Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12073 Prevalence of hypertension and its associated risk factors among secondary school students in Duhok City Ayoub Abid Abdul Majeed,1 Azad AbdulJabar Haleem2 1Master in Pediatric Nursing, Psychiatry and Pediatric Nursing Unit, College of Nursing, University of Duhok; 2Pediatric Department, College of Medicine, University of Duhok; Heevi Pediatrics Teaching Hospital; Kurdistan Pediatrics Society, Iraq Abstract Hypertension can develop in early childhood and go unnoticed unless it is screened for specifically during this developmental stage. Detecting potential hypertension risk in children is critical to avoiding the serious, long-term complications associated with the condition. The purpose of this study was to investigate the prevalence of hypertension among schoolchildren aged 13 to 18, as well as the risk factors associated with it. A cross-sectional study included 565 students aged 13 to 18 from the Duhok region. The analysis used Chi square testing and logistic regression with JMP Pro 14.3.0 software. Of the 565 students from 32 schools chosen, 242 (42.80%) were male and 323 (57.2%) were female. Notably, 5.84% (n=33) were hypertensive. A significant correla- tion was found between hypertension prevalence and body mass index, as well as gender. There was no significant relationship found with other variables. Logistic regression revealed that high blood pressure was significantly associated with excess weight, obesity, and age. We concluded that there was an increase in the incidence of hypertension among high school students. Lifestyle changes appeared to play a role in hypertension development among this population. Routine school surveys are recommended to detect potential hypertension cases in children and adolescents, allowing for timely preventative interventions. Introduction Hypertension poses a significant global health challenge and stands as a primary contributor to coronary artery and cerebrovas- cular diseases. The year 2000 witnessed around one billion adults worldwide grappling with hypertension, a number anticipated to escalate to 1.56 billion by 2025.1,2 This pervasive ailment entails substantial morbidity and mortality, silently endangering popula- tions globally. Evidently, hypertension can trace its roots back to childhood, remaining concealed unless diligently sought out dur- ing this developmental phase. Thus, timely identification of hyper- tension and its triggers assumes paramount importance to forestall its complications.3 Given the paucity of symptoms during child- hood and adolescence, hypertension often evades detection during these formative years. Its prevalence escalates with age and ado- lescence, rooted in multifaceted factors such as genetics, race, geography, culture, and dietary habits.3 Intriguingly, elevated blood pressure in this period foreshadows similar levels in adult- hood and old age Our understanding of blood pressure in children and adolescents is far from being complete and the long-term nat- ural history of blood pressure in this age group is still not well understood.4 Hypertension seldom manifests symptoms during early life, though the WHO does not advocate hypertension screening for children and adolescents. This study was undertaken due to a lack of data on adolescent hypertension prevalence in our country. Hypertension poses a substantial public health challenge among adults globally, with Iraq registering a 40.4% prevalence in a 2006 non-communicable disease risk factor survey.5 Insufficient information exists regarding blood pressure pat- terns and hypertension prevalence in Iraqi children and other Correspondence: Ayoub Abid Abdul Majeed, Psychiatry and Pediatric Nursing Unit, College of Nursing, University of Duhok, Iraqi Kurdistan. E-mail: ayoub.abid@uod.ac Key words: cross-sectional studies; hypertension; prevalence; risk fac- tors. Conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. Funding: We did not have any funding to conduct this study. Ethics approval: the Ethics Committee of Duhok General Directorate of Health approved this study (registered as 1307202I-7 -2I on 13 Jul,2021. The study is conformed with the Helsinki Declaration of 1964, as revised in 2013, concerning human and animal rights. Informed consent: the written consent forms were not applicable in this study because we collected the data of this study from the students, not patients. Patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized