
Yes 87.13 
13 
Level of Aerobic 12.87 
exercise 
> once 
92 
>= 20 mins once\twice 34.88 71 
>= 2Omins\ 3 time 25.98 
32 
>= 20 mins\>=4 times 12.81 
ever smoked 71 26.33 
No 
Yes 255 96.79 
currently smoke 9 3.21 
No 
Yes 264 99.28 
take aleohol 2 0.72 
No 
Yes 239 90.39 
,~;~~)~"'bit 27 9.61 
33 
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75 26.6 Daily 
Weekly 80 30.85 
Occasionallyl not at all 111 42.55 
roughages eating habit 
Daily 80 30.96 
Weekly 82 30.96 
Occwrionally/not at wI 104 38.08 
confectionaries eating 
hahit 
Daily 120 44.13 
Weekly 60 23.84 
Occasionallyl not at wI 86 32.03 
vegetable eating habit 
Daily 148 56.03 
Weekly 60 22.96 
Occasionally/ not at wI 58 21.01 
so: Standard Deviation 
4.1 Prevalence of pre-hypertension and hypertension among the study participants 
• No hypertension 
• Pre hypertensive 
• Hypertensive i No hypertension ; 
42% 
Figure 4.0: Distribution of hypertension status among school children 
Of the 266 students studied, the proportion of pre - hypertensive students was 42.2% 
(95% CI: 36.S -48.1%) while the prevalence of hypertension was 16% (95% CI: 12.1 _ 
20.7%) with 41.8 (95% CI: 36.2 - 47.7%) having nonnw blood pressure. 
34 
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4.2 Association between Socio-demographic, clinical and lifestyle factors of the study 
participants 
The bivariate analysis of factors associated with hypertension are shown in table 4.1. Sex 
was significantly associated with hypertension, thus, the odds of being hypertensive among 
the male students was more than three times that of females (5.56% vs 24.36%, p=O.OOl). 
Programs studied by the students was significantly associated with their hypertension status 
(p=O.019). Though the average heights of participants were not significantly different 
among hypertensive and non-hypertensive participants (165.5 cm vs 169 cm, p=0.148), 
hypertensive students were averagely heavier than non-hypertensive students (57.4 kg vs 
70.6 kg, p=O.013). The body mass index of hypertensive pupils was significantly 4.2 kglm2 
higher than that of the normal students (20.8 kg\m2 vs 24.9 kg\m2, p = 0.0189). There was 
not enough statistical evidence to conclude that smoking, alcohol intake and physical active 
are associated with the hypertension status of a student which is contrary to what literature 
has outlined. Table 4.1 Shows details of the bivariate analysis. 
35 
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Table 4.1: Association between Socio-demographic, clinical and lifestyle factors of 
the study participants 
Non-hypertensive Hypertensive 2 1.. P - value 
Sex 18.38 <0.001 ** 
Female 119(94.44) 7(5.56) 
Male 118(75.64) 38(24.36) 
age(mean ± SO) 16.45 ± 0.98 16.69± 0.92 -1.59 0.116 
Class 0.46 0.796 
SHS 1 164(83.25) 33(16.75) 
SHS2 72(85.71) 12(14.29) 
SHS3 1(100) 0 
Program offered 0.019* 
Gen Science 56(80.00) 14(20.00) 
GenArts 110(80.29) 27(19.71) 
Business 9(90.00) 1(10.00) 
Visual Arts! Home Economics 61(95.31) 3(4.69) 
Weight(mean ± SO) 164.81 ± 11.51 169.65 ± 
6.78 -3.84 <0.001*** 
Height(mean ± SO) 56.58 ± 9.11 64.20 ± 
11.83 -4.09 <0.001*** 
BMI (mean ± SO) 20.62 ± 2.75 22.34 ± 3.76 -2.91 0.005** 
Waist circumference (mean ± 
SO) 89.70 ± 10.15 92.50 ± 7.38 -2.14 0.035* 
family history of hypertension 
No 0.306 98(84.48) 
Yes 18(15.52) 19(95.0) 1(5.00) 
Central Obesity 
No 0.207 73(82.95) 
