Prevalence of Hypertension and Associated Factors among Teachers of Government and Grant-in-aid Schools of a Municipal Corporation

Abstract

Background:

As per the non-communicable diseases (NCD) country profile by the World Health Organization (WHO), NCDs account for 63% of all deaths in India. Almost a quarter of the Indian population is suffering from hypertension as per data from the National Family Health Survey (NFHS)-5. Hypertension is a disease and a risk factor for other diseases. There is a paucity of literature on hypertension in school teachers of Western India.

Materials and Methods:

This cross-sectional study was conducted among 750 school teachers from government and grant-in-aid schools to estimate the prevalence of hypertension and associated factors. The data were analyzed using Microsoft Excel and Epi Info.

Results:

The prevalence of hypertension in school teachers was 33.3%, with overall mean systolic and diastolic blood pressure at 125.8 ± 16.7 mmHg and 82.7 ± 10.0 mmHg respectively. In univariate analysis, a significant association was observed in factors including increasing age, total teaching experience, tobacco consumption, high body mass index (BMI), high waist-to-height ratio and mental stress. Based on the adjusted odds ratio, the factors found to be significantly associated with hypertension were increasing age [AOR 2.4 (1.3–4.6)] and high BMI [AOR 2.3 (1.2–4.5)].

Conclusion:

The prevalence of hypertension in school teachers is higher than the national average prevalence, which needs to be addressed by routine screening and spreading awareness.

INTRODUCTION

Blood pressure is the perpendicular force on blood vessels exerted by the blood. As per the latest classification of the Joint National Committee, if the blood pressure exceeds 140/90 mmHg, it is termed as hypertension.[1] The American College of Cardiology (ACC)-American Heart Association (AHA) gave a new guideline for the classification of hypertension, where the cutoff value of blood pressure for diagnosis of hypertension is 130/80 mmHg.[2]

The overall prevalence of hypertension in Indian males and females is 24.0% and 21.3%, respectively.[3] The burden of hypertension in teachers has been assessed in various regions of India: 20% in Maharashtra, 24.8% in Gujarat, 28.6% in Karnataka, 36% in Bengaluru, and 45.4% in Assam.[4,5,6,7,8] These figures show that teachers are at higher risk of hypertension as compared to the general population, pertaining to several risk factors associated with their job profile. These include physical inactivity, irregular diet patterns and high levels of stress due to high workloads, which include academic as well as non-academic work.

Physical inactivity and sedentary behavior are important risk factors for the development of non-communicable diseases, so much so that performing regular physical activity is a natural cure for non-communicable diseases.[9] Currently, more than four-fifths of adolescents (81%) and more than one-fourth of adults (27.5%) do not meet the WHO’s recommended levels of physical activity, and this affects not only individuals over their life span but also their families, health services and society as a whole.[10] Physical activity and physical fitness are recognized determinants of health, and thus the negative health consequences resulting from physical inactivity are not surprising.[11] Some school teachers also consume tobacco/alcohol[12,13] and such substance abuse is a known risk factor for the development of non-communicable diseases. Teachers with higher burnout, perceived their health as worse, were less committed to the school, less satisfied with their work and promoted a healthy lifestyle among their students to a lower extent.[14]

Therefore, if the teachers themselves have healthy lifestyles, they can bring about a positive change in the students, which will eventually lead to the betterment of the health of society. Few studies have been conducted across different regions of India to assess the burden of hypertension in teachers; however, they are nearly a decade old, and no such recent studies are available for western India. Hence, the current study was conducted on teachers of government and grant-in-aid schools of the municipal corporation of a city in western India. The aim of the study was to estimate the prevalence of hypertension and associated factors among teachers of Government and Grant-in-aid schools.