Students information to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgments: we would like to present our deep thanks to the Education of Duhok, the secondary and high schools, and the students who participated in this study. Received: 12 November 2023. Accepted: 27 February 2024. Early access: March 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 2024; 12:12073 doi:10.4081/hls.2024.12073 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, 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 man- ufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:12073] [page 293] Non -co mmerc ial us e o nly developing nations. Notably, a 2009 Najaf City study on school students found a 5.5% prevalence of high blood pressure while a 2002 Baghdad study on school-aged students reported a 1.7% hypertension prevalence.6 Despite strides in hypertension detection and management in select countries, the global scenario concern- ing awareness, treatment, and control remains wanting.1 To ensure public awareness and regulation of hypertension, early identifica- tion in life’s initial stages becomes pivotal. Delayed recognition burdens not only individuals but also governments due to elevated treatment costs. This study seeks to unveil hypertension prevalence and associated risk factors among secondary school students in the Kurdistan Region, thereby contributing to our understanding of this critical health issue. Materials and Methods Study design The study was carried out in secondary and high schools in Duhok provinces in the Kurdistan region (north of Iraq). A cross- sectional study design was used; the study was carried out from 3rd November 2021 to 10th April 2022. Ethical approval from the Directorate General of Health/ Duhok and Directorate General of Education/ Duhok was obtained. Consent was obtained from the respondents before the interview with their parent’s consent. Sampling technique In this research, the target group comprised adolescents aged 13 to 18, encompassing both genders and attending school. It was crucial for respondents to be an accurate representation of the intended population. To ensure this, a comprehensive multistage sampling technique was employed. In the initial phase, Duhok City was categorized into two distinct zones through stratified sam- pling. Subsequently, a list of schools in each zone was compiled, from which a total of thirty-two government schools were arbitrar- ily chosen to adequately represent both male and female secondary education. This selection was carried out using a simple random sampling method, specifically the lottery approach. This resulted in a random yet representative subset extracted from the overall population, allowing for a more precise estimation of characteris- tics. The sample size, calculated at a 95% confidence level, was established as 565 students. Students who were excluded from par- ticipation included those taking study breaks and those whose par- ents withheld consent. Additionally, students with chronic medical conditions or those reliant on specific medications affecting blood pressure, like steroids, were also omitted from the study. Instruments and data collection The collection of data will involve the utilization of a question- naire, meticulously crafted through an exhaustive analysis of pre- ceding research and literature pertinent to the current study’s sub- ject matter. This questionnaire comprises two distinct segments for data compilation. The first section of the questionnaire will be administered through face-to-face interviews with the participants. The second part, on the other hand, will involve data collection from the parents of the participants. Statistical methods The demographic information of school children was depicted using numerical values and percentages. The occurrence rate of hypertension in school children was ascertained both in numerical counts and percentages. This was achieved by dividing the number of patients exhibiting various degrees of hypertension by the total count of school children and then multiplying by 100. The assess- ment of hypertension prevalence based on factors like age, gender, and other general characteristics was conducted through the uti- lization of the Pearson chi-squared test. Similarly, the connection between hypertension in school children and parental socio-demo- graphic traits and their lifestyles was evaluated using the Pearson chi-squared test. To identify predictors