Yes 15(17.05) 13(100) 
Level of Aerobic exercise 0 
> once 8.36 
88{89.80) 0.039* 
>= 20 mins once\twice 10(10.20) 55(75.34) 
>= 20mins\ 3 time 18(24.66) 28(77.78) 
>= 20 mins\>=4 times 8(22.22) 65(87.84) 
Are you active 9(12.16) 
No 0.01 
Yes 20(83.33) 
0.921 
4(16.67) 
217(84.11) 
CVersmoked 41(15.89) 
No 
Yes 227(83.76) 44(16.24) 
8(88.89) 
currently smoke 1(11.11) 
No 
Yes 234(84.84) 43(15.52) 
2(100) 
aleob~,.!cc 0 --
213(83.86) 8(3.15) 0.603 
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1(3.70) 
Yes 23(85.19) 2.16 0.339 
Fruit eating habit 
Daily 67(89.33) 8(10.67) 
Weekly 71(81.61) 16(18.39) 
Occasionally! not at all 99(82.50) 21(17.50) 
roughages eating habit 5.05 0.08 
Daily 74(85.06) 13(14.94) 
Weekly 67(77.01) 20(22.99) 
Occasionallyl not at all 95(88.79) 12(11.21) 
confection aries eating habit 1.38 0.501 
Daily 104(83.87) 20(16.13) 
Weekly 58(88.06) 8(11.49) 
Occasionally! not at all 73(81.11) 17(18.89) 
vegetable eating habit 0.25 0.881 
Daily 119(82.64) 25(17.36) 
Weekly 50(84.75) 9(15.25) 
Occasionally/ not at all 46(85.19) 8(14.81) 
P-values in parentheses; *p<0.05, *"'p<O.OI, *"'*p<O.OOI values were based on Pearson chi-
square and Fishers exact test for categorical variables, and t-test for comparing means. SD: 
Standard Deviation. (%) represent row percentage, + estimated p-value from the Welch t-
test, § p-value estimate from Fisher's exact test. Non-hypertensive constitutes both no 
hypertension and pre-hypertensive students 
4.3 Effect of demographic, clinical and life style factors on hypertension status 
The results from multi variable logistic regression analysis showed that the sex, class and 
body mass index (BMI) were significantly related to the hypertension status of the male 
students. Among the students. Males had 4.9 times odds of being hypertensive compared to 
the females (OR: 4.91, 95% CI: 1.65 -14.62, p=0.004). The odds of being hypertensive was 
66% less among Students in SHS 2 than those in SHS 1 (OR: 0.34,95% CI: 0.12 _ 2.10, 
p=O.037). Among the study participants, the odds of becoming hypertensive increases by 
1.23 for every 1 kglm2 rise in BMI (OR: 1.23,95% CI: 1.08 - 1.40, p=0.002). Details of 
the analysis can be found in table 4.2 
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Table 4.2: Eft'ec:t of demographi•c , ch•O•l cal and )"f, style factors on hypertension status I e AOR 95% CI P-value 
OR 95% CI P-va l ue 0.004 
Sex <0.001 
Female ref 
Male 5.47 2.35 - 12.75 4.91 1.65 - 14.62 
Age 1.28 0.93 - 1.77 0.127 1.38 0.91 - 2.1 0.129 
Class 0.606 0.037 
SHS 1 ref 
SHS2 0.83 0.40 - 1.70 0.34 0.12 - 0.94 
SHS3 1.00 
Program 0.064 0.376 
Gen Science ref 
GenArts 0.98 0.47 - 2.02 0.58 0.22 - 1.49 
Business 0.44 0.05 - 3.81 0.33 0.03 - 3.92 
Visual Arts! Home 
Economics 0.2 0.05 - 0.72 0.26 0.05 - 1.32 
BMI 1.19 1.08 - 1.32 0.001 1.23 1.08 - 1.4 0.002 
Level of Aerobic 
exercise 
0.673 
ref 0.046 
20 mins .. 2.88 1.24 - 6.69 1.89 
20mins\ .. 0.66 - 5.42 2.51 0.90 - 6.99 
20mins\. . 1.52 0.45 - 5.19 1.22 0.47-3.16 1.20 
Alcohol intake 0.38 - 3.76 
No ref 0.842 
Yes 0.9 0.30 - 2.75 0.858 
Fruit eating habit 0.87 0.22 - 3.44 
Occasionallyl not at all ref 0.386 
Daily 0.347 0.56 
WeekI 0.24 - 1.35 0.44 1.06 0.13 - 1.43 0.52 - 2.188 
ROlpage eating habit 0.76 0.28 - 2.05 
Occasionallyl not at all 0.086 ref 0.166 
Daily 1.39 
WeeklX 0.60 - 3.22 1.86 2.36 0.62 - 5.59 1.08 - 5.16 
