A STUDY ON SEDENTARY BEHAVIOURS AND PREHYPERTENSION

PREVALENCE IN THE MALAYSIAN AIR FORCE TRAINING INSTITUTE

COMMUNITY

MEJ (DR) MASTURA BINTI HAMZAH

A PROPOSAL PAPER FOR MASTER OF PUBLIC HEALTH PROGRAMME

2021

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ABSTRACT

Introduction. Hypertension is one of the major causes of morbidity among adult worldwide.
Prehypertension as its precursor should be identified and intervene early. Sedentarism is also
considered as risk factor for hypertension and related diseases. Military personnel are assumed to
be medically fit, free of any diseases and physically active. However, this phenomenon is not
well explored especially in Air Force’s community.

Objectives. The objective of this study is to determine the prevalence of prehypertension and to
examine its association with sedentary behaviours characteristics among military personnel
working in Sendayan Air Force Training Institute (SAFTI), Negeri Sembilan, Malaysia.

Methodology. A cross sectional study will be conducted among SAFTI personnel. The sample
will be randomly selected. Prehypertension will be determined by measuring samples blood
pressure and sedentary behaviours will be measured using Malay-version of International
Physical Activity Questionnaire (IPAQ-M). In assessing the relationship between sedentary
behaviours and prehypertension, a multiple logistic regression method will be used.

Expected Results. This study is expected to obtain the prevalence of prehypertension and
sedentary behaviour, and the measure of association between the dependent and independent
variables.

Conclusion. This study will be a pioneer study on prehypertension and sedentary behaviour
among the Royal Malaysian Air Force population. The result of this study will add further body
of evidence of the prehypertension and sedentary behaviour and its effect on the personnel,
organisation and health services in this region. It will be an impetus for successive intervention
programmes to mitigate the problem further.

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TABLE OF CONTENTS

ABSTRACT....................................................................................................................................2

TABLE OF CONTENTS................................................................................................................3

LIST OF TABLES...........................................................................................................................5

LIST OF ABBREVIATIONS..........................................................................................................6

CHAPTER 1: INTRODUCTION....................................................................................................7

1.1 Burden of Hypertension and Prehypertension..................................................................7

1.1.1 Global Burden of Hypertension and Prehypertension in Young Adults...................7

1.1.2 Trends of Hypertension and Prehypertension in Malaysia........................................8

1.1.3 Burden of Hypertension and Prehypertension in Active-Duty Military Personnel...8

1.1.4 Impact of Hypertension and Prehypertension on Health...........................................9

1.1.5 Sedentary Behaviours Prevalence and Impacts on Health......................................10

1.2 Problem Statement..........................................................................................................11

1.3 Research Questions.........................................................................................................11

1.4 General Objective...........................................................................................................12

1.5 Specific Objectives.........................................................................................................12

CHAPTER 2: LITERATURE REVIEW.......................................................................................13

2.1 Search Strategy...............................................................................................................13

2.2 A Review of Prehypertension Prevalence.......................................................................13

2.3 Sedentary Behaviours Status Among Military Population.............................................16

2.4 Relationship Between Sedentary Behaviours and Prehypertension in Military

Population..................................................................................................................................19

2.5 Measurements of Sedentary Behaviour and Physical Activity.......................................22

2.5.1 Sedentary Behaviours Questionnaire (SBQ)...........................................................23

2.5.2 Global Physical Activity Questionnaire (GPAQ)....................................................24

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 2.5.3 International Physical Activity Questionnaire (IPAQ)............................................24

2.5.4 Ecological Momentary Assessment (EMA)............................................................25

2.6 Conceptual Diagram.......................................................................................................26

CHAPTER 3: MATERIALS AND METHODS...........................................................................27

3.1 Study Design...................................................................................................................27

3.2 Setting.............................................................................................................................27

3.3 Study Populations...........................................................................................................27

3.4 Sampling Method............................................................................................................28

3.5 Sample Size.....................................................................................................................28

3.6 Variables, Data Sources and Measurement.....................................................................28

3.7 Statistical Analysis..........................................................................................................32

3.8 Ethical Considerations....................................................................................................32

CHAPTER 4: DISCUSSION........................................................................................................33

4.1 Significance of Expected Results....................................................................................33

4.2 Public Health Implications..............................................................................................33

4.3 Public Health Significance..............................................................................................33

4.4 Study Strengths...............................................................................................................33

4.5 Study Limitations............................................................................................................34

CHAPTER 5: RESEARCH PLANNING......................................................................................35

5.1 Budget.............................................................................................................................35

5.2 Timeline..........................................................................................................................35

REFERENCES..............................................................................................................................36

Appendix A: Questionnaires for Data Collection..........................................................................42

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5
LIST OF TABLES

Table 1: List of Papers Examining the Prevalence of Prehypertension and Hypertension...........15

Table 2: Evidence of Sedentary Behaviours Status Worldwide and in the Military Populations. 18

