Prevalence of Hypertension Among Adolescents in Benue South, Nigeria
Abstract
Background
Hypertension in adolescents has been shown to tracks into adulthood, as well as causing premature cardiovascular and renal diseases.
Objectives
To determine the prevalence of elevated blood pressure and hypertension among adolescents of ages 10-19 years old attending secondary schools in Benue South, Nigeria; characterise their demographics and determine factors associated with the development of high blood pressure.
Materials and Methods
A cross-sectional descriptive study of secondary school adolescents selected through multistage sampling from across three Local Government Areas of Benue South, Nigeria. All the participants had their blood pressure measured using mercury sphygmomanometer and their height and weight taken for the calculation of their body mass index. A dipstick urinalysis with was carried out on their urine samples. Data analysis was with SPSS version 25.
Results
Atotal of 260 adolescents were studied, males were 132 (50.8%) and the mean age was 13.65 ±2.01 years. The prevalence of elevated blood pressure and hypertension was 5.4% and 2.3% respectively. Fifteen females (75.0%) had elevated blood pressure/hypertension as against five males (25%) and it was statistically significant. Adolescents in mid-adolescence age (60.0%) and lower social class (70.0%) had higher rate of high blood pressure. Significant proteinuria (+) was found among eleven (55.0%) of those with high blood pressure.
Conclusion
The prevalence of elevated blood pressure and hypertension among the adolescents was 5.4% and 2.3% respectively; being female, within mid-adolescence age and from lower social class are associated factors.
Recommendation
Regular blood pressure measurement should be part of school health programme.
Author Contributions
Academic Editor: Sasho Stoleski, Institute of Occupational Health of R. Macedonia, WHO CC and Ga2len CC.
Checked for plagiarism: Yes
Review by: Single-blind
Copyright © 2025 Rose Okwunu Abah, et al
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests
The authors have no conflict of interest to declare.
Citation:
Introduction
Hypertension is recognized as one of the major risk factors for preventable deaths worldwide. It has been described as a disease of global poverty rather than “disease of affluence”, evident by its high prevalence in low- and middle-income countries (LMICs) compared with the high-income countries.1 The prevalence of pediatric hypertension is rising; especially in low- and middle-income countries (LMICs), and its effect is far reaching as it has been shown that elevated blood pressure (BP) and hypertension in adolescent is associated with lower neurocognitive test scores, tracks into adulthood and is also associated with premature cardiovascular and renal diseases.2, 3, 4 The prevalence of pediatric hypertension in the United States is approximately 3.5% and that of elevated BP approximately 2.2% to 3.5%.5 The prevalence among African children from the systemic review carried out by Crouch et.al6 is 7.5%, 11.4% and 21.7% for hypertension, elevated BP and combined hypertension and elevated BP respectively. The prevalence of adolescent hypertension from across Nigeria ranges from 0.1% in South-west to 17.5% in North-central.7, 8, 9, 10, 11
Literature has shown that childhood and adolescent hypertension tracks into adulthood with associated complications that could only be prevented if early interventions were instituted.12, 2, 13, 14Yet, the proportion of awareness, treatment and blood pressure control in LMICs, even among adults, is low.15 The lack of routine BP check among the paediatrics population in resource constrained settings like ours, due among others factors, to unavailability of appropriatesize cuffs for the paediatrics age groups6 and the notion that hypertension is an adult disease makes the true burden of it not to be known.
According to the 2017 clinical practice guidelines of American Academy of Paediatrics (AAP), paediatric hypertension is defined as “blood pressure ≥95th percentile for age, sex and height for children from 1-13 years of age, and for adolescent above 13 years of age it is blood pressure of ≥130/80 mmHg”. Also added to the guideline is “Elevated blood pressure” which is blood pressure >90th percentile to <95th percentile or 120/80 mmHg to <95th percentile (whichever is lower) for children aged 1-13 years; and for adolescent above 13 years, it is blood pressure of 120/<80 mmHg to 129/<80 mmHg.5
The study was carried out to determine the prevalence of elevated BP and hypertension among 10-19 years old adolescents attending secondary school across Benue South, Nigeria; to characterise their demographics as well as determine factors associated with the development of high blood pressure among them.
Materials and Methods
Study Location
Benue south is one of the three senatorial districts of Benue State and is the indigenous home of the Idoma people. It is comprise of nine local government area. The population of Benue south senatorial district from the 2006 National population census was 1,307,647. Otukpo town which is the seat of power of the paramount ruler of Idomaland, the Och’idoma, is located in the senatorial district and serves as its headquarter.
Study Design and Population
It was a cross sectional descriptive study that was carried out among 10-19 year old adolescents in Secondary schools within Benue South Senatorial district.