MATERIALS AND METHODS

This study was approved by the Institutional Ethics Committee. Prior permission was obtained from the District Education Officer (DEO office) and the administrative officer (Prathmik Shikshan Samiti office). It is a cross-sectional type of study conducted among teachers of government and grant-in-aid schools of the municipal corporation of a city in western India. The teachers whose age was equal to or above 30 years, who had a minimum of 1 year of teaching experience and those who gave consent to participate in the study were all included in this study. Those teachers with an age of less than 30 years and those who did not consent to participate in the study were excluded. All teachers from the visited schools were invited to participate, except for those who declined. When it was not possible to interview and assess all eligible teachers during a single visit, additional visits were conducted to achieve complete coverage. The teachers from private schools were excluded from the study as their work profile, administrative system and management vary from those of government and grant-in-aid schools, and hence the findings of this study may be generalized only for government and grant-in-aid school teachers.

There were a total of 165 government and grant-in-aid schools and 1493 teachers based on the list and details obtained from the District Education Officer (DEO office) and administrative officer (Prathmik Shikshan Samiti office). Out of these, 851 teachers were from primary schools (group 1) and 642 teachers were from secondary (102) and higher secondary (540) schools (group 2). Considering the hypertension prevalence of 47.7% in teachers of Mysore city,[15] the calculated sample size for this study was 422 with 10% allowable error. Considering a design effect of 1.5 due to cluster sampling and adding a 10% non-response rate to that, the final sample size turns out to be 697. As taking more participants into the study wouldn’t affect resources other than time, we opted to enroll more participants, that is, half of the total population into the study, which only makes the results more robust. Out of the total 747 teachers, 426 were from primary schools and 321 were from secondary and higher secondary schools. The list obtained from the district authority had schools listed according to the areas of the city and had details about the address of the school, the principal’s name and contact number and the number of teachers working in that school. This list was randomized by using Microsoft Excel, and then these schools were approached sequentially as per their random number till the desired sample size was achieved.

Data were collected in a pre-formed, pre-tested and semi-structured questionnaire by interview technique. Anthropometric measurements like height, weight, waist circumference and blood pressure were measured. This was done by a questionnaire prepared from the WHO STEPwise approach to non-communicable disease risk factor surveillance (STEPS) instrument, which has three steps/components including questionnaire, physical measurements and biochemical measurements.[16]

Considering the local dietary habits, questions of the section “dietary salt” in the original WHO STEPS were not relevant for this study population, and hence they were adapted from Non-Communicable Disease Risk Factor Survey done by the Integrated Disease Surveillance Project (IDSP) in 2007–2008 in India.[17] Except that, all the questions were used verbatim. Mental stress assessment was done by the Perceived Stress Scale (PSS).[18] The 10-item version of the PSS scale (PSS-10) was used for this study. Individual scores on the PSS can range from 0 to 40, with higher scores indicating higher perceived stress. Scores ranging from 0 to 13 were considered as low stress. Scores ranging from 14 to 26 were considered as moderate stress. Scores ranging from 27 to 40 were considered as high perceived stress.[19] Those teachers reporting blood pressure levels equal to or more than 140/90 mmHg on measuring twice were screened positive for hypertension. The blood pressure measurement procedure was followed as given by the Ministry of Health and Family Welfare, Government of India, in the guidelines “Screening, Diagnosis, Assessment, and Management of Primary Hypertension in Adults in India.”[20] A digital sphygmomanometer approved by the British and Irish Hypertension Society (BIHS)—Omron HEM-7120 was used for the measurement of blood pressure. On the first contact, the teachers were asked to rest for at least five minutes. Thereafter, the first blood pressure measurement was taken, and the second measurement was taken 15 minutes after the first. If the two readings differ by more than 5 mmHg, a third reading is taken. The lower of the readings was taken as representative systolic and diastolic blood pressures. The measurements were taken with an appropriate cuff size on the right arm in a sitting posture with the back and arm supported, the cuff at heart level, legs uncrossed, and feet supported. The teachers were asked to breathe normally and not to speak during the blood pressure measurement. It was ensured that the teacher did not have caffeine intake in the preceding 1 hour and no tobacco consumption in the preceding 30 minutes.[20]

All the data was entered in Microsoft Excel 2021 and analysis was done with the help of Excel 2021 and Epi Info version 7.2 from CDC, Atlanta.[21] Frequency distribution and percentages of teachers based on their gender and type of school were done. Univariate analysis was performed using Chi-square test and odds ratio for assessment of statistical significance of various risk factors for hypertension. After univariate analysis, all the factors were tested by logistic regression and multivariate analysis.