Table 3: Evidence on the Relationship Between Sedentary Behaviours Domains and

Prehypertension or Hypertension in Civilians or Military Population..........................................20

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LIST OF ABBREVIATIONS

AFMeCS Armed Forces Medical Classification System

AFSQ Armed Forces Sick Quarters
BIA Bioelectrical Impedance Analyser
BMI Body Mass Index
BP Blood Pressure
CDC U.S. Center of Disease Control
CKD Chronic Kidney Disease
DBP Diastolic Blood Pressure
EMA Ecological Momentary Assessment
GATS Global Adult Tobacco Survey
GPAQ Global Physical Activity Questionnaire
IPAQ International Physical Activity Questionnaire
MET Metabolic Equivalent
MVPA Moderate-to-vigorous Intensity Physical Activity
NHANES National Health and Nutrition Examination Survey
PA Physical Activity
PICOT Population, Intervention/Observation, Comparison, Outcome, Time
RMAF Royal Malaysian Air Force
SAFTI Sendayan Air Force Training Institute
SB Sedentary Behaviour
SBP Systolic Blood Pressure
SBQ Sedentary Behaviours Questionnaire
SD Standard Deviation
SRS Simple Random Sampling
WHO World Health Organisation

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CHAPTER 1: INTRODUCTION

1.1 Burden of Hypertension and Prehypertension

1.1.1 Global Burden of Hypertension and Prehypertension in Young Adults

Cardiovascular disease and cerebrovascular disease have been the leading cause of death
globally. for the past few decades. Although there are many other risk factors that cause
cardiovascular disease and cerebrovascular disease, hypertension has been identified as the
leading factor of developing ischemic heart disease and stroke. Hypertension is a global public
health burden due to its high prevalence all around the world (Bloch, 2016). Globally, 7.5
million or 12.8% of the total death occur due to hypertension each year (Analysis of
Hypertension Prevalence , Awareness , Treat- Ment and Control in Health, 2021) Worldwide
data shows that currently 1.13 billion or 22.0% of the world population have hypertension and by
2025 estimated prevalence will increase up to 1.56 billion or 29% of the total adult globally
(World Health Organization, 2021).

Normal blood pressure for adults is a systolic at or less than 120mmHg and diastolic at or less
than 80 mmHg. Persistent raised blood pressure will lead to multiple health problems such as
chronic heart disease, coronary heart disease and also stroke. Other complications are retinal
haemorrhage, renal impairment and vascular disease. Hypertension is defined as persistent
systolic Blood Pressure (BP) at the level of more than 140 mmHg and/or diastolic BP at or more
than 90mmHg. The grey area between systolic BP at 120-139 mmHg and 80-89 mmHg diastolic
BP is defined as ‘Prehypertension’. Although it is not a medical disease, individuals with
prehypertension have twice or trice higher risk of developing hypertension than those who are
with normal blood pressure (Zhang & Li, 2011)

Early stage of hypertension is hard to detect as individuals rarely complain about any symptoms.
Without regular routine medical check-up, prehypertension and hypertension are often missed
out until a severe medical crisis takes place such as chronic kidney disease, stroke or heart attack.
Surprisingly, the prevalence of prehypertension is higher than hypertension itself. From a review

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performed on prehypertension by Malaysian Family Medicine in 2017, reported that in the US
31.0% of the population has prehypertension while in Malaysia, it is around 37.0%.

1.1.2 Trends of Hypertension and Prehypertension in Malaysia

In Malaysia, hypertension remains as one of a major risk factor for non-communicable diseases.
The prevalence of hypertension among adults were high. Approximately 3 in 10 adults of the age
from 18 to 30 were diagnosed with hypertension and about 40.0% of those above 30 years old
(Kadir et al., 2019)Prevalence of hypertension in Malaysia also shows a worrying trend. It was
reported that its prevalence has increased from 32.2% in 2006 to 32.7% in five years of duration
(Rampal et al., 2008)

Even though the knowledge on the burden of hypertension is well established, prehypertension
among adults in Malaysia should also be closely monitored. Recent studies on prehypertension
have reported that the prevalence was much higher than anticipated (S. N. Rafan et al.,
2018)Though the proportion looks small, it should be considered as only a tip of an iceberg.
Without sound intervention programmes, those at risk would be converted towards hypertension
and its associated non-communicable diseases.

1.1.3 Burden of Hypertension and Prehypertension in Active-Duty Military Personnel

Military populations are considered fitter than the general population. However, hypertension
remains a concern. In order to detect and prevent soldiers from contracting this condition,
Military organisations have devices, routines, screenings and preventive programmes.
(Malaysian Armed Forces, 2012) Through these, it is hoped that the organisation will be able to
achieve its targeted readiness status.