CODfectionariel 2.83 0.97 - 8.28 
Occasionallyl not at all 0.506 ref 0.456 
Daily 0.83 
WeekI 0.40 - 1.68 0.58 0.82 0.23 - 1.44 0.32 - 2.11 
Vegetable eating habit 0.48 0.16 - 1.52 
Occasionallyl not at all 0.882 ref 
Daily 0.778 
WeekI 1.21 0.51 - 2.87 
1.04 1.50 0.37 - 2.91 0.45 - 5.09 1.23 
ref: the reference category, AOR: adjusted odds ratio from the multiple b0i.n3a r-y4 .l9o5g istic 
regression model, CI: confidence interval. p<O.OS, "P<O.OI. ".P<O.OOI 
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CHAPTER FIVE 
DISCUSSION 
5.0 Introduction 
A total of266 senior high school students participated in the study. More than half (S3.3%) 
of the participants were males. Majority of them (69.7%) were in their first year. 
This study found a 16 % overall prevalence of hypertension. 42.2% were prehypertensive. 
Among those who were hypertensive, 1.9% were females and S.S9% were males. The 
systolic and diastolic blood pressure were averagely 123.9mmHg and 68.7mmHg 
respectively. The mean BMI was 20.9kg/m2 whilst a mean waist circumference of 90.1 em 
was recorded. 3.2% of the participants had smoked before. 34.9% exercised at least once in 
a week. About half the participants had roughages or fruits and vegetables incorporated in 
their diet. 
5.1 The prevalence of hypertension 
The findings of the study suggested 16% prevalence of hypertension. In a similar study, the 
prevalence found, fell within the range of 0-22.3% weighted prevalence in South Africa and 
certain West African countries (Essouma et al., 20IS). In a sharp contrast, this prevalence 
was higher compared to that of urban Ghana (4%) in a study that sought to identify 
hypertension and pre hypertension among 201 youths aged between IS-24years (Aftifa-
Anane et aI.,20IS). Similarly, a study that was conducted in Enugu, South Eastern Nigeria 
among 2694 adolescents recorded a lower prevalence of 5.4% (Ujunwa et aI., 2013). It is 
worthy to note that majority of the participants (69.7%) were in their first year (SHS 1), the 
apparent high prevalence could therefore be linked to the stress and the unrest that 
accompanies SHS I work. 
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5.2 The prevalence of prehypertension 
Results from the Framingham Heart Study indicate that the probability of persons with 
prehypertension developing hypertension is two to three times higher than in those with 
nonnal blood pressure (Leitschuh et al., 1991). This study found that a high proportion (42.2 
%) of the senior high school students were prehypertensive hence, the trend of prevalence 
of hypertension is likely to increase among these students in adult life ifno intervention is 
made among the prehypertensive group. This prevalence has failed to be consistent with a 
number of studies. In a study that was done by Tony et al. 2016 in Karela, India, the 
prevalence of pre hypertension among 2,438 school children aged between 13- 17 years, was 
21.4%(95% CI 19.64%- 22.96%). Similarly, the prevalence of pre hypertension in children 
2- 18 years was found to be 15% (Ewald and Haldeman, 2015). In trying to identify what 
might have caused the steep rise in the prevalence of prehypertension, it was observed that 
majority of the participants were in their first year of study and therefore had to battle with 
a number of stressful events coupled with studies. 