of hypertension among school children, nominal logistic regression was employed. A p- value below 0.05 was deemed indicative of statistically significant differences. The statistical computations were conducted using JMP Pro 14.3.0 software. Anthropometric measurements Anthropometric measurements were conducted within the school setting. Each measurement was taken twice, and the aver- age of the two readings was considered. For height measurement, participants were barefoot and measured using a portable sta- diometer (Seca 213, Measuring range 20 - 200cm). Weight was recorded with participants wearing lightweight attire, employing a digital Heine portable scale accurate to the nearest 0.1kg. BMI was computed for each child by dividing their weight (in kg) by the square of their height (in meters) (kg/m²). To gauge the appropri- ateness of participants’ BMI values, reference data from the most recent anthropometric standards specific to their sex and age were sourced from the Centers for Disease Control and Prevention (CDC). These reference standards were used to establish per- centiles for height, weight, and BMI, aiding in the assessment of participants’ BMI in relation to their age and sex.7 Children were grouped into categories determined by these percentiles as outlined: Individuals below the 5th percentile were classified as underweight, those between the 5th percentile and less than the 85th percentile were considered to have a healthy weight, those between the 85th percentile and less than the 95th percentile were classified as overweight, and those equal to or surpassing the 95th percentile were categorized as obese. For adults aged 20 years and older (i.e., children’s parents), the classification was slightly different. Adults with a BMI ranging from 18.5 to less than 25 were labeled as having a normal weight, those with a BMI between 25 and less than 30 were identified as overweight, and individuals with a BMI of 30 or higher were categorized as obese.8 Blood pressure measurement Blood pressure assessments were conducted using a standard- ized mercury sphygmomanometer, paired with a manually inflated cuff of appropriate size, and a stethoscope. Measurements were taken from the right arm while the child was in a calm sitting posi- tion for a minimum of 5 minutes to alleviate any anxiety. The researcher inquired about recent activities such as smoking, eating, exertion, or exercise within the last 30 minutes before participating in the study. The student was positioned comfortably, with their back supported, feet resting on the floor, the right arm properly supported, and the cubital fossa (elbow crease) aligned with the level of the heart. If the blood pressure reading equaled or exceed- ed the 90th percentile based on the child’s age, gender, and height, the blood pressure measurement was repeated twice during the same visit. The average values for systolic blood pressure (SBP) and diastolic blood pressure (DBP) were utilized. If the mean SBP and/or DBP readings were elevated during the initial visit, two additional blood pressure measurements were per- formed within a two-week timeframe. This multi-step approach ensured accurate and reliable blood pressure assessments, taking into consideration possible variations in measurements. Article [page 294] [Healthcare in Low-resource Settings 2024;12:12073] Non -co mmerc ial us e o nly Results The stuyd showed that 15.04% of the school children had abnormal blood pressure. The classes of abnrmal blood pressure were Elevated blood pressure (7.43%), Hypertensive (5.84%), Stage 1 hypertensive (0.71%), and Stage 2 hypertensive (1.06%). The children were males (42.83%) and females (57.17%). The childfree had different age groups from 13 to 18. They reside in urban (10.09%) and rural areas (89.91%) and had different family size (Table 1). The study showed that the prevalence of different classes of abnormal blood pressure was not statistically different based on the gender (p=0.0934), age groups (p=0.2338), residency (p=0.8967), and family size (p=0.7519; Table 2). The study showed that the children who their fathers had lower level of education were more likely to have abnormal blood pres- sures (p=0.033). In addition, those children who had the obese fathers were more likely to have different classes of abnormal blood pressures (p=0.0421). The similar pattern was found for the children whose their fathers had hypertension (p=0.0345) an sleep apnea (p=0.0002). In