Military personnel are different from others as they are a group with special occupational
characteristics. Prevalence of hypertension among military personnel is higher than expected
(Bharati & Ray, 2011). The numbers of newly diagnosed hypertension increasing each year with
25% are reported to develop complications of hypertension with 13.5 % of deaths recorded
(Egan & Stevens-Fabry, 2015). This is an alarming issue and action needs to be taken as early as
detecting the prehypertensive stage of the military populations. Among servicemen of the

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Brazilian Armed Forces, two studies that focused on hypertension were identified (Wenzel et al.,
2009; Xavier Martins, 2018). The prevalence of hypertension in the Air Force (N = 380) was
22%, higher than that found in the general population (12.7%). Whereas in the Brazilian Army,
hypertension cases account for approximately 5.63% among its graduate officers (N = 426)
(Taveira & Pierin, 2007)(Fortes et al., 2019)

The identification and assessment of prehypertension as a precursor for full-blown hypertension

is also explored by many militaries (Bharati & Ray, 2011)(Smith et al., 2012; Wenzel et al.,
2009; Xavier Martins, 2018). This condition is considered important as it is easy to detect, and
early intervention would be able to prevent risk of hypertension later among military personnel.
A study among 367 military aviators in the US in 2008 showed that 48% of the young aviators
had prehypertension and during the follow-up period at least 30% of them progressed to
hypertension (Johnson et al., 2019). Pre-hypertensive subjects had an odds ratio of 3.7 (95% CI;
2.3–6.2) to develop hypertension as compared with subjects with normal blood pressure.

Military organisation tries to minimise prevalence of hypertension among its personnel as it will
significantly impact the personnel cardiovascular morbidity as well as he or her ability to
perform occupational duties. Certain areas in military lifestyle do increase risk of these personnel
in developing hypertension; certain programmes such as high impact physical activity, may
prevent its development. Regarding prehypertension, when it is diagnosed early, optimum
intervention programmes should be provided to ensure these personnel are in sound physical,
occupational health and psychosocial well-being.

1.1.4 Impact of Hypertension and Prehypertension on Health

Prehypertension can serve as an early warning for patients and doctors. It is a sign of possible
changes that could lead to heart disease. The pressure caused by constant prehypertension can
change blood vessels and the heart in a damaging way. Prehypertension can also stress the
kidneys. A single blood pressure reading does not predict heart and blood vessel disease (also
called cardiovascular disease). Individuals won't be diagnosed with hypertension or
prehypertension until it is high on several occasions. A blood pressure reading higher than
normal will need to be carefully monitored.

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Other than cardiovascular related diseases, hypertension is also a known risk factor for kidney
diseases. Furthermore, these diseases are also known to be implicated by prehypertension
(Reckelhoff, 2018) About one out of six people with prehypertension in one study developed
chronic kidney disease (CKD) (Y. Li et al., 2016). In this study, the people with prehypertension
who developed chronic kidney disease were also often overweight or obese. Prehypertension
often co-occurring with several risk factors for heart disease. These are diabetes, cholesterol
problems, chronic kidney disease, smoking, and coronary artery disease (Singh et al., 2017)

Among military personnel, a study conducted in the United States demonstrated that
hypertension was related to mortality due to atherosclerotic coronary and aortic disease and
found a prevalence of 43.6% of these events among hypertensives (Pop et al., 2021).
Furthermore, those who were in active combat during conflict situations presented a 33% greater
risk compared to those who were uninvolved in combat (Hunter et al., 2015)

1.1.5 Sedentary Behaviours Prevalence and Impacts on Health

Sedentary behaviour is defined as any behaviour characterized by an energy expenditure at or
less than 1.5 metabolic equivalents (METs), while in sitting, reclining or lying posture (Tremblay
et al., 2017). Sedentary behaviour increases the risk of cardiovascular disease mortality, risk of
cancer and risk of metabolic disorder such as Diabetes Mellitus, dyslipidaemia, and
hypertension. Besides that, it will promote other diseases such as musculoskeletal disorder,
cognitive impairment, and depression.

Sedentary behaviours have a major impact on the health of the worldwide population. Global
population was reported to be heavily engaged in sedentary behaviours, and the prevalence of
this non-communicable disease is increasing each year (H. A. Saad et al., 2020) . Data showed
that 31% of the global population age 15 and more falls into the category of sedentary behaviour
and it is known as one of the factors that contribute to death of 3.2 million people each year
(Braveman et al., 2010) For instance, people in the US spend more than half of their waking time
(approximately 7.7 hours a day) engage in sedentary behaviour. This data is also supported by a

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study done by Korea Health Statistic of 2018 where 20.6% of the adults spend more than 12
hours of sedentary time daily (Braveman et al., 2010)

In general, military personnel are known to be physically active as their work involves high
intensity physical activities and the requirement of them to be physically fit at all time. However,
a study done among military police officers in Brazil showed that during duty, 47.3% spend most
of their time seated and have lower than recommended physical activity. Being sedentary also
lead to other problem such as obesity that will impact the image and health of the military
personnel.