5.3 Factors associated with blood pressure elevatiou 
There are various factors responsible for the elevation of blood pressure. There are 
modifiable risk factors and non-modifiable risk factors. Age is a non-modifiable. Studies 
have shown that there is a strong positive correlation between increasing age and increase 
in blood pressure (Leitschuh et al., 1991; Pinto. 2007). The results of this study however 
showed no increasing trend of blood pressure with increasing age. The gender of the senior 
high school students was observed to be associated with hypertension. The odds of being 
h rtens' 
ype lve among the male students was more than three times that offemales (5.56% vs 
24.36%. p=O.OOl). 
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Many studies have demonstrated the correlation between excess body weight and blood 
pressure. Obesity has been shown to be an independent risk factor for hypertension (park, 
2009). Overweight and obesity are modifiable risk factors for hypertension. A study 
conducted in India demonstrated a strong positive correlation between BMI and blood 
pressure (Dua et al., 2014). The average heights of participants were not significantly 
different among hypertensive and non-hypertensive participants (165.5 cm vs 169 cm, 
p=O.148). That notwithstanding, hypertensive students were averagely heavier than non-
hypertensive students (57.4 kg vs 70.6 kg, p=O.OI3). This study found that being overweight 
or obese was significantly associated with hypertension. There was a trend of increasing 
blood pressure among those who were overweight or obese. The body mass index of 
hypertensive students was 4.2 kglm2 higher than that of the normal students (24.9 kglm2 vs· 
20.8 kg/m2, p = 0.0189). 
Smoking and alcohol are notable factors that are associated with hypertension. Various 
studies (Raja et al., 2016 & Bowman et aI., 2007) however indicate significant associations 
between smoking, alcohol intake and hypertension. However, no significant association was 
found between alcohol drinking habit, cigarette smoking habit and hypertension, in this 
present study. Even though the amount and frequency of alcohol intake and smoking 
significantly influence the development of hypertension, most of the senior high school 
students who participated in this study did not respond to questions related to the amount 
and frequency of intake of such substances. 
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CHAPTER SIX 
CONCLUSION, RECOMMENDATIONS AND LIMITATIONS 
6.1 Conclusion 
. d amazingly high prevalence 
This study revealed a high prevalence of hypertensIOn an an 
of pre hypertension among the senior high school students. Hypertension among these senior 
high school students was associ.a ted mal.O  Iy  ·th BMI There was no link between WI . 
hypertension and the other established factors such as alcohol intake, tobacco use and 
physical inactivity. 
6.2 Reeommendations 
Hypertension, which is a significant driver of the cardiovascular disease burden in Africa 
bas reached epidemic proportions in the adult population. Given that senior high school 
students presenting with high blood pressure have a major risk of becoming hypertensive, 
specific cost- effective interventions need to be introduced early in life to prevent 
cardiovascular disease in adulthood. Based on the findings of this study and as part of 
interventions to prevent the cardiovascular disease burden, there must be an urgent need to 
intensify awareness of hypertension among senior high school students, their parents and 
teachers. Parents and guardians should be sensitised on the effect of nutrition on the BMI of 
their wards. Physical education should be an integral part of the curriculum of senior high 
schools to ensure that the students are active physically. The Ministry of Health and the 
Ghana Health Service should incorporate Screening and blood pressure monitoring 
programmes into the school health programmes and general public health education on 
hypertension and its associated factors should be strengthened. Most studies on adolescent 
hypertension has been cross sectional or a review of already existing papers. The causal 
'~~ of associated factors has been difficult to provide. To ascertain the true 
42 
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prevalence of adolescent hypertension, it is recommended that a prospective cohort study 
be carried out within adolescent years as a follow up to this study. 
6.3 Limitations 
Blood pressure measurement of students was collected on only one occasion; the estimated 
prevalence of high blood pressure may be overestimation. It was a cross- sectional study, 
therefore, the causal interference of the associated factors could not be provided. 