terms of mothers, the similar pattern was found for the education and hypertension. Also, the children who had employee mother were more likely to have hypertension (Table 3). The stuyd showed that the children who sued the free fat in their food by the family were more liley to be affected by abnor- mal blood pressure (p=0.0375). In addition, the children who were obese were more liley to be affected by abnormal blood pressure compared ot those children with normal and underweight (p<0.0001; Table 4). The stuyd showed that the age and obeisty of the children predicted the blod prressure among secondary school chidlren (Table 5; Figure 1). The study did not show the signficnat diference of QoL among children with different classes of abnor- mal blood pressure (p=0.2103 Table 6; Figure 2). Discussion Although the occurrence of clinical hypertension among chil- dren is significantly lower compared to adults, substantial evidence indicates that the origins of essential hypertension can be traced back to childhood. Numerous epidemiological investigations have addressed blood pressure levels in children. However, there exists considerable diversity in the methodologies employed and in the criteria defining normal and elevated blood pressure. Just as in Article Table 1. Prevalence of hypertension by age and gender among sec- ondary school children. General characteristics Statistics no (%) Hypertension Abnormal blood pressure 85 (15.04) Normotensive 480 (84.96) Hypertension Normotensive 480 (84.96) Elevated blood pressure 42 (7.43) Hypertensive 33 (5.84) Stage 1 hypertensive 4 (0.71) Stage 2 hypertensive 6 (1.06) Gender Male 242 (42.83) Female 323 (57.17) Age groups 13 74 (13.10) 14 122 (21.59) 15 89 (15.75) 16 98 (17.35) 17 76 (13.45) 18 106 (18.76) Residency Urban 57 (10.09) Rural 508 (89.91) Family size 1-3 79 (13.98) 4-6 337 (59.65) 7 and above 149 (26.37) Table 2. Prevalence of hypertension by age and gender among secondary school children. Characteristics Blood pressure no (%) p (n=565) Normotensive Elevated blood Hypertensive Stage 1 Stage 2 pressure hypertensive hypertensive Hypertension 480 (84.96) 42 (7.43) 33 (5.84) 4 (0.71) 6 (1.06) Gender 0.0934 Male 205 (84.71) 18 (7.44) 11 (4.55) 4 (1.65) 4 (1.65) Female 275 (85.14) 24 (7.43) 22 (6.81) 0 (0.00) 2 (0.62) Age groups 0.2338 13 66 (89.19) 6 (8.11) 2 (2.70) 0 (0.00) 0 (0.00) 14 104 (85.25) 7 (5.74) 11 (9.02) 0 (0.00) 0 (0.00) 15 73 (82.02) 10 (11.24) 4 (4.49) 1 (1.12) 1 (1.12) 16 86 (87.76) 5 (5.10) 5 (5.10) 2 (2.04) 0 (0.00) 17 59 (77.63) 8 (10.53) 6 (7.89) 0 (0.00) 3 (3.95) 18 92 (86.79) 6 (5.66) 5 (4.72) 1 (0.94) 2 (1.89) Residency 0.8967 Urban 433 (85.24) 37 (7.28) 29 (5.71) 4 (0.79) 5 (0.98) Rural 47 (82.46) 5 (8.77) 4 (7.02) 0 (0.00) 1 (1.75) Family size 0.7519 1-3 65 (82.28) 7 (8.86) 6 (7.59) 1 (1.27) 0 (0.00) 4-6 282 (83.68) 27 (8.01) 21 (6.23) 2 (0.59) 5 (1.48) 7 and above 133 (89.26) 8 (5.37) 6 (4.03) 1 (0.67) 1 (0.67) Pearson chi-squared test was performed for statistical analyses. [Healthcare in Low-resource Settings 2024;12:12073] [page 295] Non -co mmerc ial us e o nly adults, a variety of environmental and genetic factors impact chil- dren’s blood pressure. As a result, it is crucial to conduct extensive population-based research efforts to gather standardized reference data concerning blood pressure levels in children. Symptoms aris- ing from hypertension are infrequent during the early stages of life. Importantly, it should be highlighted that the World Health Organization (WHO) does not endorse routine blood pressure screening for children and adolescents.9 Much like in adults, the blood pressure of children is impacted by various environmental and genetic factors. Consequently, it is essential to conduct popu- lation studies to gather standard reference data concerning blood pressure levels in children. In the early years of life, symptoms stemming from hypertension are uncommon. It’s important to note that the World Health Organization (WHO) does not endorse rou- Article Table 3. Association of school children blood pressure with socio-demographic characteristics of father. Characteristics Blood pressure with father characteristics no (%) p (n=565) Normotensive Elevated blood Hypertensive Stage 1 Stage 2 pressure hypertensive hypertensive Education 0.0333 Illiterate 59 (86.76) 6 (8.82) 2 (2.94) 0 (0.00) 1 (1.47) Read and write 125 (86.21) 10 (6.90) 8 (5.52) 0 (0.00) 2 (1.38) Primary school 120 (91.60) 6 (4.58) 4 (3.05) 0 (0.00) 1 (0.76) Intermediately