RESULTS

A total of 750 teachers participated in this study [Table 1]. The highest proportion of teachers [167 (22.3%)] belonged to the age group of 51–55 years. Almost one-fourth of all teachers [173 (23.1%)] had teaching experience of 16–20 years. The mean fruit consumption was one serving per day. The mean daily vegetable consumption was 2.7 (~3) servings per day. Hence, the combined daily consumption of fruits and vegetables was four servings per day. Only male teachers had tobacco addiction—79 (31.5%) of all male participants and 10.5% of all participants of the study. All 79 teachers consumed a smokeless form of tobacco, of which 74 (93.7%) consumed chewing tobacco and the rest consumed betel, quid or pan masala. The overall mean BMI of teachers was found to be 26.6 ± 4.2 kg/m². The overall mean waist-to-height ratio was 0.58 ± 0.14. The mean waist circumference of the teachers was 92.3 ± 10.5 cm. The overall mean stress score was found to be 13.99 ± 5.49.

Table 1.

Sociodemographic profile and other details of teachers

Variable		Male n (%) n=251		Female n (%) n=499		Total n (%) n=750
Type of school
Primary schools     Secondary and Higher Secondary schools		93 (27.1) 158 (62.9)		336 (67.3) 163 (32.7)		429 (57.2) 321 (42.8)
School management
Government     Grant-in-Aid		105 (41.8) 146 (58.2)		344 (68.9) 155 (31.1)		449 (59.9) 301 (40.1)
Age
30–40 years     41–50 years     ≥51 years		57 (22.7) 79 (31.5) 115 (45.8)		170 (34.1) 189 (37.9) 140 (28.0)		227 (30.3) 268 (35.7) 255 (34.0)
Religion
Hindu     Muslim     Christian		246 (98.0) 04 (1.6) 01 (0.4)		489 (98.0) 10 (2.0) 00 (0)		735 (98.0) 14 (1.9) 01 (0.1)
Marital status
Unmarried     Married     Widow/Widower     Divorced		01 (0.4) 248 (98.8) 01 (0.4) 01 (0.4)		32 (6.4) 455 (91.2) 10 (2.0) 02 (0.4)		33 (4.4) 703 (93.7) 11 (1.5) 03 (0.4)
Type of family
Nuclear     Joint		175 (69.7) 76 (30.3)		329 (65.9) 170 (34.1)		504 (67.2) 246 (32.8)
Educational qualification
PTC     Bachelor’s degree     Master’s degree     Others		17 (6.8) 46 (18.3) 183 (72.9) 05 (2.0)		84 (16.8) 119 (23.8) 295 (59.1) 01 (0.2)		101 (13.5) 165 (22.0) 478 (63.7) 06 (0.8)
Socioeconomic class*
I     II     III		246 (98.0) 05 (2.0) 00 (0)		488 (97.8) 07 (1.4) 04 (0.8)		734 (97.9) 12 (1.6) 04 (0.5)
Total teaching experience
≤10 years     11–20 years     21–30 years     ≥31 years		12 (4.8) 93 (37.1) 106 (42.2) 40 (15.9)		70 (14.0) 193 (38.7) 151 (30.3) 85 (17.0)		82 (10.9) 286 (38.1) 257 (34.3) 125 (16.7)
Type of diet
Vegetarian     Mixed		233 (92.8) 18 (7.2)		485 (97.2) 14 (2.8)		718 (95.7) 32 (4.3)
Tobacco consumption
Yes     No		79 (31.5) 172 (68.5)		00 (0) 499 (100)		79 (10.5) 671 (89.5)
BMI (kg/m2)†
Underweight (<18.5)     Normal (18.5–22.9)     At risk (23–24.9)     Obese class 1 (25.0–29.9)     Obese class 2 (≥30)		04 (1.6) 45 (17.9) 48 (19.1) 117 (46.6) 37 (14.7)		09 (1.8) 82 (16.5) 91 (18.3) 206 (41.4) 110 (22.1)		13 (1.7) 127 (17.0) 139 (18.6) 323 (43.1) 147 (19.6)
Waist-to-Height Ratio†
<0.5     ≥0.5		31 (12.4) 220 (87.6)		45 (9.0) 453 (91.0)		76 (10.1) 673 (89.9)
Perceived Mental Stress
Low     Moderate     High		138 (54.9) 113 (45.1) 00 (0)		210 (42.1) 280 (56.1) 09 (1.8)		348 (46.4) 393 (52.4) 09 (1.2)