43 
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REFERENCES 
A global brief on Hypertension, Silent killer, global public health crisis (WHO), I?oc~~nt 
number: WHOIDC01WHD/2013. Retrieved from: http://apps.who.mtlms/ 
bitstreamll0665/79059111 WHO_DCO_W HD_2013.2 
Addo, J., Amoah, A.G., &Koram, K. A. (2006). The changi?g ~atterns ~~hyperte~sion in 
Ghana: a study of four rural communities in the Ga dlstnct. Ethniclty and disease 
th 
Retrieved from: https:l/www.ncbLnlm.nih.gov/pubmedlI7061743. [Accessed: 7
July, 2017] 
Alicke, M., Boakye-Appiah, J. K., Abdul-JalH, I., Henze, A Giet, M.,Schulze, B.M., 
Schweigert F. J., Mockenhaupt, F. P., Bedu-Addo, G., & Danquah. I. (2017). 
Adolescent health in rural Ghana: A cross- sectional study on the co- occurance of 
infectious diseases. malnutrition and cardio- metabolic risk factors. Retrieved from: 
https:lldoi.orglI0.137I1journal.pone.0180436. [Accessed: 2nd November. 2017] 
Ary&, R., Antonisamy, B., & Garg, S.K. (2012). Sample Size Estimation in 
PrevalenceStudies. The Indian Journal of Pediatrics, 79(11). Retrieved from: doi: 
1O.1007/s12098-012-0763-3. [Accessed: 20th June, 2016]. 
Crisafulli, A., Pagliaro, P., Cohen- Solal, A, & Coats, J. A (2015). The effect of 
physical exercise on cardiovascular diseases: Biochemical, Cellular and Organ 
Effect. Retrieved from: https:llwww.ncbi.nlm.nih-gov/pmc/articlesIPMC4692999. 
[Accessed: 19th November, 2017] 
Drouin- Chartier, J-P., Gigleux, I., Tremblay, A. 1., Poirier, L., Lamarche, B., & Couture, 
P. (2014). The impact of dairy consumption on essential hypertension: a clinical 
study. Retrieved from: https:llnutritionj.biomedcentral.comlarticlesll0.1186/1475-
2991-13-83. [Accessed: 22nd December, 2017]. 
Edwald, D.R., & Haldeman, L.A (2016). Risk factors in adolescent hypertension. Global 
paediatric health. Retrieved from: 001: 10.1177/2333794XI5625159. [Accessed: 
8111 December 2016]. 
Ezenw~su, O. U., & Ekw~chi,. u. (2014). Elevated arterial blood pressure and body mass 
lDdex ~ong Nigenan preschool children popUlation. Retrieved from: 
https:lldol.orgll 0.1186/1471-2431-14-64 . [Accessed: 3rd August, 2017] 
F<>ex, P., . & Sear, J. W. (2004). Hypertension: pathophysiology and treatment 
Retri~edfrom: c:accp.oxfordjournals.org [Accessed 8th June, 2016]. Globai 
C~ovasc~ar di~s (CVDs) Fact sheet (WHO), 2015. Available at 
http.llwho.mtl medlacentrel factsheets/fs317/enl. 
Global status report .on n~n-communicable diseases 2014 (WHO), ISBN 978 92 4 1564854 
(NLM classIficatIon: WT 500) Available at http'll h" . 
106651148114/119789241564854. . apps.w o.mtl msl bitstream/ 
Google maps (2016). www.maps.google.com.gh. 
University of Ghana  http://ugspace.ug.edu.gh
Hedge, M. S., & Scott, D. S. (2015). Influence of physical activity on hypertension ann~ 
cardiac structure. Retrieved from:DOIlO.1007/s11906-015-0588-3. [Accessed: 22 
December,2017]. 
Husain, K., Ansari, RA, & Ferder, L. (2014). Alcohol-induced hypertensi.on: mechani~m 
and prevention. World J Cardiol. 6 (5): 245-252. Retrieved from: dOl: 10. 4330/wJc. 
v6.l5.245. [Accessed: 20th June, 2016]. 
Landsberg, L., Aronne, L.J., Beilin, L.J., Burke, V., Leon, I., Igel, L.I., Lloyd-Jones, D., 
Sowers, J. (2013). Obesity-Related Hypertension: Pathogenesis, Cardiovascular 
Risk, and Treatment. The Journal o/Clinical Hypertension. 15(1), 14-33. 