Sample Size
The sample size for the study was determined using the Fischer’s formula16 given as N=Z2PQ/D2, where N is the minimum sample size; Z is the standard normal deviate at 95% confidence interval (1.96); P is the prevalence of hypertension among Nigerian adolescents from a previous study (17.5%);11 Q is the complimentary probability (1-P) and D is the allowed margin of error at 5%. Attrition rate of 15% was allowed in case of incomplete data.
Hence N= 1.96x1.96(0.175x0.825)/0.0025
N= 255.
The participants were recruited via multistage sampling techniques. Three Local Government areas (LGA) were selected through random sampling from the nine LGAs in Benue South senatorial zone. The list of government approved secondary schools within each of the LGA was obtained from their respective Education Authority unit. From the list of schools, participating schools were selected by random sampling and the number of participants per school was based on proportional sampling according to the school population.
Data Collection
A total of 260 adolescents were recruited for the study from the three selected Local Government Areas (LGA) namely Ogbadibo, Ohimini and Otukpo LGA. The data collection was done using an interviewer administered questionnaire on Kobocollect toolbox by trained research assistants. The sociodemographic information of the adolescents as well as information on the educational level, occupation and history of hypertension of their parents were obtained. The weight, height and blood pressure of the adolescents were measured following standard procedures and documented. Each participant was provided with sample bottle for urine sample and a dipstick urinalysis was carried out using Combi-9 test strips on the spot and the results documented.
The weight of each participant was taken with a digital scale to the nearest 0.1 kg in light clothing and barefooted while their height was measured with a portable stadiometer to the nearest 0.1 cm also while barefooted. The body mass index (BMI) was calculated for each participant using the formula of weight (kg)/height (m2). The World Health Organization (WHO) BMI-for-age percentile classification guideline was adopted for the determination of underweight, normal weight and overweight.
The blood pressure was measured in the right arm using a standard mercury sphygmomanometer (Accoson®, England) according to the standard protocol for BP measurement as described by the AAP 2017 clinical practice guideline.5 (Flynn et.el, 2017). Each participant’s BP was measured in the right arm after resting for 10 mins in a sitting position with the arm on a table. The systolic and diastolic blood pressure was read off at the 1st and 5th Korotkoff sound respectively. The AAP 2017 clinical practice guideline definition of elevated BP and hypertension was adopted.
The socioeconomic classes of the participants were determined using the revised scoring scheme for classifications of socioeconomic status developed by Ibadin. et.al.17
Ethical Issues
The ethical clearance for the study was obtained from the Federal University of Health Sciences Otukpo (FUHSO) Research and ethics committee (reference number: FUHSO-HREC/02/05/2023). Approval was obtained from the Benue State Ministry of Education while informed consent and assent was obtained from the parents and the participants respectively. Confidentiality of the participants’ details was maintained throughout the study.
The inclusion criteria were adolescents within the age bracket of 10-19 years old attending secondary schools in Benue South who assented and their parents/guardians gave consent for the study. Exclusion criteria were history of being on chronic medications known to affect blood pressure, for example steroids and refusal of the adolescents to give assent or parents to give consent.
Data Analysis
The data was analysed using IBM Cooperation Statistical Package for Social Sciences (SPSS) version 25.0 software. Results are presented in frequency tables. Chi-square test was used for testing association between variables while logistic regression was employed to identify predictors of high blood pressure. A probability value (P-value) of <0.05 was set as being statistically significant.
Results
A total of 260 adolescents were recruited with the males making up 50.8% and those of Idoma ethnic group accounting for 91.2%. The mean age was 13.65±2.01 years. The early adolescence group (10-13 year) accounted for 46.5% followed by the middle adolescence group with 45.4%. The mean weight, height and BMI of the participants were 42.9±9.34, 153.4±10.95 and 18.08±2.37 respectively. Table 1 shows the sociodemographic characteristics. None of the participants had ever smoked cigarette and only one (0.4%) agreed to have ever taken alcohol.
Table 1. Sociodemographic Characteristics of Participants| Variables | Frequency(N=260) | Percent |
|---|---|---|
| Age(years) | ||
| 10-13 | 121 | 46.5 |
| 14-16 | 118 | 45.4 |
| 17-19 | 21 | 8.1 |
| Mean (Standard Deviation) | 13.65(2.01) | |
| Sex | ||
| Male | 132 | 50.8 |
| Female | 128 | 49.2 |
| Ethnicity | ||
| Idoma | 237 | 91.2 |
| Others | 23 | 8.8 |
| Class | ||
| JSS1 | 77 | 29.6 |
| JSS2 | 47 | 18.1 |
| JSS3 | 38 | 14.6 |
| SS1 | 35 | 13.5 |
| SS2 | 35 | 13.5 |
| SS3 | 28 | 10.8 |
| Socioeconomic Class | ||
| Lower Class | 218 | 83.8 |
| Middle Class | 42 | 16.2 |
| Upper Class | 0 | 0 |
| BMI for Age Percentile | ||
| Underweight | 29 | 11.2 |
| Normal/Healthy | 228 | 87.7 |
| At Risk of Overweight | 3 | 1.2 |
Elevated blood pressure was found among 14(5.4%) of the respondents while 6(2.3%) had hypertension. The highest prevalence of elevated blood pressure/hypertension 12(60%) was among the middle adolescence age group of 14-16 years with the females being more prone (75%) and this was statistically significant at a p-value of 0.02. Table 2 depicts the prevalence of elevated blood pressure and hypertension.