1.2 Problem Statement

Most of the time individuals are unaware that they are being sedentary. Furthermore, military
personnel are generally thought to be fit, healthy and physically active. However, there are
limited studies that explore sedentary behaviours within the military community, especially so in
a training establishment. Assumptions that all military personnel within it are pursuing a healthy
lifestyle needs to be explored. Being sedentary is also known to have a negative impact on
cardiometabolic health. Prehypertension is an important condition that needs to be detected early.
To date, there are limited studies within the Asian military communities that accounts for its
prevalence. As prehypertension is strongly associated with the development of hypertension, and
this condition is easily intervened, further study is needed exploring its association with
sedentary behaviours.

1.3 Research Questions

Based on the stated problem statements, this study aims to answer these following three research
questions:
1. What is the evidence available for the burden of prehypertension among
Malaysian Armed Forces personnel?

2. What are the characteristics of sedentary behaviours among military personnel in

Malaysia?

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 3. Is there an association between the burden of prehypertension and levels of
sedentary behaviours among military personnel in Malaysia?

From the research questions, the general and specific study objectives were determined and are
outlined in the following section.

1.4 General Objective

The general objective of this study is to determine the prevalence of prehypertension and to
examine its association with sedentary behaviours characteristics among military personnel
working in Sendayan Air Force Training Institute (SAFTI), Negeri Sembilan, Malaysia.

1.5 Specific Objectives

In order to answer the above research questions and achieve the above-mentioned general
objective, this study aims to meet the following three specific objectives:
1. To estimate the prevalence of prehypertension in the SAFTI community.

2. To evaluate the characteristic of sedentary behaviours among the SAFTI

community.

3. To assess the relationship between sedentary behaviours and prehypertension in

the SAFTI community.

It is hypothesised that the prevalence of prehypertension would be lower than the general
population rate. However, the time spent in sedentary behaviours would be equal to those in a
similar working environment. Those who spend more time in sedentary behaviours would have
higher odds of being prehypertensive.

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CHAPTER 2: LITERATURE REVIEW

2.1 Search Strategy

The literature review is conducted via a snowball search pattern. Initially, a systematic type of
review is planned, however, due to the limited number of papers related to the queries found, we
have decided to continue reviewing relevant papers using the technique.

We started our searches based on our research questions encompassing population,

intervention/observation, comparison, time (PICOT). Searchers performed includes these
keywords, “sedentary behaviours”, “sedentarism”, “physical inactivity”, “physical activity”,
“sitting time”, “commuting time”, “prehypertension”, “hypertension”, “elevated blood pressure”,
“cross sectional”, “military”, “Armed forces”, “army”, “navy” and “air force”.

Sources of the papers are from “PubMed”, “Web of Science” and “Google Scholar”. Upon
obtaining the results, we scanned the title and abstracts. Only relevant papers are included and
populated in an evidence table. Following that, the papers are reviewed, synthesised and the
findings are summarised.

The review for this proposal is divided into 4 sections, a review of prehypertension prevalence in
military, sedentary behaviours status in military, relationship between sedentary behaviours and
prehypertension in military and a review of methods to measure sedentary behaviours.

2.2 A Review of Prehypertension Prevalence

The term “Prehypertension” was introduced in May 2003 in the guidelines of The Seventh
Report of the Joint national Committee on Prevention, Detection, Evaluation and Treatment of
High Blood Pressure (JNC-7). (Chobanian et al., 2003) It is defined as a systolic blood pressure
(SBP) of 120-139 mmHg and/ or diastolic BP (DBP) of 80-89mmHg. The terminology is a
revised version of the previous term “borderline hypertension” as it was rather confusing and did
not show the seriousness of the condition. Prehypertension is associated with the major risk of
developing cardiovascular disease and other end organ complications. (Bloch, 2016; Elliott &
Black, 2007; Sagaro et al., 2021; Shanta et al., 2020) Based on the recent Framingham Heart

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Study, prehypertensive individuals are twice or thrice at risk to develop a high BP than those
with normal BP (Niiranen et al., 2018)

Multiple study regarding prehypertension has been done since 2003. Based on the study by the
National Health and Nutrition Examination Survey (NHANES), the prevalence of
prehypertension worldwide is 31% (C. Li & Shang, 2021) In Saudi Arabia, data showed that
nearly half of their population are prehypertensive whereas the percentage of the population with
prehypertension in other countries, the US, China, India and Indonesia, prehypertension
prevalence ranged approximately 30% to 35% (Iii et al., 2017) In Malaysia, two studies
conducted among undergraduate university students showed a relatively high prevalence of
prehypertension, 30.1% and 42.9% (S. N. H. Rafan et al., 2018). Refer Table 1 for the list of
papers examining the prevalence of prehypertension and hypertension in civilian and military
populations.