Leitschuh, M., Cupples, L.A, Kannel, W., Gagnon, D., & Chobanian, A (1991). High-
normal blood pressure progression to hypertension in the Framingham Heart Study. 
Hypertension, 17(1),22-7. 
Medical University of Vienna. (2014). Higher risk of high blood pressure for socially 
disadvantaged. Retrieved from: 
httpsllwww.sciencedaily.comlreleases/2014/05/140513091659.htm. [Accessed: 
220d December, 2017]. 
O"keefe, J.H., Bybee, K.A., & Lavie, C.J. (2007). Alcohol and Cardiovascular Health. 
Journal o/the American College o/Cardiology, 50 (11). 
Papadopoulos, D.P., Makris, T.K., & Papademetriou, V. (2008). Is it time to treat 
prehypertension? Hypertens Res., 31(9), 1681-6. 
Pinto, E. (2007). Blood pressure and ageing. Postg rad Med J., 83(976), 109-114. 
Rashid, ~t Khalid, Y., & Chia, Y. (2011). Management of Hypertension. Cardiovasc 
Dlabetol. 6(1),40-43. 
Reckelhoff, J.F. (2001). Gender Differences in the Regulation of Blood Pres 
Hypertension, 37,1199-1208. sure. 
Roger, V.L., Go, AS., Lloyd-Jones, D.M., Benjamin, E J Berry J D Bo d W B & 
Bravata StataCorp. (2014). Stata Statistical Softw~;e: Rele~s~ i4 C~l~ng'e S~ti': 
TX: StataCorp LP . on, 
Sadoh, ~ ~io~~d:~s~~;'in& ~:iriuka, A N. (~016), Physical activity, body mass index 
Sci, 16(4), 947-95/ Rea;;;e~~~OO~:IlS att:nding ~rivate schools. Afti Health 
(Accessed: 26th July, 2017] http.//dx.dol.org/l0.4314/ahs.vI6i4.10. 
Sarmento, D. R, & Yehadji D (2016) An anal ' 
developing a compreh.;;ive natiOnal s y~l~ of gl~ba~ yo~th tobacco survey for 
from doi: 101186/s12889-o16_274 5 [Amokimdg pOI h;y m Ttmor- Leste. Retrieved 
-. ccesse: 6 March 2018], 
T~,,~,. Ateekal,B., Nair, A. T. S., Ramachandran R Phil' . , 
\:f;~,Y~~;{{. (lOI6). Prevalence ofhype~ ," dIP R. R., Ra.~as~. R S., & 
l". k ". ... ... nsl0n an pre- hypertension among 
University of Ghana  http://ugspace.ug.edu.gh
adolescents school children in Thiruvananthapuram, Karela, India. Retriev;d from: 
hnp:lldx.doi.org/l 0.1820312394-6040.ijcmph20 164291. [Accessed: 26 July, 
2017]. 
Ujunwa, F. A., Ikefuna, A.N., Nwokocha, A. R., & Chinawa, J.M . (201?). Hypertension 
and prehypertension among adolescents in secondary schools m Enugu, South 
Nigeria. Retrieved from: doi: 10 .1186/1824-7288-39-70. [Accessed: 17th July, 2017] 
Virdis, A., Giannarelli, C., Neves, M.F., Taddei, S., & Ghiadoni, L. (2010). Cigarette 
smoking and hypertension. Curr Pharm Des. 2010,16(23),2518-25. 
WHO. (2017). New global estimates of child and adolescent obesity released on World 
Obesity Day. Retrieved from: www.who.intlend-childhood -obesity/news/new-
estimates-child-adolescent-obesity. [Accessed: 24th December, 2017] 
WHO. Fact sheet. (May, 2017). Cardiovascular disease (CVDs). Retrieved from: 
www.who.intlmediacentre/factsheets/fs317/enl. [Accessed: 24th December, 2017]. 
