Hrev_master Healthcare in Low-resource Settings 2025; volume 13:11961 Early diagnosis of stroke risk factors in high school students in Makassar, South Sulawesi, Indonesia Muhammad Awal, Darwis Durahim, Andi Halimah, Hasbiah, Arpanjaman, Agus Supriatna, Fahrul Islam, Muh Ikbal Department of Physiotherapy, Makassar Health Polytechnic, Indonesia Abstract The number of stroke patients in Indonesia is ranked as the first country to experience the most strokes in all of Asia. The prevalence of stroke in Indonesia reaches 8.3 out of 1000 popula- tion. This prevalence rate increases with increasing age. Indonesian national data shows that stroke is the highest cause of death, at 15.4%, with approximately 750,000 strokes per year in Indonesia and 200,000 recurrent strokes. People who are physical- ly inactive (those who exercise less than three times per week, each for 30 minutes) have an almost 50% increased risk of stroke compared to those who are active. Physical inactivity can lead to weight problems and increased blood pressure and is associated with diabetes, all of which are important risk factors for stroke. Inactivity also contributes to the onset of early atherosclerosis and other cardiovascular diseases, such as heart attacks. This study is an analytical observational study with a cross sectional design to see and observe the risk factors for stroke that exist in school chil- dren in Makassar city. Data processing was carried out using computer application programs and SPSS version 22.0 with data analysis methods using the Chi Square Test with the Yate’s Correlation formula in SPSS called Continuity Correction and Risk. The number of respondents studied was 896 people. Hypertension is a major risk factor for health problems in society, especially in socioeconomic transition. Hypertension is a primary risk factor for the onset of heart disease and stroke. Doing physical activity will prevent us from various diseases, by doing adequate physical activity we can suppress the increase in blood sugar lev- els, cholesterol levels, and avoid obesity and strengthen the heart. All of which are risk factors for stroke. So thus by doing adequate physical activity we can avoid stroke. There is a relationship between gender, obesity, hypertension, family history of disease, stress, physical activity, risky diet and smoking on stroke risk fac- tors and there is no relationship between age and knowledge with stroke risk factors. Introduction Stroke is defined as rapidly developing signs of focal (or glo- bal) impairment of brain function lasting 24 hours (unless inter- rupted by surgery or death) without an obvious nonvascular cause.1-4 The definition includes patients presenting with clinical signs and symptoms of subarachnoid hemorrhage, intracerebral hemorrhage, thrombosis and embolism. Hemorrhagic stroke is defined as a stroke event with a diagnosis of subarachnoid hemor- rhage or intracerebral hemorrhage and ischemic stroke is defined as an event with a diagnosis of thrombosis or embolism. Transient Ischemic Attack (TIA) and chronic cerebral vascular disease were excluded. On the basis of survival status within 28 days of the event, located stroke events were subdivided into fatal and nonfa- tal events so Stroke is the rapidly developing clinical signs of focal (or global) impairment of brain function with symptoms lasting 24 hours or more or leading to death, in the absence of other obvious causes other than vascular.5-7 Indonesia is the country with the largest number of stroke patients in Asia, it is estimated that every year 500,000 people are affected by stroke, and about 25% or 125,000 people die and the rest experience mild or severe disability. Currently stroke ranks third as a deadly disease after heart disease and cancer, while in Correspondence: Muhammad Awal, Department of Physiotherapy, Makassar Health Polytechnic, Indonesia E-mail: daengngerang73@gmail.com Key words: stroke, risk factors, physical activity. Contributions: MA, DD, AH, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; HA, resources, investigation, and writing –review & editing; aj formal analysis, validation, writing – review & editing; AS, resources, supervision, and writing –review & editing; FI and MI, resources, investigation, and writing –review & editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: this research has received eth- ical approval from the Health Research Ethics Committee of the Makassar Health Polytechnic with Ethical Approval Recommendation No. 111 / KEPK-PTKMS/ III/2022. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research was supported by research funds from [Makassar Health Polytechnic] with contract number No: LB.02.03/4.3/0421/2019 Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgement: we would like to thank the director of the Makassar Health Polytechnic and his staff who have provided support in carrying out this research. Received: 13 October 2023. Accepted: 20 September 2024. Early access: 14 October 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13:11961 doi:10.4081/hls.2024.11961 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13:11961] [page 47] Indonesia stroke ranks first as a cause of death in hospitals. If there are no better stroke prevention efforts, the number of stroke patients in 2020 is predicted to increase 2-fold.8-10 Based on Riskesda 2013 data, stroke prevalence in Indonesia increased from 8.3 per 1000 population in 2007 to 12.1 per 1000 population in 2013. South Sulawesi has the highest prevalence of stroke compared to other provinces in Indonesia based on the highest diagnosis of health workers and symptoms at 17.9%, an increase of 10.5% from 2007 at 7.4%.11 People who are physically inactive (those who exercise less than three times per week, each for 30 minutes) have almost a 50% increased risk of stroke compared to those who are active. Physical inactivity can lead to weight problems and increased blood pres- sure and is associated with diabetes, all of which are important risk factors for stroke. Inactivity also contributes to the onset of early atherosclerosis and other cardiovascular diseases, such as heart attacks.10-13 The results of stroke disease surveillance that we carried out at Dr. Wahidin Sudirohusodo Hospital, which is a referral hospital for stroke patients in eastern Indonesia, showed fluctuations in stroke patients treated. Data obtained from Wahidin Sudirohusodo Hospital Makassar in 2017 showed that the incidence of stroke ranked 6th of all hospitalized patients, in this case stroke associa- ted with cerebral infarction was 269 people, including 148 men and 121 women, with the highest age classification of 45-65 years (115 people), followed by age ≥65 years (88 people), 35-44 years (61 people), and 25-34 years (5 people). Meanwhile, stroke caused by intracerebral hemorrhage ranked 20th of all patients treated at Wahidin Sudirohusodo General Hospital, which reached 123 peo- ple, of which 66 were men and 57 were women, with the highest age classification also occupied by 45-64 years of age (73 people), then successively ≥65 years of age (39 people), 35-44 years (10 people), and 25-34 people (1 person).14-16 Materials and Methods Research design This study is an analytical observational study with a cross sec- tional design, which is a research design where risk and effect fac- tors are taken together at one time.17 Article Table 1. Analysis of relationships between variables. High risk Low risk Total (cl 95%) OR Ρ N % N % N % Lower Uper 0.708 0.163 Age 15-16 30 9.2 297 90.8 327 100 0.452 1.112 0.163 expectet 0 cell 17-19 71 12.5 498 87.5 569 100 Total 101 11.3 795 88.7 896 100 Gender 1.580 3.650 2.402 0.000 expectet 0 cell Male 51 17.7 237 82.3 288 100 Female 50 8.2 588 91.8 608 100 Total 101 11.3 795 88.7 896 100 BMI 8.078 20.797 12.961 0.000 expectet 0 cell Fat 51 46.8 58 53.2 109 100 Normal - skinny 50 6.4 737 93.6 787 100 Total 101 11.3 795 88.7 896 100 Hipertension 5.067 18.305 9.639 0.000 expectet 0 cell Prahipertensi 90 19.8 365 80.2 455 100 Normal 11 2.5 430 97.5 441 100 Total 101 11.3 795 88.7 896 100 Family history of disease 4.252 10.403 6.651 