| Research Article |
Open Access |
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| Assessment of Cardiovascular Disease Risk Factors among School
Children in Private Schools in Karachi, Pakistan: A Pilot Study |
| Alia Nasir1*and Hakim Shah2 |
| 1Head, Aman Community Health Programme, Aman Foundation, Karachi, Pakistan |
| 2Assistant Professor, Institute of Nursing, Dow University of Health Sciences, Karachi, Pakistan |
| *Corresponding author: |
Ms. Alia Nasir, RN, RM, BscN, MA.EHPID (UK)
Head,
Aman Community Health Programme
Aman Foundation, Karachi, Pakistan
E-mail: alia.nasir@amanfoundation.org |
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| Received June 20, 2012; Accepted August 04, 2012; Published August 09, 2012 |
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Citation: Nasir A, Shah H (2012) Assessment of Cardiovascular Disease Risk
Factors among School Children in Private Schools in Karachi, Pakistan: A Pilot
Study. J Obes Wt Loss Ther 2:144.
doi:10.4172/2165-7904.1000144 |
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| Copyright: © 2012 Nasir A, 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. |
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| Abstract |
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| The prevalence of cardiovascular diseases is increasing in Pakistan due to unhealthy life style, and lack of
awareness. As these diseases have their origin in the early period of life therefore, the prevention of these diseases in
early stage is necessary to prevent and control them. |
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| This study aimed at identifying the children at higher risk for developing CVDs at their later ages, and providing
more focused interventions for them. |
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| A cross sectional pilot study was conducted at a private school in Karachi, Pakistan. A total of 24 students (10 boys,
14 girls) were selected through a systematic random sampling. Data was collected through a structured questionnaire.
Their height and weight were taken to calculate BMI. |
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| Majority of the study participants (66.7 and 62.5%) reported that CVDs were the leading cause of death among
the adults in Pakistan, while 25% were not aware. Only 29.2% agreed that CVDs were preventable diseases. They
had poor knowledge regarding the prevention of CVDs, 50 % reported only exercise as being a preventive measure
of CVDs. The mean time spent on doing home work was 19.46 hours/week, and doing sedentary recreational activity
was 15.80 hours/week for both genders. Boys were more active, and they showed less tendency of obesity/overweight
as compared to girls. |
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| The findings of this study highlight a significant lack of knowledge of modifiable risk factors among the study
participants. The results suggest a need of planning health promotion program through schools by focusing on children
and their parents in a participatory approach. |
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| Keywords |
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| Cardiovascular diseases; School Health Promotion
Program; Body Mass Index |
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| Abbreviations |
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| BMI: Body Mass Index; CDC: Center for Disease
Control; CtC: Child-to-Child; CVD: Cardiovascular diseases; NCD:
Non-communicable diseases; SHPP: School Health Promotion Program |
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| Introduction |
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| The burden of Non-Communicable Diseases [NCDs] is emerging
as a major public health challenge for the developing countries. World
Health Organization [WHO] estimates that NCDs account for 63% of
mortality globally out of which around 80% of all deaths in low-income
and developing countries [1]. These diseases are projected to increase
15% by the year 2010-2020 [1]. |
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| Most common NCDs are cardiovascular diseases [CVDs],
hypertension, and diabetes mellitus. Unhealthy lifestyle, which includes
unhealthy dietary habits, physical inactivity, and smoking, is largely
attributed to these diseases [2] apart from family history, age and
gender. Studies reveal that CVDs account for a major cause of death
globally [3,4]. The Prevalence of CVDs is increasing significantly in
developing countries; unfortunately, there is a lack of awareness about
the preventive measures of controlling, and reducing its expansion in
these countries [4]. Furthermore, developing countries are facing the
challenge of a demographic transition. On one hand, many of these
countries are still unable to manage communicable diseases; on the
other hand, their health system is not prepared to provide care to
NCDs. According to report of United Nation International Fund for
Children and Education [UNICEF], Pakistan is a developing country
with poor health and socio-economic indicators, which cannot afford
the emergence of this costly epidemic of NCDs to manage [5]. |
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| According to a study, during the year 1990 in the Middle Eastern
crescent region including Pakistan, CVDs were responsible for nearly 11% of Disability Adjusted Life Years [DALYs], and this was second
only to infectious and parasitic diseases [6]. Moreover, South Asians are
at a greater risk of developing CVDs at younger ages with more severity,
and it is likely that escalation of the global CVDs epidemic will be
most marked in Pakistan and India. One in four middle-aged adults in
Pakistan has coronary artery disease (24% in men and 30% in women)
[7]. Literature has revealed that less physical activity and unhealthy
dietary habits are strongly associated with CVDs. Approximately, 58%
of children had at least one of the modifiable risk factors for CVDs,
such as obesity, physical inactivity and unhealthy dietary habits [8]. It
is observed that children are adopting unhealthy lifestyles. There is an
increased trend of indoor games and entertainment including watching
TV, and playing computer and video games among the children [9,10].