school 54 (75.00) 9 (12.50) 7 (9.72) 1 (1.39) 1 (1.39) Secondary 21 (75.00) 1 (3.57) 6 (21.43) 0 (0.00) 0 (0.00) Institute/college and above 89 (81.65) 10 (9.17) 6 (5.50) 3 (2.75) 1 (0.92) Overweight/obesity 0.0421 No 365 (87.53) 24 (5.76) 22 (5.28) 3 (0.72) 3 (0.72) Yes 115 (77.70) 18 (12.16) 11 (7.43) 1 (0.68) 3 (2.03) Hypertension 0.0345 No 381 (85.62) 36 (8.09) 23 (5.17) 1 (0.22) 4 (0.90) Yes 99 (82.50) 6 (5.00) 10 (8.33) 3 (2.50) 2 (1.67) Sleep apnea 0.0002 No 469 (85.27) 41 (7.45) 32 (5.82) 4 (0.73) 4 (0.73) Yes 11 (73.33) 1 (6.67) 1 (6.67) 0 (0.00) 2 (13.33) Blood pressure and mother characteristics no (%) Education 0.0291 Illiterate 168 (85.28) 13 (6.60) 13 (6.60) 1 (0.51) 2 (1.02) Read and write 133 (90.48) 7 (4.76) 6 (4.08) 0 (0.00) 1 (0.68) Primary school 74 (81.32) 11 (12.09) 5 (5.49) 1 (1.10) 0 (0.00) Intermediately school 42 (91.30) 2 (4.35) 1 (2.17) 0 (0.00) 1 (2.17) Secondary 19 (90.48) 0 (0.00) 1 (4.76) 0 (0.00) 1 (4.76) Institute/college 38 (66.67) 9 (15.79) 7 (12.28) 2 (3.51) 1 (1.75) Occupation 0.0083 Housewife 431 (86.37) 33 (6.61) 28 (5.61) 2 (0.40) 5 (1.00) Employee 43 (71.67) 9 (15.00) 5 (8.33) 2 (3.33) 1 (1.67) Pearson chi-squared test was performed for statistical analyses. Non significnat factors were not presneted in this table. [page 296] [Healthcare in Low-resource Settings 2024;12:12073] Figure 1. Prevalence of hypertension among children with differ- ent BMI. Figure 2. Comparisons of QoL among school children with blood pressure category. Non -co mmerc ial us e o nly tine blood pressure screening for children and adolescents.10 Simultaneously, the notion of the cardiovascular continuum under- scores the importance of adopting preventive measures at the ear- liest opportunity. Being aware of changes at a young age can trig- ger early preventive strategies, yielding favorable long-term out- comes. Our motivation for conducting this prevalence survey is the lack of data on hypertension prevalence among adolescents in our country. Hypertension, a significant contributor to coronary artery disease and stroke, originates in childhood. Screenings for hyper- tension, even in cases of borderline hypertension and when risk factors are present, can significantly enhance the quality of life for these children, helping them lead healthier lives.11 Article [Healthcare in Low-resource Settings 2024;12:12073] [page 297] Table 4. Association of hypertension with lifestyle related factors among school children. Life style factors Blood pressure no (%) p (n=565) Normotensive Elevated blood Hypertensive Stage 1 Stage 2 pressure hypertensive hypertensive Exercise 0.3080 No 234 (83.27) 20 (7.12) 19 (6.76) 3 (1.07) 5 (1.78) Yes 246 (86.62) 22 (7.75) 14 (4.93) 1 (0.35) 1 (0.35) Smoking 0.1754 No 404 (85.05) 35 (7.37) 29 (6.11) 4 (0.84) 3 (0.63) Yes 76 (84.44) 7 (7.78) 4 (4.44) 0 (0.00) 3 (3.33) Sleep 0.8568 Short sleeper 18 (78.26) 2 (8.70) 2 (8.70) 0 (0.00) 1 (4.35) Normal sleeper 278 (84.76) 24 (7.32) 21 (6.40) 2 (0.61) 3 (0.91) Long sleeper 184 (85.98) 16 (7.48) 10 (4.67) 2 (0.93) 2 (0.93) Breakfast 0.2382 No 162 (88.04) 9 (4.89) 10 (5.43) 0 (0.00) 3 (1.63) Yes 318 (83.46) 33 (8.66) 23 (6.04) 4 (1.05) 3 (0.79) Lunch 0.6383 No 77 (81.91) 10 (10.64) 6 (6.38) 0 (0.00) 1 (1.06) Yes 403 (85.56) 32 (6.79) 27 (5.73) 4 (0.85) 5 (1.06) Dinner 0.4956 No 53 (89.83) 5 (8.47) 1 (1.69) 0 (0.00) 0 (0.00) Yes 427 (84.39) 37 (7.31) 32 (6.32) 4 (0.79) 6 (1.19) Snack 0.5333 No 218 (82.89) 22 (8.37) 16 (6.08) 3 (1.14) 4 (1.52) Yes 262 (86.75) 20 (6.62) 17 (5.63) 1 (0.33) 2 (0.66) Junk food 0.4753 No 41 (83.67) 6 (12.24) 2 (4.08) 0 (0.00) 0 (0.00) 1-3 time a week 247 (84.30) 25 (8.53) 16 (5.46) 1 (0.34) 4 (1.37) > 3 times week 192 (86.10) 11 (4.93) 15 (6.73) 3 (1.35v 2 (0.90) Type of foods 0.5178 Fast food 40 (83.33) 2 (4.17) 4 (8.33) 1 (2.08) 1 (2.08) Homemade food 440 (85.11) 40 (7.74) 29 (5.61) 3 (0.58) 5 (0.97) Sugar sweeter beverage 0.8457 No 49 (84.48) 5 (8.62) 4 (6.90) 0 (0.00) 0 (0.00) Yes 431 (85.01) 37 (7.30) 29 (5.72) 4 (0.79) 6 (1.18) Salt consumption 0.6364 Mild to moderate 439 (85.08) 39 (7.56) 29 (5.62) 3 (0.58) 6 (1.16) Freely used by family 41 (83.67) 3 (6.12) 4 (8.16) 1 (2.04) 0 (0.00) Fat consumption 0.0375 Mild moderate 397 (85.38) 33 (7.10) 29 (6.24) 1 (0.22) 5 (1.08) Freely used by family 83 (83.00) 9 (9.00) 4 (4.00) 3 (3.00) 1 (1.00) Past medical history 0.9255 No 475 (84.82) 42 (7.50) 33 (5.89) 4 (0.71) 6 (1.07) Yes 5 (100.