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Table 1: List of Papers Examining the Prevalence of Prehypertension and Hypertension

No. Author Year Military Study Prehyperte Results

/Country Design nsion /
Hypertensi
on

Civilian

1 Calin 2020 Romania Cross Prehyperten 11 % of adult

Sectional sion reported to have
prehypertension

2 Rustom 2018 Bangladesh Cross Prehyperten 39.2% among

ATMA Military sectional sion Bangladesh military
are prehypertensive

3 Ghulam 2020 Pakistan Cross Prehyperten 18% of nurses’

Mustafa Nursing sectional sion / student have
Rajpal School Sedentary prehypertension
6% involved in
sedentary lifestyle

4 Balkhish 2019 Malaysia Cross Prehyperten High percent of

Mahadir sectional sion / 48.5% are
Naidu Hypertensio prehypertensive
n

5 Mohammad 2018 Singapore Cross Prehyperten 11.5% among total

Talaei Chinese sectional sion Singaporean Chinese

6 Getu gamo 2021 Seafarers Cross Prehyperten 39% of seafarers

Sagaro Italy sectional sion reported to have

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 prehypertension

7 Lihua Hu 2017 Jiangxi Cross Prehyperten 32.2% of Jiangxi

Province, sectional sion province adult
China

Military

8 Department 2011 Military USA Cross Prehyperten 17% of active-duty

of defence sectional sion military personnel
reported to have
prehypertensive

9 Sougat Ray 2011 Indian Cross Prehyperten 80% of Indian

Military sectional sion military have
prehypertension

10 Alice 2019 US Military Cohort High blood 27 % high blood

Shrestha study pressure pressure

Global studies on prehypertension among military personnel showed that the prevalence of
prehypertension is approximately similar to the general population (Egan & Stevens-Fabry,
2015). In addition, obtained data also showed that the percentage of military personnel with
prehypertension is higher than those with hypertension (Bharati & Ray, 2011). Regular and
improved screenings as well as early intervention plays an important role in suppressing
incidence of full-blown hypertension. However, a study conducted among Danish Naval
personnel showed that the percentage of prehypertension is 41.7% which is lower than the
percentage of hypertensive itself, which is 44.7% (Tu & Jepsen, 2016). The author contributed
this difference due to a possible better education and lifestyle factors among the study
participants.

Several factors have been identified as important risk factors in the development of hypertension.
These can be divided into two categories, modifiable and non-modifiable risk factors. Known

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modifiable risk factors include lack of physical activities, poor dietary selections, smoking
habits, excessive alcohol intakes and poor weight management (Ha et al., 2013; Klietz et al.,
2019; Pop et al., 2021). Whereas age, sex, ethnicity and family history of hypertension are
proven as important non-modifiable risk factors for hypertension (Blumenthal et al., 1995;
Chidinma et al., 2021; Grotto et al., 2008; Taveira & Pierin, 2007). Although risk factors for
hypertension have been well studied, there seems to be little studies exploring potential risk
factors for prehypertension, in the general public as well as in the military population (Iii et al.,
2017). Identification of potential risk factors are paramount for the development of health
promotion programmes in mitigating any rise of prehypertension conditions. Reduction of
prehypertension incidence or prevalence would lead to reduced cases of hypertension and its
associated cardiovascular morbidity.

Based on the evidence gathered, prehypertension among military personnel is quite prevalent.
Without appropriate intervention programmes, those personnel would be at risk of developing
hypertension and its associated complications. Although many countries have known these
burdens, there is still limited knowledge available within our militaries. Thus, there is a need to
explore this further and device further intervention actions.

2.3 Sedentary Behaviours Status Among Military Population

Sedentary is defined as work or activities in which one spends a lot of time sitting down while
behaviour is an action or reaction of a human or organism towards in relation to the environment.
Behaviour can be conscious or unconscious, voluntary or involuntary, overt or covert (Tremblay
et al., 2017). Sedentary behaviour is widely spread all over the world due to the changes in
urbanisation where there is less area and time to involve in physical activities. Traffic
congestion, lack of pedestrian walkways, and a lack of sports facilities are some of the
environmental factors that contribute to the problem. It is also related to the culture of working
and lifestyle which are mostly desk jobs and handphone or computer related. Multiple studies
have shown that sedentary behaviour among adults is alarming based on its rising prevalence
(Activity et al., 2019; Braveman et al., 2010; A. Saad et al., 2017; Tremblay et al., 2017)

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A large observational study was done assessing the interactions between SB and PA, reported
that a person has to perform 60-75 minutes per day of moderate-to-vigorous intensity physical
activity (MVPA) in order to reduce the risk of being sedentary (H. A. Saad et al., 2020)
However, the current PA guideline promotes a threshold of 150 minutes of MVPA per week
which is far less than the 60-75 minutes as mentioned earlier sedentary (Tremblay et al., 2017).
Very few adults today meet these MVPA guidelines and most spend their days being sedentary
especially in developed countries (Activity et al., 2019; H. A. Saad et al., 2020). This suggests
that large proportions of adults, even those who exercise regularly and within the PA guidelines,
could still be exposed to the health risks of sedentarism