In addition, there is an increased tendency of eating junk and dense
caloric foods. Several studies reveal that many health problems, such
as CVDs appear to originate from the childhood [11-13]. Pathological
change, which results in CVDs, such as atherosclerosis begins in early
childhood but it manifests itself clinically in adulthood [13]. |
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| Obesity is one of the major modifiable causes for atherosclerosis
development. The unhealthy dietary habits and lack of physical activity contribute to obesity. Therefore, it is recommended that this condition
could be better tackled at an early age to avert the development of
atherosclerosis, and reduce the risk of CVDs in adult life [14]. It is
important to identify the unhealthy lifestyle and behaviors early to
promote healthy changes during childhood and the adolescence period,
as there is evidence that behavior once established in childhood is
difficult to change in adulthood [15]. The available evidences suggests
that a few studies are planned, and there is scarce data available
regarding obesity, lack of exercise and unhealthy dietary habits among
school children in Pakistan. Hence, there is nothing to prove the
existence of any lifestyle problems relating to these areas in Pakistan.
Through further research a more detailed analysis and explanation
would be necessary to tackle this health problem in Pakistan. Health
related behavioral data is regarded by the researcher as being valuable
for future reference. It is expected that findings of this pilot study will
raise new research questions and will point to a deeper and more
qualitative and qualitative investigation on a larger scale. |
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| The purpose of this pilot study is to explore the knowledge gap
between CVDs and their risk factors, and to develop implementations
to make up this gap in order to promote health, and thwart the risk
factors of CVDs among School children in Karachi, Pakistan. The
findings of this pilot study can be used as an indicator for determining
the risk factors of CVDs in early childhood, and will serve as a baseline
data for the next steps of research. This study, probably, can contribute
to the existing pool of research related to preliminary risk factors of
CVDs among school children in Karachi, Pakistan. The findings of
this study can be used as a source to provide a basis for enhancing and
expanding the research work on CVDS among children to prevent
CVDs in their later ages. |
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| Materials and Methods |
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| Study procedures and participants |
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| A cross sectional pilot study was conducted at a private school in
urban area of Karachi, Pakistan. This school was selected because the
management and researcher were planning to initiate a School Health
Promotion Program [SHPP] focusing on CVD risk factors in future in
the schools of same network. The study subjects were school children
(both girls and boys) of class 10 who had consented to participate in
the study. |
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| The selection of the sample for this pilot study was a random
sampling method [16]. Twenty four students were recruited for data
collection. There were 40 boys and 55 girls, in separate classes of class
10. A total of 10 students from the boys and 14 from the girls sector
were selected on a systematic random sampling method. Using their
roll call register, every fourth student was selected for the sample of
study. The first number was randomly selected by putting the finger by
closing eyes. |
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| Measures |
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| Data was collected through a structured questionnaire (Appendix
1). This questionnaire was developed by the researcher after an extensive
literature review on this topic, and then it was pilot tested. The major
variables included in the questionnaire were: (a) demographic data, (b)
knowledge variables, (c) non-modifiable risk factors, and (d) modifiable
risk factors. Moreover, BMI was calculated by using Center for Disease
Control (CDC) charts for both girls and boys separately [17]. Following
CDC web based calculator used to calculate the study participant’s BMI based on their height, weight and demographic information [18]. The
formula used for web-based calculation was taken from Source: Online
Available. |
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| http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/
about_childrens_bmi.html (accessed 15 March 2007). The cutoff point
to detect under weight, norm al weight, over weight and obesity were
drawn [18]. |
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| Data was collected by the Community Health Volunteers
(nurses), who were trained for this task by the researcher through a
teleconference (as the researcher was in London and the interviewers
were in Pakistan). |
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| Questionnaires were circulated among all the selected participants.