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) Past surgical history 0.4252 No 413 (84.46) 38 (7.77) 30 (6.13) 4 (0.82) 4 (0.82) Yes 67 (88.16) 4 (5.26) 3 (3.95) 0 (0.00) 2 (2.63) BMI <0.0001 Underweight 40 (97.56) 1 (2.44) 0 (0.00) 0 (0.00) 0 (0.00) Normal weight 342 (93.19) 15 (4.09) 9 (2.45) 0 (0.00) 1 (0.27) Overweight 57 (68.67) 12 (14.46) 11 (13.25) 1 (1.20) 2 (2.41) Obese 41 (55.41) 14 (18.92) 13 (17.57) 3 (4.05) 3 (4.05) Pearson chi-squared test was performed for statistical analyses. Non -co mmerc ial us e o nly Prevalence of hypertension In this current investigation, we present data pertaining to blood pressure readings from a representative group of 565 school children aged 13 to 18 in Duhok. Through a comprehensive analy- sis involving three distinct visits, each comprising triplicate blood pressure measurements, we identified that the overall prevalence of hypertension among this cohort, spanning ages 13 to 18, was 5.84%. The study sample encompassed individuals aged 13 to 18 years. These findings become particularly concerning when juxta- posed with the outcomes of other investigations, like the study conducted by Macedo et al. In their research, they examined the prevalence of hypertension in 889 children aged 5 to 18 in northern Portugal, specifically exploring its correlation with obesity. Their study reported an estimated hypertension prevalence of 5.2%, which is remarkably close to the prevalence observed in our study.12 This value aligns well with our own findings concerning prevalence. Furthermore, the occurrence and frequency of hyper- tension among school children in Turkey have been subjects of investigation by numerous researchers. The hypertension rates have exhibited variations across studies conducted in various countries, including those carried out within Turkey. In the context of school children studied in Shimla, north India, the observed prevalence of hypertension was 5.9%. This rate of prevalence notably exceeded the predicted 5% prevalence of high blood pres- sure in children in the United States using the same criteria.13 Across the board, systematic reviews have reported varying estimates for hypertension in children, with Africa having a preva- lence estimate of 5% and America showing a prevalence of 3.5%.14 Another study in 2014 by Patel et al. from Bhopal documented a prevalence of hypertension at 5.36% In various regions of Africa, such as Ghana in West Africa and Tunisia in North Africa, preva- lence rates of 6% and 9.6%, respectively, were documented by Addo et al. and Harrabi et al.15 Similarly, in a study by Kidy et al., the prevalence of hypertension was examined.16 The prevalence of hypertension reported in this study is con- sistent with the prevalence reported in the literature. The reason for the difference between the prevalence of hypertension in this study and those in the previous studies might be the usage of different age groups.17 and maybe because of different food intake and lifestyles in different populations. Relationship between BMI and hypertension Blood pressure demonstrated a positive correlation with BMI (height and weight), and this association remained statistically sig- nificant (p=0.00) according to the results of our multivariate regression analysis. In our study, a notable trend emerged wherein Article Table 5. Predictors of hypertension in school-aged children. Table 6. Association of blood pressure with quality of life among secondary school children. Life style factors Blood pressure no (%) p (n=565) Normotensive Elevated blood Hypertensive Stage 1 Stage 2 pressure hypertensive hypertensive QoL 23.85 (4.31) 23.57 (5.23) 24.00 (4.18) 28.25 (5.25) 26.17 (3.71) 0.2103 The comparisons were not statistically Signiant by gender as well. ANOVA one-way was performed for statistical analysis. [page 298] [Healthcare in Low-resource Settings 2024;12:12073] Non -co mmerc ial us e o nly the prevalence of hypertension heightened as BMI status increased, showcasing strong statistical significance. This finding reinforces the conclusions drawn by Jonathan et al., underscoring the substantial risk factors that obesity and overweight represent in relation to hypertension.18 This linkage, where higher blood pres- sure levels correspond with increased obesity rates, has been con- sistently documented in a multitude of reports.19 This study uncovered a notable pattern: the prevalence of ele- vated blood pressure grew consistently with higher BMI per- centiles. This trend appears to indicate a connection that is not solely