0.000 expectet 0 cell Present 47 33.8 92 66.2 139 100 None 54 7.1 703 92.9 757 100 Total 101 11.3 795 88.7 896 100 Stress 4.395 11.529 7.118 0.000 expectet 0 cell Present 77 23.8 247 76.2 324 100 None 24 4.2 548 95.8 572 100 Total 101 11.3 795 88.7 896 100 Physical activity 2.503 6.739 4.107 0.000 expectet 0 cell Heavy 29 29.0 71 71.0 100 100 Medium-light 72 9.0 724 91.0 796 100 Total 101 11.3 795 88.7 896 100 Risk eating 1.693 89.203 12.288 0.003 Expectet 0 cell High risk 100 12.4 708 87.6 808 100 Low risk 1 1.1 87 98.9 88 100 Total 101 11.3 795 88.7 896 100 Smoking behavior 4.401 11.947 7.521 0.000 expectet 0 cell Present 34 39.5 52 60.5 86 100 None 67 8.3 743 91.7 810 100 Total 101 11.3 795 88.7 896 100 [page 48] [Healthcare in Low-resource Settings 2024;12:11961] Study participants The population in this study were all high school students in Makassar City as many as 29440 students, the sample in this study were some high school students in Makassar City totaling 896 stu- dents. Sample size calculation Because the population is known, the large formula using Slovin is: Where : N = Population n = Sample e² = Margin of Error = 0.05 So : n = N / (1 + (N x e²)) = 29440/(1+(29440x0.05²) = 29440/(1+ 29440x0.0025) = 29440/74.6 = 394.68 = 395 How to draw samples with Random Sampling (random) The data collected is primary data originating from 10 schools in the city of Makassar. Data collection was done by filling in observation sheets in the form of a checklist through questions and answers to the research sample. This study began after obtaining permission from the South Sulawesi provincial education office followed by visiting the scho- ol that became the research site by collecting students who became research samples and taking blood pressure measurements, measu- ring height and weight and asking questions and filling out a list of questions according to the research variables, namely age, gender, obesity, hypertension, family history, stress, physical activity risky foods and smoking which was carried out for less than 15 minutes per student. Data analysis For general analysis such as percentage and distribution of each research variable, bivariate analysis in the form of Odds Ratio test to determine the risk of independent variables on the depen- dent variable and for multivariate analysis to determine the effect of one or more of the independent variables on the dependent variable. Ethical clearance This research used ethical clearance issued by the Ethics Committee of the Faculty of Medicine, Hasanuddin University. Number: 925/H04.8.4.5.31/PP36-KOMETIK/2020 Results The results of the study based on bivariate analysis and multivariate analysis can be seen in Tables 1 and 2. Discussion Analysis of stroke risk factors is intended to answer research questions, as well as to identify variables that are the main predic- tors of stroke. In this study, the statistical test used was the Odds Ratio test to see the magnitude of the risk of each variable on the incidence of stroke, then to see the influence of variables on the incidence of stroke was carried out by path analysis. The results showed that the risk factors for blood pressure at an early age are very high, this is evidenced in several related studies where blood pressure that continues to increase slowly will dama- ge the walls of blood vessels by hardening the arteries and encou- raging the formation of blood clots and aneurysms, which will eventually lead to stroke, especially in people over 45 years old.18- 20 Hypertension is the most important stroke risk factor in America. Nearly 80% of patients diagnosed with first-time stroke have a Blood Pressure (BP) of [140/90. There is an additional risk of stroke at BP above 115/75, in developed countries, such as the United States, which have an older population that tends to have higher BP, the impact of BP on stroke risk is very obvious.21-23 Diabetes causes changes in the blood vessel system, and plays a role in the atherosclerosis process which will ultimately cause stroke. In people with diabetes, the blood