Table 2: Evidence of Sedentary Behaviours Status Worldwide and in the Military

Populations

No. Author Year Military Study Sedentary Results

Country Design Behaviour
Domain
Civilian
1. Kegel 2021 USA Longitud Physical
inal Activity
Study
2. Graba 2021 Poland Cross Sitting Time
Sectional Energy
Expenditure on
Physical
Activity
3. Alemany 2021 USA Cohort Physical Basic Combat Training's
Activity physical demands are
high, where trainees
achieved 1.7 to 2.7 times
greater daily ambulation
and 6 times the

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 recommended weekly
moderate-to-vigorous PA
compared with civilian
counterparts and
performed weight-
bearing load carriage for
nearly half of the day.

4. Santi 2016 Switzerla Cross Sedentarism The following risk

nd Sectional factors were detected:
smoking (n = 656; 43%
of the study participants),
sedentariness (n = 594;
39%),

Military
5. Moshe 2016 Israel Retrospe Sedentary Positive history of LBP
ctive was found as a risk factor
Cohort for the recurrence of LBP
in all occupation types
and particularly in
sedentary ones.

6. Pasiakos 2012 USA Cohort Sedentary At baseline, 14% of

recruits were obese
(BMI>30 kg/m (2)), 27%
were cigarette smokers,
37% were sedentary

7. Olszews 2009 Poland Cross Sedentary Lesser-known risk

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 ki Sectional Lifestyle factors (average 54% of
correct answers) were:
male gender, abnormal
diet, sedentary lifestyle,

Worldwide data showed that at least one third or 31% of the worldwide populations aged 15 and
more are engaged with sedentary behaviour (H. A. Saad et al., 2020). Refer Table 2 for evidence
on the sedentary behaviour's status worldwide and in the military. It is one of the leading risk
factors for global mortality(Mills et al., 2016) where it contributes to approximately 6% of the
number of deaths worldwide (Rees-Punia et al., 2019). For instance, Americans spend 55% of
their waking time or 7.7 hours a day on sedentary behaviours and a high percentage among
Europeans spend 40% their leisure time or 2.7 hours a day watching television (Moore et al.,
2012) Similar studies done among Koreans also showed almost the same result where they spend
7.5 to 8.3 hours of their daily duration being in sedentary (Guo et al., 2019). In Malaysia, based
on the latest report from National Health and Morbidity Survey 2019 showed that 25.1% of the
Malaysian population spend most of their waking time in sedentary and it is responsible for the
quarter cause of death among Malaysians (IPH et al., 2019)

Military personnel are assumed to be physically active. Having to perform military training and
works in physically challenging environment require soldiers to be fit and have a high physical
fitness level (Sammito and Mayer-Falcke  2017). To achieve this, regular physical activity of
daily life is needed for basic fitness and can be enhanced together with specific physical training.
Multiple studies have proved that military personnel performed more physical activity than the
recommended 10,000 steps per day as compared to the civilians. Based on the systemic review
that was published in Pub Med database on May 2020 reported that on average, the activity of
daily life among military personnel is around 11,540 steps per day (Schilz & Sammito, 2021)
However, exploring the report, average steps varied among military services types. Although
those from the army branch have higher means daily steps, those from the navy especially
working in ships or submarines have much lower mean daily steps. The restriction of working
and leisure space may limit their physical activities.

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For the purpose of this research proposal, sedentary behaviours classification pertains to a person
who did not meet 150 min/week MVPA guidelines (Tremblay et al., 2017), where they spent a
significant proportion of their days sitting or lying behaviours.

2.4 Relationship Between Sedentary Behaviours and Prehypertension in Military

Population
Theoretically, sedentary behaviour or lack of physical activities such as prolonged sitting may
cause three systemic effects, vascular, autonomic and metabolic, to a human body (Dunstan et
al., 2021)Metabolic demand will be lowered due to lack of activity, this will consequently cause
adenosine that act as vasodilatory metabolites to be reduced and therefore resulted in
minimisation of the calibre of the capillaries. Low metabolic demand would also increase the
potential of peripheral resistance and promote vasoconstriction. These may mechanically
increase in peripheral resistance and promote turbulent blood flow which will cause acute and
chronic consequences for blood flow and increase the systolic or diastolic level in the human
body leading to abnormal conditions. These reasonings may explain the findings between
sedentary livings (lack of physical activities) and cardiometabolic diseases (Blumenthal et al.,
1995; Pop et al., 2021; Ras & Leach, 2021; Webber et al., 2012)

Table 3: Evidence on the Relationship Between Sedentary Behaviours Domains and

Prehypertension or Hypertension in Civilians or Military Population

No Author Year Country Study Sedentary Outcome Results

Design Behaviour (Prehypertens
Domain ion /
Hypertension)

Civilian

1 Sanam 2018 Oman Cross Sedentary Prehypertensio Approximately

Anwar sectional occupation n 47.7 %
(Civilian) respondents
were identified
as

22
 prehypertensiv
e

2 Rabiya 2018 Kerala Cross Physically Prehypertensio Out of 300

Koori India sectional inactive n participants
(Civilian)l 27.3%
prehypertensiv
e – 47.3% of
them being
physically
inactive

3 Achmat 2019 South Cross Physical Prehypertensio The majority

Africa Sectional Activity n (Cardio (51.1%) of the
(Civilian) metabolic) participants
reported non-
participation in
regular
physical
activity.