Once they completed the questionnaire, their height and weight were
taken by the interviewers to calculate BMI. Their height was measured
to the nearest 0.1 centimeter. In the beginning, measuring tapes with
a centimeter scale were taped on a wall of the room. Then the study
participants were asked to take off their shoes and stand erect with
their back to the wall. Their weight was also measured to the nearest
0.1 kilogram. A bathroom scale was used for taking the weight. Study
participants were asked to take off their shoes, extra clothes and to
empty their pockets and (dupatta for girls). For every participant, first
the scale was placed on the plain floor and was assured that the scale
was on 0.1 kilogram, and then the participant was asked to stand erect
on the scale. Data collectors noted down the actual weight in kilograms
from the front and from the centre. Data collectors noted the height
and weight in the relevant questionnaire. |
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| The errors in the data were reduced at different stages by using
quality assurance. Errors of non-observation were controlled by proper
sampling technique, which have been discussed earlier. While errors
of observation were controlled by; (a) Developing an appropriate
questionnaire by pre-testing and pilot-testing of the instrument,
(b) translating and back translating of the questionnaire in the local
language (Urdu), and (c) training the interviewers. |
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| Statistical Package for Social Sciences (SPSS) version 14 was used to
analyze the data. Proportions of all variables of interest were calculated. |
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| Ethical considerations |
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| The proposal was sent to the school administration for their
approval after a telephonic conversation with the head teacher. Prior to
the interview, all participants signed on the consent form (Appendix 2).
Anonymity of the individuals and institution was maintained during
data analysis and findings. No invasive method and/ or technique was
used, hence no harm to the study participants. |
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| Results |
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| The mean ages of the participants were 14.7 years. Table 1 shows
the distribution of the socio-demographic characteristics of the study
subjects. The majority of the study participants (66.7 and 62.5 per
cent) stated that heart disease was the major health problem and was
the leading cause of death among adults in Pakistan. While 25 per cent
were not aware about the issue. Only 29.2 per cent agreed that CVD
were preventable diseases (Figure 1). There was no difference in the
knowledge about CVD among the boys and the girls |
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Table 1: Socio-demographic Characteristics of the study participants. |
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Figure 1: Heart diseases are preventable conditions. |
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| A majority of the study subjects were not aware about the other
leading causes of CVD (Table 2). This table also shows a marked
difference in the knowledge among boys and girls. Comparatively, boys
seem to be more aware than the girls. |
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Table 2: Awareness about causes of heart diseases. |
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| Generally, there is poor knowledge regarding what to do to prevent
heart diseases, except exercise i.e. 50 per cent (Table 3). There is no
significant gender difference in the knowledge of the participants. |
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Table 3: Awareness about prevention of heart diseases |
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| The prevalence of CVD risk factors among the study participants
has been presented in Table 4 and Table 5 and Figure 2 to Figure 4.
Table 5 shows the BMI of the study population. There was no significant
difference in the boys and girls regarding under-weight and normal
weight. However, girls were remarkably more overweight/obese as
compared to the boys (Figure 2). Other risk behaviours of developing
CVD among the study population are presented in Table 5. There was
no significant difference in the family history of CVD in both genders;
however, boys were more active than girls in terms of physical activity
and life style (Table 5). The mean time spent on doing home work in
a week was 19.46 hours, and sedentary recreational activities 15.80
hours/week for both genders. |
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Table 4: Frequency of BMI categories among study subjects. |
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Table 5: Frequencies of other risk factors of developing CVD among study
population. |
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Figure 2: Status of weight/obesity among boys and girls. |
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Figure 3: Frequencies of taking snacks in a week by gender. |
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Figure 4: Frequencies of taking snacks in a week by gender. |
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| The following pie charts and bar chart in figures 3-5 represent
the prevalence of risk factors related to nutrition among the study
participants. |
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Figure 5: Frequencies of types of food ate by study participants in a week. |
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| Choice of food selection is influenced by friends (62.5 percent),
family (75 percent) and taste (66.7 percent). |
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| Discussion and Implications of the Study |
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| There is limited data available in this area of research in Pakistan
which can help to assess the situation. This school based survey in an
urban private school of Karachi, Pakistan has presented an estimation of knowledge regarding CVD risk factors and behaviour variables.