becomes thicker and the load on the blood vessel walls becomes greater so it is feared that it will become thicker and the load on the blood vessel walls becomes greater so it is feared that they will become clogged more easily (especially in small blood vessels such as those in the brain and heart).24-27 In people who suffer from heart disease (for example abnormalities in the heart valves) due to impaired heart function, embolus/blood clots will arise. The embolus will travel along the circulation to the brain, and become blocked because the diameter of the blood vessels in the brain is very small, resulting in an ischemic (non-haemorrhagic) stroke. The results of the study showed an increase in body weight to Article [Healthcare in Low-resource Settings 2024;12:11961] [page 49] Table 2. Multivariate analysis of variables with stroke risk in high schools in Makassar City, South Sulawesi Province. NO Variables SE Beta t Sig 1 Gender 0.015 -0.038 -2.123 0.034 2 BMI 0.018 -0.009 -0.564 0.573 3 Hipertension 0.039 0.000 -0.060 0.952 4 Family history of disease 0.024 0.889 38.021 0.000 5 Stress 0.012 -0.009 -0.573 0.567 6 Physical activity 0.018 0.033 2.134 0.033 7 Risk eating 0.019 -0.003 -0.171 0.864 8 Smoking behavior 0.022 0.015 0.867 0.386 obesity, one of the causes of which is a lack of physical activity. This is reinforced by other studies that show there is evidence of a strong relationship between BMI and physical activity, but there is no evidence of a modifying effect by smoking, alcohol intake or BMI. There is no evidence that the relationship varies by vascular type.28-30 Smoking behavior in this study shows that this influential risk factor is supported by research Seo explaining the age distribution, men aged 40-49 years were the largest population (25.4%). In terms of smoking period, smoking for 10-19 years represents the largest population at 22.1%; 3.8% had smoked for more than 50 years. The prevalence of diagnosed diseases was 2.6% for stroke, 1.5% for myocardial infarction, 20.7% for hypertension, and 8.7% for diabetes Excess cholesterol in the blood, the medical term is called hyperlipidemia, is an indirect risk factor for stroke. Why is it called that because excessive cholesterol in the blood does not directly cause stroke, but rather increases the risk of atherosclerosis plaque formation in blood vessels. As is known, atherosclerotic plaque is responsible for the process of stroke due to blockage (ischemic stroke). This is supported by Ryu’s research and Ren’s research that high serum non-HDL-C, age, education, homocysteine levels, and Hamd score are independent risk factors for cognitive decline in patients with acute ischemic stroke. The risk of cognitive impairment after acute ischemic stroke increases with increasing levels of non-HDL-C. These parameters are easy to assess in a clinical setting.31-33 Risk factors for stroke that cannot be modified are: i) Stroke can affect any man and woman from childhood to adulthood. There is no benchmark on how old a person is prone to stroke, although stroke usually affects someone over 65 years old (stroke in chil- dren is very rare and is usually associated with congenital abnor- malities). Nowadays, with unhealthy lifestyles in urban areas, stro- ke can even affect someone who is 30 years old; ii) Stroke can be caused by heredity because risk factors for stroke such as hyper- tension and diabetes are generally passed down from one genera- tion to the next and in some studies there is indeed a link between heredity and the incidence of stroke. In a study Seo concluded his findings that genetic variations of the ABO gene may contribute to LAA susceptibility but not to ischemic stroke and SVD in a Chinese population.31 Doing physical activity will prevent us from various diseases, by doing adequate physical activity we can reduce the increase in blood sugar levels, cholesterol levels, and avoid obesity and stren- gthen the heart. Where all of that is a risk factor for stroke. Thus, by doing adequate physical activity we can avoid stroke. In a study with