4 Zachary 2016 Arizona, Cross Physical Prehypertensio Accumulation

S. USA sectional activity n of very-light-
Zeigler (Civilian) intensity
physical
activity (~2
METs) over
the course of a
single workday
using a
walking
workstation
may reduce BP
burden in
prehypertensiv
e individuals.

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 Military

5 Andor 2007 Hungary Cross Physical hypertension Of 250 male

Grósz sectional inactivity pilots 23.9 %
300 pilots physical
(Military) inactivity, HPT
14.7%

6 Wenzel 2009 Brazil Cross Physical hypertension 22 % HPT,

D sectional inactive 48% physically
380 inactive
Brazilian
Air Force
(Military)

7 Frances 2017 USA Cross Physical Prehypertensio 63.1%

M. Army, sectional activity n and involved in
Barlas Marine (Military) hypertension moderate
Corps, physical
Air activity per
Force, week
and
Coast
Guard.

8 CDC 2020 US Cross Physical Cardio 1 in 4 military

Military sectional inactivity metabolic pers physically
(Military) disease and inactive
colon cancer

Relationships between sedentary behaviour and its effect on development of hypertension or

prehypertension have been studied worldwide as shown in Table 3. In regards to these
conditions, a recent study among South African firefighters has reported that non-participation in

24
physical activity accounted for more than half of its respondents and were associated with high
prevalence of prehypertension(Ras & Leach, 2021). This finding was also supported by a study
in India, where out of 300 of its participants, 27.3% were prehypertensive and 47.3% of them
being physically inactive Sedentary occupations, such as working mostly in sitting position, as
reported from a study in Oman, has also been associated with prehypertension (Iii et al., 2017)
These studies have proven that, among civilians, throughout the world, being inactive were
strongly associated with either hypertension or prehypertension.

Studies among military personnel or occupation types on the relationship or association-ship

between sedentary behaviours or lack of physical activities and prehypertension are limited.
Most studies focused on hypertension which is already late to initiate any meaningful preventive
public health intervention(Xavier Martins, 2018). The most recent report was in 2020, from a
study conducted and reported by the U.S. Center of Disease Control (CDC), among its military
personnel, physical inactivity was associated with cardiometabolic diseases and colon cancer
(Rees-Punia et al., 2019). The report has also highlighted that 1 in 4 of its personnel were
inactive. For hypertension and prehypertension in the military, a cross sectional study conducted
among U.S. Army, Marine Corps, Air Force and Coast Guard personnel have reported a strong
link between those conditions and physical activity (Schilz & Sammito, 2021)They have also
reported that up to 63.1% of their respondents are involved in moderate physical activity per
week. These figures may be considered low when considering military personnel need to be
always physically active in ensuring their readiness.

In other militaries, studies on physical activities and hypertension were also conducted among
pilots (Schilz & Sammito, 2021). In Hungary, they found that out of 250 male pilots, 23.9% were
physically inactive and approximately 14.7% had hypertension. Whereas in Brazil, about 22% of
its Air Force pilots were found to have hypertension and on average 48% of them were in the
category of physically inactive. Though these studies were performed in pilots, they were a
selected group of military personnel and should show a better outcome. Furthermore, the
outcome measure reported was hypertension and not prehypertension which limits early
intervention. Interventions like reducing sedentary time by doing walking breaks or standing

25
breaks, have shown able to reduce systolic or diastolic blood pressure by as much as 16 mmHg
magnitude, and these findings are meaningful (Tremblay et al., 2017)

Although much work on sedentary behaviours and physical inactivity with hypertension or
prehypertension were performed in many militaries, there seems to have a dearth of reports
coming from this region. Its lacking, limits comparison among neighbouring countries on the
impact of behaviours on maintaining good physical activity throughout the working and leisure
times on risk factors or precautionary alerts from becoming hypertensive. Having a dependable
knowledge on both the level of inactivity as well as prevalence of prehypertension will pave a
good plan for focused and comprehensive prevention programmes within the military itself. Due
to the lack of this evidence, such works need to be executed.

2.5 Measurements of Sedentary Behaviour and Physical Activity

Sedentarism is often assumed as a person with low levels of physical activity (PA), but it is a
distinct term referring to any wakeful state of sitting, lying or reclining where energy expenditure
is ≤ 1.5 metabolic equivalents (METs). The action or inaction of sedentarism is normally termed
as Sedentary Behaviour (SB). Therefore, it is possible for people to be physically active and yet
having high levels of SB. SB can occur at different times for example during working time,
commuting time or during leisure time. It can also be due to different types of work for example
working on the computer, clerking work, watching television, and playing video games.