WHO. Fact sheet. (October 2017). Obesity and overweight. Retrieved from: 
www.who.intlmediacentre/factsheets/fs3111enl. [Accessed: 24th December, 2017] 
World Health Organization (2013). A global brief on hypertension. Silent killer a global 
public health crisis. Retrieved from: 
http://www.who.inticardiovascular_diseases/publications/g lobal brief hypertensio 
n/en! [Accessed: 25th November, 2015]. - -
Yang, Y., Dong, B., Wang, S., Zhiyong, Z., Fu, L., & Ma, J. (2017). Prevalence of high 
blood press~e subtypes and its association with BMI in Chinese children: A national 
cross- sectIonal survey. Retrieved from: DOl 10.1186/s12889-017-4522-2 
[Accessed:26th July, 2017] . 
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APPENDIX: QUESTIONAIRE 
PARTICIPANT CONSENT 
Dear respondents, 
I am Michael Obu- Afful a student of the School of Public Health, University of Ghana 
Legon, I am researching on the topic:" Prevalence and risk factors of Hypertension among 
Senior High School Students". This exercise will give the opportunity to know your blood 
Pressure, height, weight, waist- hip ratio and body mass index (BMI). You will be 
contributing immensely towards the success of this study by responding to these questions. 
Kindly give adequate information to the under listed questions. Your identity will not be 
disclosed in any way. Information gathered would be used only for the purpose of this 
research. 
Thank you for your cooperation. 
LID Number ................................................ Date of Recruitment. ................. . 
2. Gender/sex: female [] male [ ] 3.Age .......................... . 
4. AddresslTelephone number.................. 5. Ethnicity ............................. . 
6. EducationaIlevel: SHS 1 [] SHS 2 [] SHS 3 [ ] 
7. Course of Study: Science [ ] General Arts [ ] BusI'ness [ ] V' ual 
IS Arts [ ] Home 
Economics: ( 1O thers (specify) ................. . 
ANTHROPOMETRIC MEASUREMENT 
8. Height ............ cm 
9. Weight ...........................K g 
10. Waist circumference 
..................c m 11. Body mass index (BMI) ....... .............. 
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CLINICAL ASSESSMENT 
12. Blood pressure ............... mmHg 13. Family history of hypertension yes [] no [ ] 
14. Central obesity yes [] no [ ] 
LIFESTYLE ASSESSMENT 
Physical exercise 
15. How much aerobic exercise do you do? (By aerobic exercise we mean activity that raises 
your heart rate and makes you slightly breathless) 
[] 20 minutes or more four or more times a week 
[1 20 minutes or more three times a week 
{] 20 minutes or more once or twice a week 
[] Less than once a week 
16. Are you generally active as part of your daily routine? eg do you walk a lot, do you use 
.1the  stairs instead of the lift, are you a keen gardener? Yes [1 No 
"&noking 
17. Have you ever smoked any form of tobacco before? (Cigarrete, pipe, cigars etc.) 
J] Yes [] No 
18. Do you currently smoke any form of tobacco? (Cigarrete, pipe, cigars etc) 
{J Yes [] No 
19. How long have you been smoking? 
:P less than one year [] 1-3years [] more than 3years 
48 
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ALCOHOL INTAKE 
20. Do you take alcohol? 
[J Yes [] No 
21. How long have you been drinking? 
[] less than one year [] 1-3years [] more than 3 years 
22. How often do you take alcoholic drinks? 
[ ] Daily [ ] Weekly [ ] occasionally [ ] Not at all 
Dietary assessment 
23. How often do you take fruits? 
I] Daily [ ] Weekly [ ] occasionally [ ] Not at all 
24. How often do you take Vegetables? 
[ ] Daily [ ] Weekly [] occasionally [ ] Not at all 
25. How often do you take roughages (Foods that have fibre)? 
[ ] Daily [ ] Weekly [ J occasionally [ ] Not at all 
!6. How often do you take confectionaries? (Sugary drinks, sweets etc) 
[ ] Weekly [] occasionally ( ] Not at all 
!7. HOV'l~. .~  ~u .take Vegetables? 
, .. 1 ] occasionally [ ] Not at ail 
I'. .'<";'yI ',' ';~ '. d. 
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