Table 2. Prevalence of Elevated Blood Pressure (BP) and Hypertension| Variables | Frequency | Percent |
|---|---|---|
| Normal | 240 | 92.3 |
| Elevated BP | 14 | 5.4 |
| Hypertension | 6 | 2.3 |
| Total | 260 | 100.0 |
The prevalence of high blood pressure (elevated BP/hypertension) was found to be higher, 15(75%) among the adolescents from Ogbadibo local government area and the difference was statistically significant. The adolescents from the lower socioeconomic class and those with normal BMI percentile had higher prevalence of high blood pressure, 14(70%) and 19(95%) respectively but neither was statistically significant. Eighty-seven (33.5%) of all the adolescents had protein in urine, (+ ) of protein (≥30 mg/dl) on dipstick urinalysis. Eleven out of the adolescents with high blood pressure (55.0%) had proteinuria but this was statistically significant at a p-value of 0.047. Table 3 shows the sociodemographic factors associated with elevated blood pressure/hypertension.
Table 3. The Sociodemographic factors associated with Elevated BP/Hypertension (HTN)| Variables | Normal BP Freq (%) | Elevated BP/HTN Freq (%) | Total | Chi-square test | P- value |
| Age (years) | |||||
| 10-13 | 116 (48.3) | 5 (25.0) | 121 (46.5) | 4.465 | 0.091 |
| 14-16 | 106 (44.2) | 12 (60.0) | 118 (45.4) | ||
| 17-19 | 18 (7.5) | 3 (15.0) | 21 (8.1) | ||
| Sex | |||||
| Female | 113 (47.1) | 15(75.0) | 128 (49.2) | 5.756 | 0.020* |
| Male | 127 (52.9) | 5(25.0) | 132 (50.8) | ||
| Class | |||||
| JSS 1 | 74 (38.5) | 3 (15.0) | 77 (29.6) | 17.163 | 0.004* |
| JSS 2 | 47 (19.6) | 0 (0.0) | 47 (18.1) | ||
| JSS 3 | 32 (13.3) | 6 (30.0) | 38 (14.6 | ||
| SS 1 | 32 (13.3) | 3 (15.0) | 35 (13.5) | ||
| SS 2 | 28 (11.7) | 7 (35.0) | 35 (13.5) | ||
| SS 3 | 27 (11.3) | 1 (5.0) | 28 (10.8) | ||
| Local Govt Area | |||||
| Otukpo | 114 (47.5) | 4 (20.0) | 118 (45.4) | 27.033 | <0.001* |
| Ogbadibo | 53 (22.1) | 15 (75.0) | 68 (26.2) | ||
| Ohimini | 73 (30.4) | 1 (5.0) | 74 (28.5) | ||
| Socioeconomic Class | |||||
| Lower Class | 204 (85.0) | 14 (70.0) | 218 (83.8) | 3.067 | 0.107 |
| Middle Class | 36 (15.0) | 6 (30) | 42 (16.2) | ||
| Upper Class | 0 (0.0) | 0 (0.0) | 0 (0.0) | ||
| BMI for Age Percentile | |||||
| Underweight | 29 (12.1) | 0 (0.0) | 29 (11.2) | 5.326 | 0.056 |
| Normal/Healthy | 209 (87.1) | 19 (95.0) | 228 (87.7) | ||
| At Risk of Overweight | 2 (0.8) | 1 (5.0) | 3 (1.2) | ||
| Parental History of HTN | |||||
| No | 214 (89.2) | 15 (75.0) | 229 (88.1) | 3.528 | 0.073 |
| Yes | 26 (10.8) | 5 (25.0) | 31 (11.9) | ||
| Protein in Urine | |||||
| Absent | 164 (68.3) | 9 (45.0) | 173 (66.5) | 4.514 | 0.047 |
| Present | 76 (31.7) | 11 (55.0) | 87 (33.5) |
Discussion
The prevalence of hypertension of 2.3% among the adolescents in Benue South Senatorial zone falls within the documented prevalence range of 0.1-17.5%7, 8, 9, 10, 11 among adolescents across Nigeria. It is however lower than the 17.5% recorded by Ejike et al.11from neighbouring Kogi State in North Central Nigeria and the 5.4% from Enugu State in South-east Nigeria.18 The wide range of prevalence from different region of the country could be attributable to different methodologies and definition of hypertension adapted by the various authors. There is no national guideline for the diagnosis of hypertension among children hence various authors use different international guidelines that is prevalent at the time of their study. The obvious fact from this finding is that hypertension is a health problem among adolescents in Benue South as reported from other parts of the country but it requires intentionally seeking for it. This underscores the need to incorporate regular blood pressure monitoring among adolescent into school health programme for early detection and intervention, knowing the deleterious effects of long standing hypertension on the health of adolescents.2, 3