*As per Modified B.G. Prasad classification. ^†1 female teacher did not give consent for anthropometric measurements

The prevalence of hypertension in the teachers was found to be 33.3% [29.9–36.7]. Different factors were then analyzed for their association with the hypertension status of the teachers [Table 2]. In univariate analysis, the factors found to be significantly associated with hypertension were increasing age, marital status of being a widow/widower, increasing years of teaching experience, tobacco consumption, increasing BMI, waist-to-height ratio ≥0.5 and mental stress. In multivariate logistic regression analysis, increasing age and obesity were significantly associated with hypertension. The waist-to-height ratio was significant on univariate analysis (OR 2.9 [1.5–5.5]) but became non-significant on multivariate analysis (OR 1.4 [0.6–3.1])—this likely reflects collinearity with BMI, as both represent adiposity in the body. Both have significant odds ratios in univariate analysis, but when put together in multivariate analysis, one of them will give a non-significant adjusted odds ratio because it is not adding any additional risk measurement above the other factor. Hence, the adjusted odds ratio of that variable would be shown as non-significant. This could be either BMI or waist-to-height ratio, depending on the sequence of variables entered in the regression model. In our regression model, BMI was entered first, followed by waist-to-height ratio and hence the BMI shows significant adjusted odds ratio while waist-to-height ratio shows non-significant adjusted odds ratio.

Table 2.

Distribution of teachers according to their hypertension status and associated factors