a sample size of 79 subjects experiencing lethargy and 46 mild dizziness. Subjects with severe dizziness were less physically active, reported more fear of falling, falling, depression/anxiety, diabetes, stroke/TIA, heart disease, higher number of medications and antihypertensive drugs, low quality of life and health, and worse appearance physically. Physical activity is not merely doing sports, by doing gardening activities, walking or cycling to work, to the mosque, to the market or other places will burn calories in the body so as to avoid accumulation in the blood, especially on the walls of blood vessels. There are even wise people who say every footstep will prevent heart disease and stroke. It would be better if you can take the time to do sports 3 - 4 times a week for 30 - 45 minutes, of course it will nourish the body and prevent the body from dangerous diseases.34-38 Conclusions There is a relationship between gender, hypertension, obesity, family history, stress, physical activity, smoking behavior and the risk of stroke in high school children in the city of Makassar, while age has nothing to do with the risk of stroke, and in the multivaria- te analysis the factor that is most related is family history. The sample size and students’ knowledge about stroke risk fac- tors are limitations of this study. References 1. Casarin FS, Pagliarin KC, Altmann RF, et al. Montreal com- munication evaluation brief battery-MEC B: Reliability and validity. Codas 2020;32:1-7. 2. Park SJ, Oh S. Changes in gait performance in stroke patients after taping with scapular setting exercise. Healthc 2020;8:128. 3. Luan FJ, Zhang J, Wang HQ. Epidemiological study of adole- scent idiopathic scoliosis using low/non-radiation screening methodology. J Rehabil Med 2018;50:765-6. 4. Lee JP, Chen S, Tsai CT, et al. Characteristics associated with the differential activity of nondominant and dominant affected hands in patients with poststroke right hemiparesis. Occup Ther Int 2020;2020:2387378. 5. Khattab S, Eng JJ, Liu-Ambrose T, et al. Sex differences in the effects of exercise on cognition post-stroke: Secondary analy- sis of a randomized controlled trial. J Rehabil Med 2020;52:jrm00002. 6. Matsushita T, Nishioka S, Taguchi S, et al. Sarcopenic obesity and activities of daily living in stroke rehabilitation patients: A cross-sectional study. Healthc 2020;8:255. 7. Ahmadi HS, Mehraban AH, Amini M, Sheikhi M. The effects of Virtual Reality on upper limb function in chronic stroke patients: A clinical trial. Iran Rehabil J 2019;17:81-9. 8. Hernández ED, Galeano CP, Barbosa NE, et al. Intra- And inter-rater reliability of Fugl-Meyer assessment of upper extre- mity in stroke. J Rehabil Med 2019;51:652-9. 9. Gallowayphd M, Marsden DL, Callister R, Nilsson M, Erickson KI, English C. The feasibility of a telehealth exercise program aimed at increasing cardiorespiratory fitness for peo- ple after stroke. Int J Telerehabilitation 2019;11:9-28. 10. Oberlin LE, Waiwood AM, Cumming TB, et al. Effects of phy- sical activity on poststroke cognitive function a meta-analysis of randomized controlled trials. Stroke 2017;48:3093-100. 11. Riskesda. Riset Kesehatan Dasar Nasional 2013; 2013. 12. Stewart RAH, Held C, Hadziosmanovic N, et al. Physical acti- vity and mortality in patients with stable coronary heart disea- se. J Am Coll Cardiol 2017;70:1689-700. 13. Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation 2018;137:E67-492. 14. Braakhuis HEM, Roelofs JMB, Berger MAM, Ribbers GM, Weerdesteyn V, Bussmann JBJ. Intensity of daily physical acti- vity–a key component for improving physical capacity after minor stroke? Disabil Rehabil 2020;0:1-6. 15. Fini NA, Bernhardt J, Said CM, Billinger SA. How to address physical activity participation after stroke in research and cli- nical practice. Stroke 2021;52:E274-E277. 16. Lynch EA, Jones TM, Simpson DB, et al. Activity monitors for increasing physical activity in adult stroke survivors. Stroke 2019;50:4-5. Article [page 50] [Healthcare in Low-resource Settings 2024;12:11961] 17. Supratiknya A. Metodologi penelitian kuantitatif & kualitatif dalam psikologi. Universitas Sanata Dharma; 2022. 