The prevalence of elevated blood pressure (pre-hypertension) of 5.4% among the adolescents in Benue South Senatorial zone is similar to the 5% Ezeudu et al9 found in their study from South-east Nigeria but lower than the 22.2% & 25% findings of Ejike et al11from neighbouring Kogi State in North-central Nigeria, the global prevalence of 9.67% documented by Song et al19 from a systemic review and meta-analysis carried out in 2019. The lower prevalence of elevated blood pressure in the present study as against the findings from the neighbouring State of Kogi might be due to differences in the age groups and methods of blood pressure measurement used. The Kogi study was among 13-18 years old and the blood pressure was measured using an automated device. It has been documented that oscillometric (automated) method of blood pressure measurement tend to overestimate the blood pressure when compared with the standard blood pressure measuring method of using mercury sphygmomanometer which was used in the present study. Also the definition of elevated blood pressure in that study was based on the 2004 fourth report whereas in this study it was based on the 2017 AAP guidelines.
The sociodemographic characteristics of those with elevated BP or hypertension also showed variations from other studies. The participants in mid-adolescence had the highest proportion of those with elevated BP/HTN, and this is similar to the findings of the study done by Ator et al.20and by Okagua et al.21 while it is at variance with Odunaiya et al.,22where hypertension was more common in late adolescence. The mid-adolescence period coincides with the peak of puberty with its rapid physical changes as well as emotional and hormonal fluctuations. These pubertal changes could be responsible for the higher prevalence of high blood pressure observed among the group. Nonetheless, there is need for routine blood pressure monitoring across the various age groups.
Three-quarters of those with high blood pressure (elevated BP/HTN) were females; this is similar to the report by Ezeudu et al.,9 Ujunwa et al.,19 and Uwaezouke et al.23 where females had a higher prevalence of hypertension compared to males. Females generally tend to have earlier onset of puberty than males, and this could contribute to why the females have higher prevalence of high blood pressure. Okpokowuruk et al8 however, found that gender was not significantly associated with development of hypertension. The lower socioeconomic class also have the highest proportion of adolescents with high blood pressure compared to the middle socioeconomic class and this is similar to what Akinkugbe et al.24 and Kacsmarek et al.25 reported in their respective studies. Low socioeconomic class is linked to poor nutrition, chronic stress and poor access to healthcare, which ultimately leads to prehypertension/hypertension. However, Mahlati et al.26from South Africa, did not find any association between socio-economic status and prevalence of hypertension among adolescents in their work.
Almost all of the respondents that have elevated BP/hypertension have a normal BMI for age, a finding that is in contrasts to earlier studies which showed that obesity is a predictor for elevated BP/hypertension.23,27,28,29 It is however consistent with the findings of Ajite et al30 and Rosner et.al31 who found that at lower BMI, black adolescents have higher BP and more prevalence of hypertension than white adolescents. This underscore the importance of screening for elevated blood pressure among all adolescents, irrespective of whether the adolescent appears healthy, underweight or obese.
The presence of significant proteinuria (+), {≥30 mg/dl} among the adolescents had a correlation with elevated BP/hypertension just as demonstrated by Adekanubi et al32and Rahama et al33 who found proteinuria to be an independent risk factor for elevated BP and hypertension. It is however in contrast with the findings of Ezeudu et al34and Ajite et al30 among adolescents from Eastern and Western Nigeria respectively; and Battaglia et al35among Italian adolescents. They found no correlation between proteinuria and high blood pressure.
Conclusion
The prevalence of hypertension and elevated blood pressure among the adolescents in Benue South was 2.3% and 5.4% respectively. Being a female, in mid-adolescence age group, from the lower socioeconomic class and Ogbadibo LGA predisposes to higher prevalence of high blood pressure. High blood pressure was also found to be associated with presence of significant proteinuria.
Recommendation
Regular blood pressure measurement should be incorporated into school health programmes and at every opportunity that brings an adolescent in contact with health facility.
Funding
The study was supported by the 2023 TETFUND Institutional Based Research (IBR) funding (FX302-IBR)
References
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