Variable		Hypertensive n (%) n=250		Normotensive n (%) n=500		Crude OR [95% CI]		Adjusted OR [95% CI]
Age*
30–40 years     41–50 years     ≥51 years		47 (20.7) 95 (35.4) 108 (42.4)		180 (79.3) 173 (64.6) 147 (57.6)		Reference 2.1 [1.4–3.2] 2.8 [1.9–4.2]		Reference 1.8 [1.1–3.0] 2.4 [1.3–4.6]
Marital status†
Unmarried     Ever Married		11 (33.3) 239 (33.3)		22 (66.7) 478 (67.7)		Reference [0.5–2.1]		Reference 0.6 [0.3–1.4]
Type of family
Nuclear     Joint		170 (33.7) 80 (32.5)		334 (66.3) 166 (67.5)		Reference 1.1 [0.8–1.5]		Reference 1.3 [0.9–1.9]
Educational qualification
PTC/equivalent     Bachelor’s degree     Master’s degree		38 (35.5) 57 (34.5) 155 (32.4)		69 (64.5) 108 (65.5) 323 (67.6)		Reference [0.6–1.6] 0.9 [0.6–1.4]		Reference 1.1 [0.6–2.0] 0.9 [0.6–1.6]
Socioeconomic class
I     II and lower		247 (33.7) 02 (16.7)		487 (66.3) 10 (83.3)		Reference 0.5 [0.1–1.6]		Reference 0.5 [0.1–2.2]
Total teaching experience*
≤10 years     11–20 years     21–30 years     ≥31 years		16 (19.5) 79 (27.6) 107 (41.6) 48 (38.4)		66 (80.5) 207 (72.4) 150 (58.4) 77 (61.6)		Reference 1.6 [0.9–2.9] 2.9 [1.6–5.4] 2.6 [1.3–4.9]		Reference 1.4 [0.7–2.6] 1.7 [0.8–3.7] 1.1 [0.4–2.7]
Fruit servings per week*
0     1–5     6–10     >10		27 (45.8) 116 (31.7) 87 (31.6) 14 (42.4)		32 (54.2) 250 (68.3) 188 (68.4) 19 (57.6)		Reference 0.6 [0.3–1.0] 0.6 [0.3–1.0] 0.8 [0.4–1.7]		Reference 0.8 [0.4–1.5] 0.7 [0.4–1.4] 1.2 [0.5–2.7]
Vegetable servings per week
1–10     11–20     >20		14 (35.9) 95 (37.1) 141 (31.0)		25 (64.1) 161 (62.9) 314 (69.0)		Reference 1.1 [0.5–2.1] 0.8 [0.4–1.6]		Reference 1.2 [0.6–2.7] 0.9 [0.4–2.0]
Extra salt added in food
Always     Often     Sometimes     Rarely     Never		57 (36.8) 14 (33.3) 34 (37.8) 12 (27.9) 133 (31.7)		98 (63.2) 28 (66.7) 56 (62.2) 31 (72.1) 287 (68.3)		1.3 [0.9–1.9] 1.1 [0.6–2.1] 1.3 [0.8–2.1] 0.8 [0.4–1.7] Reference		1.3 [0.8–2.0] 1.1 [0.5–2.2] 1.3 [0.8–2.2] 0.8 [0.4–1.7] Reference
Salty food habit*
Always     Often     Sometimes     Rarely     Never		74 (38.1) 31 (41.3) 84 (31.5) 41 (29.7) 20 (26.3)		120 (61.9) 44 (58.7) 183 (68.5) 97 (70.3) 56 (73.7)		1.7 [1.0–3.1] 2.0 [1.0–3.9] 1.3 [0.7–2.3] 1.2 [0.6–2.2] Reference		1.5 [0.8–2.9] 1.9 [0.9–4.0] 1.2 [0.7–2.3] 1.1 [0.6–2.1] Reference
Hotel food frequency per month
0     1–5     >5		76 (32.3) 167 (33.7) 07 (36.8)		159 (67.7) 329 (66.3) 12 (63.2)		Reference 1.1 [0.8–1.5] 1.2 [0.5–3.2]		Reference 1.1 [0.8–1.6] 1.0 [0.3–3.1]
Physical activity
Mild exercise
Yes         No		131 (33.7) 119 (33.0)		258 (66.3) 242 (67.0)		Reference 1.0 [0.7–1.3]		Reference 1.0 [0.7–1.3]
Moderate exercise
Yes         No		27 (29.0) 223 (33.9)		66 (71.0) 434 (66.1)		Reference 1.3 [0.8–2.0]		Reference 1.2 [0.7–2.0]
Vigorous exercise
Yes         No		01 (20.0) 249 (33.4)		04 (80.0) 496 (66.6)		Reference 2.0 [0.2–18.1]		Reference 2.0 [0.2–21.3]
Yoga
Yes     No		48 (33.8) 202 (33.2)		94 (66.2) 406 (66.8)		Reference 1.0 [0.7–1.4]		Reference 0.9 [0.6–1.4]
Sedentary hours per day*
<2     2–4     >4		33 (30.0) 75 (29.2) 142 (37.1)		77 (70.0) 182 (70.8) 241 (62.9)		Reference 1.0 [0.6–1.6] 1.4 [0.9–2.2]		Reference 0.9 [0.5–1.5] 1.1 [0.7–1.9]
Tobacco Consumption*
Yes     No		37 (46.8) 213 (31.7)		42 (53.2) 458 (68.3)		1.9 [1.2–3.0] Reference		1.5 [0.9–2.6] Reference
BMI*‡
Underweight     Normal     At risk     Obese class 1     Obese class 2		02 (15.4) 25 (19.7) 36 (25.9) 122 (37.8) 65 (44.2)		11 (84.6) 102 (80.3) 103 (74.1) 201 (62.2) 82 (55.8)		0.7 [0.2–3.6] Reference 1.4 [0.8–2.5] 2.5 [1.5–4.1] 3.2 [1.9–5.6]		1.0 [0.2–5.3] Reference 1.2 [0.6–2.3] 1.8 [1.0–3.3] 2.3 [1.2–4.5]
Waist-to-Height Ratio*‡
<0.5     ≥0.5		12 (15.8) 238 (35.3)		64 (84.2) 436 (64.7)		Reference 2.9 [1.5–5.5]		Reference 1.4 [0.6–3.1]
Perceived Mental Stress
Low     Moderate     High		106 (30.5) 142 (36.1) 02 (22.2)		242 (69.5) 251 (63.9) 07 (77.8)		Reference 1.3 [1.0–1.8] 0.7 [0.1–3.2]		Reference 1.2 [0.9–1.7] 0.6 [0.1–3.4]

