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Effect of stress on hypertension among professional groups at Bareilly: a cross sectional study

Hypertension also known as high or raised blood pressure is a global public health issue. It is a major risk factor for stroke and coronary heart diseases and is a major contributor to the onset and progression of chronic heart failure and chronic kidney failure. Blood pressure is the force of blood pushing against the walls of arteries as flows through them. Blood pressure is highest when the heart beats to push out blood into the arteries (systolic blood pressure) and when the heart relaxes to fill with blood again the pressure is at its lowest point (diastolic blood pressure). The global prevalence of raised blood pressure defined as systolic and/or diastolic blood pressure ≥140/90 mmHg in adults aged 18 years and over was around 22% in 2014. In India, hypertension is the leading non communicable disease risk and estimated to be attributable for nearly 10 per cent of all deaths. Adult hypertension prevalence has risen dramatically over the past three decades from 5 per cent to between 20-40 per cent in urban areas and 12-17 per cent in rural areas. The number of hypertensive individuals is anticipated to nearly double from 118 million in 2000 to 213 million by 2025. High blood pressure is increasing in India due to rapid urbanization and globalization leading to adoption ABSTRACT


INTRODUCTION
Hypertension also known as high or raised blood pressure is a global public health issue. It is a major risk factor for stroke and coronary heart diseases and is a major contributor to the onset and progression of chronic heart failure and chronic kidney failure. Blood pressure is the force of blood pushing against the walls of arteries as flows through them. Blood pressure is highest when the heart beats to push out blood into the arteries (systolic blood pressure) and when the heart relaxes to fill with blood again the pressure is at its lowest point (diastolic blood pressure). 1 The global prevalence of raised blood pressure defined as systolic and/or diastolic blood pressure ≥140/90 mmHg in adults aged 18 years and over was around 22% in 2014. In India, hypertension is the leading non communicable disease risk and estimated to be attributable for nearly 10 per cent of all deaths. Adult hypertension prevalence has risen dramatically over the past three decades from 5 per cent to between 20-40 per cent in urban areas and 12-17 per cent in rural areas. The number of hypertensive individuals is anticipated to nearly double from 118 million in 2000 to 213 million by 2025. 2 High blood pressure is increasing in India due to rapid urbanization and globalization leading to adoption of unhealthy lifestyles. Many people are unaware that they have high blood pressure and remain undiagnosed. Even the majority of those who are diagnosed do not get treated to control the blood pressure. It became evident in early 1970s that only about half of the hypertensive subjects in the general population of most developed countries were aware of the condition only about half of those aware of the problem were being treated and only about half of those treated were considered adequately treated. Stress has become a public health menace of the day. It cannot be eliminated from life and it's absolutely essential that we learn to manage it. Stress management is of special relevance to doctors who encounter extreme challenges in their professional and personal life. It will pave the way for working out appropriate coping strategies and interventions. 3 Decreased physical activities coupled with increased mental tension are important contributors. Several studies have shown that lifestyle factors have their significant role in causing hypertension in professionals. Keeping this in view the present study was done to study the impact of stress on hypertension among three professional groups, doctors, school teachers and managerial staff of Bareilly, Uttar Pradesh.

Study design
It is a cross sectional study done in three professional groups; doctors, school teachers and managerial staffs.

Study period
The total study period was two year from 1 st August 2015 to 30 th August 2017.

Study tool
A predesigned and pretested questionnaire comprising of demographic data and mental stress was prepared in English language after reviewing the available literature; however questions were asked in local language at the time of interview after obtaining verbal consent.

Study area
The present cross sectional study was done in district Bareilly.

Inclusion criteria
All individual willing to participate from each profession, have been included in the study.

Exclusion criteria
Subjects with co-morbid conditions were not included in the study and subjects not willing to participate were also excluded.

Sampling technique
The study subjects were selected randomly from three professional groups.