dependent on regular physical development. This observa- tion implies that obesity functions as an autonomous risk factor for hypertension, underscoring its independent role in contributing to high blood pressure.20 Our results confirm the findings of Erlingsdottir et al.21 who showed an association between over- weight/obesity and higher blood pressure. The mechanism where- by overweight/obesity may lead to higher blood pressure seems to be due to enhanced adipocyte secretion of adipokines and pro- inflammatory cytokines which may disrupt normal physiological function leading to increased blood pressure.21 Age and gender In the current study, Age was not associated with hypertension. Similar findings have been documented by Oyewole and Oritogun.22 but disagree with a Nigerian study that found age was associated with increases in blood pressure among adolescents, as well as the mid-adolescent age group (13-15 years).23 The present study indicated that obese and overweight boys had a larger preva- lence risk of high normal BP or hypertension than counterpart girls. The finding among Portuguese school adolescents aged 10- 18 also showed a higher risk of being hypertensive among obese and overweight boys than girls.24 In addition, the prevalence of hypertension in boys was greater than in girls, and this may be due to the role of testosterone in hypertension observed in males com- pared to non-menopausal women, which may explain the cause of hypertension in boys in this study.25,26 The reason for girls having low blood pressure compared to boys may be attributed to estrogen and its protective effect on the cardiovascular system, because estrogen causes vasodilatation by modulating the function of vas- cular endothelial cells.27,28 The other probable cause of high blood pressure in adolescents aged (12-18) years could be a persistent hyperactive sympathetic nervous system even at rest which increases the smooth muscle tone of the vessels increasing resist- ance and hence persistently elevating pulse rate, cardiac output and hence elevating blood pressure.29,30 Recommendations Raising awareness among school students, particularly adoles- cents, regarding hypertension and its associated complications holds paramount importance. To achieve this objective, educational initiatives should be consistently organized by school authorities. These programs have the potential to inspire students to adopt healthier lifestyles and dietary habits. Additionally, such efforts can contribute to enhancing parents’ understanding of hypertension, particularly when it is in its early stages. Screening procedures should be implemented to detect asymptomatic hypertension in children, with a specific focus on mitigating influential factors such as obesity. This can be accomplished by offering guidance on bal- anced diets and regular physical activity, both within the home environment and at schools. Parents should also be actively encour- aged to integrate these measures into their children’s routines. To this end, the Task Force on Blood Pressure Control in Children advocates for annual blood pressure measurements for all children aged 3 and above. These regular assessments hold significant value, as they can effectively identify hypertension in children. By collec- tively adhering to these practices, we can proactively address the issue of hypertension among the younger population. Conclusions This study showed that the prevalence of different classes of abnormal blood pressure was high in secondary school children in this region. The higher prevalence of hypertension among second- ary school children was associated with being obese, using free fast in food, low level of education of parents. But being older and obesity predicted the prevalence of hypertension among secondary school children in this region. References 1. Kearney PM, Whelton M, Reynolds K, et al. Global burden of hypertension: analysis of worldwide data. Lancet 2005;365:217-23. 2. Silverstein DM, Champoux E, Aviles DH, Vehaskari VMJPN. Treatment of primary and secondary hypertension in children. Pediatr Nephrol 2006;21:820-7. 3. Charan J, Buch N, Goyal JP, et al. Prevalence of hypertension in school going children of Surat city, Western India. J Cardiovasc Dis Res 2011;2:228-32. 4. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the joint national committee on prevention, detection, evalua- tion, and treatment of high blood pressure. Hypertension 2003;42:1206-52. 