*Variables with P<0.2. They were entered first in regression model followed by forcing in the remaining variables. ^†The teachers classified as “Widow/widower” and “Divorced” in Table 1 are merged with “Married” and the category is named “Ever married.” This was done to address the misleading odds ratio values due to small-cell instability of these variables. ^‡1 female teacher did not give consent for anthropometric measurements

The overall prevalence of hypertension in the teachers was found to be 33.3% [29.9–36.7], that is, 250 out of 750 teachers were hypertensive. Of these 250, 219 (87.6%) had their blood pressure measured in the past. Of these 219, 50 (22.8%) were known cases of hypertension and the remaining 169 (77.2%) were newly screened in the study. Out of 250 hypertensives, 31 (12.4%) never had their blood pressure measured in past [Table 3].

Table 3.

Distribution of teachers according to blood pressure ever measured in past*

Blood pressure ever measured in past		Screened to be hypertensive in study				Total n (%)
		Yes n (%)		No n (%)
Yes		219 (87.6)		443 (88.6)		662 (88.3)
No		31 (12.4)		57 (11.4)		88 (11.7)
Total		250 (33.3)		500 (66.7)		750 (100)

*Percentages for the primary column categories (“Yes,” “No” and “Total”) are computed column-wise. Percentages for the “Total” of “Blood pressure ever measured in past” are computed row-wise

Those factors associated with hypertension in univariate analysis with P < 0.2 (Age, Total Teaching Experience, Fruit servings per week, Salty food habit, Sedentary hours per day, Tobacco Consumption, BMI and Waist-to-Height Ratio) were analyzed by logistic regression to check whether they are significantly associated with hypertension after controlling other factors’ confounding effect. The remaining factors were forced into the regression model. Forward selection strategy was used, where the factors with P < 0.2 were added first followed by forcing in the remaining variables. With an increase in age, those with higher BMI are at increased risk of developing hypertension as compared to those who do not have these risk factors.

DISCUSSION

Out of the total 750 teachers, there were 251 (33.5%) male teachers and 499 (66.5%) female teachers. Similarly, a cross-sectional study was conducted by Narayanappa S. et al.[15] in which a total of 300 teachers participated, out of which 112 (37.3%) were males and 188 (62.7%) were females. In another cross-sectional study conducted on government school teachers of Rajasthan, 394 teachers participated out of which 100 (25.4%) were males and 294 (74.6%) were females.[22] More than two-thirds (67%) of the teachers assessed by Azuogu B.N. et al.[23] were females. The participants of this study were all from government/grant-in-aid schools; private schools were excluded as the work profile, administrative system, and management of private schools vary from those of government and grant-in-aid schools. In this study, 449 (59.9%) teachers were from government schools, and 301 (40.1%) teachers were from grant-in-aid schools. The study conducted on teachers from Mysore included private schools in addition to government and grant-in-aid schools. The distribution of teachers in this study was 19.3%, 32.3%, and 48.3% in government, grant-in-aid, and private schools, respectively.[15]

In the current study, the overall mean age of the teachers was 45.7 ± 7.9 years. In the cross-sectional study conducted by Narayanappa S. et al.,[15] it was found that the overall mean age was 42.5 ± 10.1 years. In the present study, the maximum proportion of teachers was observed in the age group of 51–55 years. In the studies conducted by Joshi V. et al. and Chhaya J. et al., the highest proportion of teachers was observed in the age group of 45–54 years.[5,22] The mean age of Iranian and Bangladeshi teachers was 40.26 ± 4.82 years and 46.5 ± 7.8 years respectively.[24,25] The overall mean age of Indian teachers is around 45 years.