These variables include obesity, physical inactivity, unhealthy dietary
habits and positive family history of cardiac diseases. It forms the basis
for future interventional projects both at school and community levels
using a “whole school approach to health promotion”. |
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| The results of the study suggest that there is a lack of awareness
about the causes, preventive methods and risks factors (Table 3 and
Table 4) A study shows a similar lack of awareness among school
age children in the Hispanic population of North America, India
and Pakistan respectively [19,20]. A lack of awareness regarding risk
factors may impede taking preventive measures, as well as making
positive lifestyle changes. This shows that boys are more aware about
exercise than girls, both regarding the causes of heart diseases and their
preventive strategies. |
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| This study has reported higher prevalence of obesity (33.2 per cent)
(Table 5) as compared to other local studies [8]. There could be several
reasons of obesity in this pilot study. The reason could be the inactive
lifestyle of girls as compared to boys (Table 5). |
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| Moreover, literature reveals that childhood obesity is an epidemic
problem throughout the world [21]. These trends are of particular
importance because being an overweight in childhood and in young
adults has been associated with an increased risk of hypertension, high
cholesterol level, diabetes and early atherosclerosis [22]. |
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| There is a marked difference in the knowledge about heart disease
and prevalence of obesity among boys and girls. Boys have more
knowledge, and are less obese whereas girls have less knowledge and
are more obese. This may indicate that knowledge can contribute to
prevent the obesity, however, it is difficult to conclude; therefore further
analysis and studies would be required to arrive at a final conclusion. |
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| Family history is a strong predisposing factor for the development
of cardiac diseases. In this study 62.5 per cent participants had a strong
family history in which 6.66 per cent were parents and 93.33 per cent
were grandparents. |
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| A significant majority of the participants (62.5 per cent) do not
perform any physical exercise. Out of 37 per cent, only 11 per cent
perform exercises daily, the remaining 55, 22 and 11 percent perform
exercise 1-2, 3-4 and 5-6 days per week respectively. In addition, their
recreational activities and study time also contribute to their sedentary
life style (Table 5). It is strongly recommended that sports and other
physical activity sessions should be planned for children at the school
level. Thus, providing them an enabling environment helps them in
reducing the risks [23]. |
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| Rapid urbanisation and globalisation has changed the life style at all
levels of the community from the affluent to the middle and the lower
socio-economic status level. There is a dire need to develop awareness,
and provide an enabling environment for all age groups, specially
school going children, for the promotion of a healthy life [23] |
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| Conclusion |
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| The findings of this study highlight a significant lack of knowledge
of modifiable risk factors among the study participants. Moreover, there
is a tendency of increased prevalence of CVD risk factors, behaviour
and obesity in an urban private school in Karachi, Pakistan. |
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| The results of the study can help to identify the need of planning
health promotion program through schools by focusing on children and
their parents in a participatory approach. As identified by WHO, health
promoting schools are those that provide health related knowledge and
skills, change the social and physical environment and create links with
community [24]. This study suggests that preventive CVD programs
are needed at community level, particularly, in urban areas of Karachi,
Pakistan. In addition, this pilot study can be further planned at a
macro level, as these studies are needed in Pakistan to assess the level
of knowledge about modifiable risk behaviour and their prevalence in
order to plan preventive CVD programs for the high risk population. |
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| Limitations |
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| The result of the study cannot be generalized to all children of
Pakistan, as the sample size is small and the study participants were
recruited from only one selected school. Owing to the time and
financial constraints, biological risk factors are not assessable, such as
serum insulin level, lipid profile, blood sugar levels etc. As we do not
have BMI values for Asian children, hence, will use the CDC charts
to calculate BMI which are not specifically designed for south-Asian
populations as in case of adults BMI values which are recommended
specifically and separately for Asian population. In addition, in this
report some of the risk factors mentioned may be under-reported like
family history of heart diseases as of the possibility of unawareness
among study participants about the health status of their family
members, particularly of grandparents. |
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| Acknowledgements |
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| I would like to thank Dr Pat Pridmore for her sincere advice and guidance. |
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| I am also grateful to Mr. Hussain Maqbool Ahmed and his team for collecting
the data from the school. Special thanks to all study participants who shared their
personal and intimate information in this survey. |
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| The Institute of Education (IoE), University of London; Institute of Educational
Development (IED), Aga Khan University and School of Nursing (SON), Aga Khan
University are highly acknowledged for providing opportunities to make the study
successful. |
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