18. Gjellesvik TI, Becker F, Tjønna AE, et al. Effects of High- Intensity Interval Training after Stroke (The HIIT Stroke Study) on physical and cognitive function: a multicenter ran- domized controlled trial. Arch Phys Med Rehabil 2020;101:939-47. 19. Li J, Ogbole G, Aribisala B, et al. Association between white matter hyperintensities and stroke in a West African patient population: Evidence from the Stroke Investigative Research and Educational Network study. Neuroimage 2020;215:116789. 20. Tejada Meza H, Artal Roy J, Pérez Lázaro C, et al. Epidemiology and characteristics of ischaemic stroke in young adults in Aragon. Neurologia (Engl Ed) 2022;37:434-40. 21. Hamre C, Fure B, Helbostad JL, et al. Factors associated with level of physical activity after minor stroke. J Stroke Cerebrovasc Dis 2021;30:105628. 22. Russell JBW, Charles E, Conteh V, Lisk DR. Risk factors, cli- nical outcomes and predictors of stroke mortality in Sierra Leoneans: A retrospective hospital cohort study. Ann Med Surg 2020;60:293-300. 23. Smith RW, Barnes I, Green J, et al. Social isolation and risk of heart disease and stroke: analysis of two large UK prospective studies. Lancet Public Heal 2021;6:e232-9. 24. Altable M, de la Serna JM. Cerebrovascular disease in COVID-19: Is there a higher risk of stroke? Brain, Behav Immun - Heal 2020;6:100092. 25. Al-Senani F, Al-Johani M, Salawati M, et al. An Epidemiological Model for First Stroke in Saudi Arabia. J Stroke Cerebrovasc Dis 2020;29:1-7. 26. Zhang Y, Vittinghoff E, Pletcher MJ, et al. Associations of blood pressure and cholesterol levels during young adulthood with later cardiovascular events. J Am Coll Cardiol 2019;74:330-41. 27. Tsujimoto T, Kajio H. Strategies for glycemic control in nono- bese and obese type 2 diabetic patients with coronary artery disease. Int J Cardiol 2019;282:1-6. 28. Karki A, Shrestha A, Subedi N. Prevalence and associated fac- tors of childhood overweight/obesity among primary school children in urban Nepal. BMC Public Health 2019;19:1055. 29. Zaprutko T, Florczak-Wyspiańska J, Kopciuch D, et al. Costs of stroke and incidence of first diagnosis of atrial fibrillation at time of stroke. Neurology Ward Hospital Poznań, Poland 2018. Healthcare 2021;9:999. 30. Angoorani P, Heshmat R, Ejtahed HS, et al. The association of parental obesity with physical activity and sedentary behaviors of their children: the CASPIAN-V study. J Pediatr (Rio J) 2018;94:410-8. 31. Seo SH, Lee D, Lee SH, Choi KY. Blockade of CXXC5-dishe- velled interaction inhibits adipogenic differentiation, obesity, and insulin resistance in mice. Sci Rep 2022;12:20669. 32. Ryu YC, Kim Y rin, Park J, et al. Wnt/β-catenin signaling acti- vator restores hair regeneration suppressed by diabetes melli- tus. BMB Rep 2022;55:559. 33. Ren Q, He C, Huang Q, Zhang D, et al. Impacts of global urban expansion on natural habitats undermine the 2050 vision for biodiversity. Resour Conserv Recycl 2023;190:106834. 34. Cook P, Sunnerhagen KS, Persson HC. Level of physical acti- vity is positively correlated with perceived impact on life 12 months after stroke: A cross-sectional study. J Rehabil Med 2020;52:2667 35. Jha RK, Yadav AK, Shrestha S, et al. Study of body mass index among medical students of a medical college in nepal: A descriptive cross-sectional study. J Nepal Med Assoc 2021;59:280-3. 36. Alt Murphy M, Andersson S, Danielsson A, et al. Comparison of accelerometer-based arm, leg and trunk activity at weekdays and weekends during subacute inpatient rehabilitation after stroke. J Rehabil Med 2019;51:426-33. 37. Bazan R, Luvizutto GJ, Braga GP, et al. Relationship of spon- taneous microembolic signals to risk stratification, recurrence, severity, and mortality of ischemic stroke: a prospective study. Ultrasound J 2020;12:1-12. 38. Umar AB, Koehler TJ, Zhang R, et al. Stroke knowledge among middle and high school students. J Int Med Res 2019;47:4230-41. Article [Healthcare in Low-resource Settings 2024;12:11961] [page 51]