In this study, 93.7% of teachers were married. More than three-fourths (84.3%) of the teachers from Mysore city were married.[15] Almost two-thirds (65.2%) of the teachers of Jodhpur city were married.[22] This study shows that 67.2% of teachers were living in a nuclear family and 32.8% were living in a joint family. The teachers from Mysore show a compatible profile in this area, as out of all the participants of this study, 65% of the teachers were living in a nuclear family.[15] In the study by Agrawal S. et al.,[26] almost three-fourths (74.3%) of teachers belonged to a nuclear family. Almost a quarter (23.1%) of the total teachers in this study belonged to the group with 16–20 years of teaching experience. Similar to this finding, the study conducted by Narayanappa S. et al.[15] also reported similar findings where 21.7% of teachers had a total teaching experience of 15 years. While the study conducted on Nigerian teachers found that 42.1% of teachers had their teaching experience of less than 10 years and 41.3% of teachers had experience of 10–20 years.[27]

As per the WHO, the recommended amount of daily fruit and/or vegetable consumption is five servings per day.[16,28] The fruit consumption profile of teachers in this study is unsatisfactory, as almost half of the teachers (48.8%) consumed only 1–5 fruit servings per week. The mean fruit consumption is one serving per day. More than half of teachers (58.9%) consumed 21–30 vegetable servings per week. The mean daily vegetable consumption is 2.7 (~3) servings per day. The combined mean daily consumption of fruits and vegetable servings is four servings per day. In the study conducted by Joshi V. et al.,[22] more than two-thirds (68.8%) of teachers consumed fewer than five fruit or vegetable servings per day. Only the male teachers consumed tobacco, and all of them consumed the smokeless form of tobacco. Of all the male teachers, 79 (31.5%) consumed tobacco. The prevalence of tobacco consumption in this study was relatively higher as compared to the general population estimation of 28.8% for males (≥15 years) in the urban area (NFHS-5).[3] Among the teachers assessed by Savadi P. et al.,[29] only male teachers consumed tobacco with a prevalence of 46.0%, which was higher than this study. Also, the teachers of this study exclusively consumed smokeless tobacco, while among the teachers assessed by Savadi P. et al., 37.9% used smoking tobacco, 46.6% used smokeless tobacco, and 15.5% used both type of products.[29] The tobacco consumption profile of the teachers of this study varied from the general population data from NFHS-5 in that none of the female teachers consumed any form of tobacco, which can be due to social desirability bias. The general population estimation for consuming any form of tobacco is at 5.4% for females (≥15 years) in the urban area (NFHS-5).[3] Pertaining to this variation, the findings regarding tobacco consumption may not be generalized, and this may have sampling implications for future studies.

The overall mean BMI of teachers of this study was found to be 26.6 ± 4.2 Kg/m². Highest proportion—43.1% of teachers were observed in “Obese class 1” with their BMI ranging between 25.0 and 29.9 kg/m²; and 19.6% of teachers in “Obese class 2” with their BMI ≥30 kg/m². The mean BMI values of male and female teachers were 26.1 ± 3.8 kg/m² and 26.9 ± 4.7 kg/m², respectively. In the study conducted by Narayanappa S. et al.,[15] 19.3% of teachers were overweight, and 52.3% of teachers were obese. A very high prevalence of overweight/obesity at 60.0% and 81.0% was found in teachers of Brazil and Kerala, respectively.[30,31] The overall mean waist-to-height ratio was 0.58 ± 0.14. The mean waist-to-height ratio of males and females was 0.56 ± 0.05 and 0.59 ± 0.16, respectively. In the current study, 89.9% of teachers had obesity with a waist-to-height ratio of ≥0.5. Nearly half (45.7%) of the teachers were found to have abdominal obesity (increased waist circumference) in the study conducted by Delfino et al.[32]