Sample size estimation
According to a study conducted by Ramachandran et al on young physicians in India, the using prevalence of hypertension 35.6%. 4 Absolute errors was taken as 5% and the required sample size was 352.The sample size is rounded to 390. The study includes 3 professional groups i.e., doctors, school teachers and managerial staff. Therefore the total sample size is divided into 3 parts and 130 sampling units are assigned to each professional group.  Blood pressure was measured using standard protocol. The auscultatory method of BP measurement with a calibrated and validated manual mercury sphygmomanometer was used. An adult sized cuff bladder was used to ensure accuracy. Subjects were asked to be seated quietly for at least 5 minutes in a chair with feet on the floor, and arm supported at heart level. The systolic and diastolic pressures were measured three times over a period of at least 3 minutes and the lowest reading was recorded. Hypertension was diagnosed using JNC 7 criteria. 5

Data management and statistical analysis
Data so obtained were compiled and presented in tabular form and statistical analysis was done with the help of appropriate statistical test and software. The data collected were entered in the Excel spread sheet and statistical analysis was done using IBM SPSS v20.0.0.  Table 4 shows stress level among doctors, school teachers and managerial staff (stress level was assessed by a scoring system suggested by Holmes and Rahe stress inventory scale). 6 Majority of school teachers (84.62%) were found mildly stressed followed by managerial staff (30.77%) and doctors (24.62%).

RESULTS
Majority of managerial staff (53.08%) was found moderately stressed followed by doctors (20.77%) and school teachers (13.08%). Majority of doctors (54.61%) were found severely stressed followed by managerial staff (16.15%) school teachers (2.30%).On applying χ 2 test association between stress level and professional groups was found to be highly significant with p value (<0.001).

DISCUSSION
In the present study majority of the study population (64.61%) belonged to socioeconomic upper class, followed by 23.34 % in middle class, 11.29% in upper middle class, and 0.76% in lower middle class which is comparable to Mendez et al (2003) reported in a cross sectional study to examine the association between socioeconomic status and hypertension (SBP ≥140/ DBP ≥90 mm Hg) in 2082 adults in Jamaica. 7 The income distribution of BP and hypertension were non-linear and moreover, the hypertension was found to be the highest in wealthiest women. In men with same high school education, income was positively associated with BP whereas Ribet et al reported a study analyzed the relationship between major cardiovascular risk factors in French men (aged 40-50 years) and their spouse's occupational category. 8 Spouse's occupational category was independently associated with men's hypertension.
The present study showed stress level among doctors, school teachers and managerial staff and found that in mild category, majority (84.62) were school teachers followed by managerial staff (30.77%) and (24.62%) in doctors. In moderate category maximum stress level (53.08%) was found in managerial staff followed by in doctors (20.77%) and 13.08% in school teachers. In severe category majority (54.61%) were doctors followed by 16.15% in managerial staff and 2.30% in school teachers. By applying Chi-square test for association p value <0.001 was found highly significant which is comparable to study of Cesana et al studied the association between job strain and blood pressure in four population samples of age 25 to 54 years from northern Italy. 9 Among men there was a 3 mmHg increase of systolic blood pressure (p<0.001) moving from low to high strain job categories. Nakanishi et al showed the association of long working hours with the risk of hypertension in men (35-54 years) and reported the relative risk of Hypertension above the borderline levels to be 0.63 in subjects working <8.0 hours/day. 10

CONCLUSION
The present study showed highly significant association for hypertension with stress level among doctors and managerial staff with p value (0.005) and (0.001). The odds of developing high blood pressure and its adverse consequences in professional groups can be minimized by management of stress by recreational activities, meditation and yoga.
Individuals who already have hypertension can actively participate in managing their condition by, adopting the healthy behaviors such as monitoring blood pressure at regular intervals at home if feasible, checking blood sugar and blood cholesterol and urine albumin twice a year, following medical advice and prescribed medications for lowering blood pressure.