5. Alikhani S, Delavari A, Alaedini F, et al. A province-based sur- veillance system for the risk factors of non-communicable dis- eases: A prototype for integration of risk factor surveillance into primary healthcare systems of developing countries. Public Health 2009;123:358-64. 6. Subhi MD. Blood pressure profiles and hypertension in Iraqi primary school children. Saudi Med J 2006;27:482-6. 7. Grummer-Strawn LM, Reinold C, Krebs NF; Centers for Disease Control and Prevention (CDC). Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States. MMWR Recomm Rep 2010;59:1- 15. Erratum in: MMWR Recomm Rep 2010;59:1184. 8. Goran MI, Ball GD, Cruz MLJTJoCE, Metabolism. Obesity and risk of type 2 diabetes and cardiovascular disease in chil- dren and adolescents. J Clin Endocrinol Metab 2003;88:1417- 27. 9. Monge R, Beita OJJoah. Prevalence of coronary heart disease risk factors in Costa Rican adolescents. J Adolesc Health 2000; 27:210-7. 10. Braveman P, Tarimo E. Screening in primary health care: set- ting priorities with limited resources: World Health Organization; 1994. 11. Raja T, Muthukumar T, Mohan AP. A cross sectional study on prevalence of hypertension and its associated risk factors among rural adults in Kanchipuram district, Tamil Nadu. Int J Community Med Public Health 2017;5:249-53. 12. Macedo ME, Lima MJ, Silva AO, et al. Prevalence, awareness, treatment and control of hypertension in Portugal: the PAP study. J Hypertens 2005;23:1661-6. Article [Healthcare in Low-resource Settings 2024;12:12073] [page 299] Non -co mmerc ial us e o nly 13. Jafar TH. Children, obesity, and high blood pressure: Asian populations at high risk. Am J Hypert 2009;22:6-7. 14. Falkner B. Hypertension in children and adolescents: epidemi- ology and natural history. Pediatr Nephrol 2010;25:1219-24. 15. Harrabi I, Belarbia A, Gaha R, et al. Epidemiology of hyper- tension among a population of school children in Sousse, Tunisia. Can J Cardiol 2006;22:212-6. 16. Kidy F, Rutebarika D, Lule SA, et al. Blood pressure in pri- mary school children in Uganda: a cross-sectional survey. BMC Public Health 2014;14:1-9. 17. Nur N, Çetinkaya S, Yilmaz A, Ayvaz A, Bulut MO, Sümer HJJoh, population,, et al. Prevalence of hypertension among high school students in a middle Anatolian province of Turkey. J Health Popul Nutr 2008;26:88. 18. Sorof JM, Lai D, Turner J, et al. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics 2004;113:475-82. 19. Karatzi K, Protogerou A, Rarra V, Stergiou GJ. Home and office blood pressure in children and adolescents: the role of obesity. The Arsakeion School Study. J Hum Hypertens 2009;23:512-20. 20. Meng L, Liang Y, Liu J, et al. Prevalence and risk factors of hypertension based on repeated measurements in Chinese chil- dren and adolescents. Blood Press 2013;22:59-64. 21. Erlingsdottir A, Indridason OS, Thorvaldsson O, Edvardsson VO. Blood pressure in children and target-organ damage later in life. Pediatr Nephrol 2010;25:323-8. 22. Oyewole O, Oritogun KS. Pre-hypertension and hypertension in adolescence: how much does it occur in a Nigerian commu- nity? West Afr J Med 2012;31:71-5. 23. Ujunwa FA, Ikefuna AN, Nwokocha AR, Chinawa JM. Hypertension and prehypertension among adolescents in sec- ondary schools in Enugu, South East Nigeria. Ital J Pediatr 2013;39:1-6. 24. Rebelo D, Teixeira J, Marques-Vidal P, Oliveira JM. Obesity markers and blood pressure in a sample of Portuguese children and adolescents. Eur J Cardiovasc Prev Rehabil 2008;15:73-7. 25. Palmieri D, Perego P, Palombo DJA. Estrogen receptor activa- tion protects against TNF-α-induced endothelial dysfunction. Angiology 2014;65:17-21. 26. Kolovou G, Giannakopoulou V, Vasiliadis Y, Bilianou H. Effects of estrogens on atherogenesis. Curr Vasc Pharmacol 2011;9:244-57. 27. Mendelsohn ME, Karas RH. The protective effects of estrogen on the cardiovascular system. N Engl J Med 1999;340:1801- 11. 28. Alhalaiqa F, Abu-shbeeb I, Batiha A-M, Masa’Deh R, Amarneh B. The relation of demographic characteristics with fatigue levels among coronary heart disease patients: A Jordanian study. Adv Stud Biol 2015;7:301-22. 29. Grassi G, Mark A, Esler M. The sympathetic nervous system alterations in human hypertension. Circ Res 2015;116:976-90. 30. Kalil GZ, Haynes WGJHR. Sympathetic nervous system in obesity-related hypertension: mechanisms and clinical impli- cations. Hypertens Res 2012;35:4-16. Article [page 300] [Healthcare in Low-resource Settings 2024;12:12073] Non -co mmerc ial us e o nly