Of all teachers, 662 (88.3%) were screened for hypertension at least once. Out of all those who were screened for hypertension, almost three-fourths (71.4%) were screened in the last 12 months. In the study conducted by Joshi V. et al.,[22] 25.9% of teachers were screened for hypertension at least once in their lifetime. The prevalence of hypertension found in this study was 33.3%. Of all the hypertensive teachers, 79.2% belonged to hypertension stage 1 category, and the remaining 20.8% belonged to hypertension stage 2 category. The overall mean systolic blood pressure was 125.8 ± 16.7 mmHg. The overall mean diastolic blood pressure was 82.7 ± 10.0 mmHg. The mean systolic and diastolic blood pressure of males was 128.8 ± 14.9 mmHg and 85.8 ± 9.3 mmHg respectively. The mean systolic and diastolic blood pressure of females was 124.3 ± 17.3 mmHg. and 81.2 ± 10.0 mmHg, respectively. The prevalence of hypertension in the teachers of Mysore city was 47.7%, which is much higher than in this study.[15] Out of all the teachers studied in Ahmedabad city, 24.8% of teachers were found to be hypertensive.[5] The prevalence of hypertension in teachers of Ethiopia was found to be 29.28%, with mean systolic and diastolic blood pressure of 122.23 ± 18.3 mmHg and 81.75 ± 9.84 mmHg, respectively.[33] The prevalence of hypertension in secondary school female teachers of Basrah and female teachers of Chennai was 21.3% and 12%, respectively.[34,35] Khadka K. et al.[36] reported a high prevalence of hypertension (37.7%) in teachers of a university in Kathmandu. Although these comparative studies follow the same guidelines for detection of hypertension, the age group and gender segregation vary between the studies which can lead to some heterogeneity in the comparison with this study.

The primary objective of having teachers as the target population of this study was to assess the effect of occupational stress on blood pressure. The moderate levels of mental stress showed a significant association with hypertension on univariate analysis with OR 1.3 [1.0–1.8], which lost significance after adjusting in the logistic regression model and had AOR 1.2 [0.9–1.7]. The teachers from Kerala showed a significant association between hypertension and moderate mental stress with an AOR of 2.8 [1.0–7.7], which is much higher than the current study.[37] Teachers of Dibrugarh district were also having an association between hypertension and moderate levels of mental stress with OR 9.3 [5.5–15.7].[8] Hence, the presence of mental stress is an important determinant of hypertension.

The strengths of this study include its large sample size, visiting each school until all of its teachers are assessed (except non-consenting teachers) and a focus on the high-risk occupational group of teachers. Although some research has been conducted on teachers, similar studies in our area were lacking, and hence this study added on to the available literature and strengthened the association between hypertension and various other known factors. The limitations included the inherent nature of the study, that is, a cross-sectional study and hence the incidence and causality cannot be assessed. The habits of intake of salty food, adding extra salt in food, consuming hotel food and junk food were assessed by a Likert scale, the responses to which are subjective. Better responses may be obtained when these habits are assessed by their quantity and frequency. The sub-categories “Widow/widower” and “Divorced” of marital status had to be collapsed with “Married” in the logistic regression model to avoid the misleading AOR values because of small-cell instability of these cells, and hence the association of hypertension with these categories could not be assessed by logistic regression. The teachers from private schools were not included in this study as their health profile might be significantly different from that of teachers in government and grant-in-aid schools because of variation in job responsibilities. The findings of this study may not be extrapolated to the teachers from private schools. The incidence and causality of hypertension and its association with various factors may be assessed further by a case-control study or a cohort study in similar settings.

CONCLUSION

This study shows that many of the known risk factors for the development of hypertension are widely prevalent in teachers, and the prevalence of hypertension in teachers is alarming at 33.33%. Although many of the risk factors were not found to be statistically significantly associated with hypertension in this study, they are known to be prominent risk factors for the development of hypertension. Those found to have the concerned risk factors at the time of interview were counseled at the same time for the alleviation of the risk factors by lifestyle modification. An initiative to monitor the health of school teachers by routine NCD screening may be taken up as a part of the National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD). Also, the “health ambassadors” of School Health and Wellness Programme could play an important role in generating and spreading awareness about the common risk factors that teachers face and how to prevent non-communicable diseases. Along with awareness activities, a pilot project may be carried out where the “health ambassadors” are trained to measure blood pressure and its classification. After the training, they carry out monthly/quarterly blood pressure screening for their peers and any teacher who is found to be hypertensive, should be referred to the nearest healthcare provider.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.