Measuring sedentary behaviour properly and as accurately as possible is important to get the true
reflection of sedentarism. The behavioural patterns captured will assess the type of activity and
its intensity which may have an effect towards the metabolic health of one person (Atkin et al.,
2012). Sedentary behaviour can be measured objectively or subjectively. Objective measure
includes the usage of equipment or wearables (accelerometers, posture monitors, and heart rate
monitors) to log frequency, duration, and intensity of activities for a given time. It is accurate
and objective, however its usage is costly. Subjective measures use a set of questionnaires in
asking a person to recall his or her past activities. There are quite several standardised and
validated questionnaires readily available. Examples of these questionnaires are Sedentary
Behaviours Questionnaire (SBQ) (H. A. Saad et al., 2020), Global Physical Activity

26
Questionnaire (GPAQ) (Cleland et al., 2014), International Physical Activity Questionnaire
(IPAQ) (Hagströmer et al., 2006) and Ecological Momentary Assessment (EMA) (Shiffman et
al., 2008). These self-reported tools are inexpensive and easy to administer, however, they are
prone to recall bias. Although the subjective tools have their limitations, they are valuable for use
in large population studies. Specific descriptions and characteristics of these tools are as follows:

2.5.1 Sedentary Behaviours Questionnaire (SBQ)

The SBQ is a measurement used to measure 9 activity behaviours duration. The activities
assessed were watching television, reading while sitting, playing games or watching movies on
the computer, listening to music while sitting, talking to the phone sitting, doing office or
paperwork at the desk, playing music instruments while sitting, doing arts and crafts and
commuting in cars or buses. The 9 activity behaviours were categorised into 2 which are
weekdays and weekend days. The time spent on each behaviour was converted into hours for
example 30 minutes was re-coded as 0.5 hour. For the total scores of sedentary behaviours, hours
per day for each item were summed. To obtain weekly hours estimates of sedentary, weekday
hours were multiplied by 5 and weekend hours were multiplied by 2 and these were summed for
total hours/week. For the summary variables of total hours/day spent in sedentary behaviours
(weekday and weekend) and total sedentary hours/week, responses higher than 24 hours/day
were truncated to 24 hours/day. SBQ compares well with other subjective measures such as the
IPAQ and objective measures using pedometer with good validity (Hagströmer et al., 2006).
However, due to the complexity whereby the assessor has to have a face-to-face interview with
the respondents, its usage in a large-scale population-based study, it is not well received.

2.5.2 Global Physical Activity Questionnaire (GPAQ)

The GPAQ was first introduced in 2002 by the World Health Organization (WHO) as part of the
WHO Stepwise Approach to Chronic Disease Risk Factor Surveillance to observe PA (Cleland
et al., 2014). It is applied internationally as a tool to assess the level of physical activity. WHO
used the GPAQ in their 2004 Global Strategy on Diet, Physical Activity and Health (Cleland et
al., 2014) The GPAQ was designed as an interview, including the use of show cards, which
visualise activities of moderate and intensive physical activity and support the distinction
between these intensities. It consists of 16 questions designed to evaluate an individual’s level of

27
PA in 3 different domains (at work, during transportation and leisure time) and time spent in SB
(H. A. Saad et al., 2020) Similar to SBQ, GPAQ needs to be applied via a face-to-face interview
approach. For large scale study, resources in terms of human capital as well as time needs to be
factored in if GPAQ wants to be used. The balance between the usage of objective measures
versus GPAQ needs to be made. Based on the information provided from the WHO website, the
GPAQ has been well received by more than 100 countries. They applied the GPAQ for assessing
activities at workplace, leisure and for work journey time measurement. The GPAQ can
differentiate moderate, vigorous activities and can assess daily sedentary behaviour (Cleland et
al., 2014). It has been validated by various studies showing acceptable validity and reliability (H.
A. Saad et al., 2020)

2.5.3 International Physical Activity Questionnaire (IPAQ)

The IPAQ consists of a set of 4 questionnaires. Long (5 activity domains asked independently)
and short (4 generic items) versions for use by either telephone or self-administered methods
(Hagströmer et al., 2006) The questionnaires aimed to provide common and standardized
instruments to obtain data on health–related physical activity that can be used internationally.
The questionnaire was commenced and developed in Geneva around 1998 as international
measures and in 2000 it was followed by multiple extensive reliability and validity testing
undertaken across 12 countries (14 sites). The results suggest that these measures have
acceptable measurement properties for use in many settings and in different languages, and are
suitable for national population-based prevalence studies of participation in physical activity
(Hallal & Victora, 2004). The Malay version of the IPAQ has been well validated and used in
many studies within the country (Chu & Moy, 2015). As these measures rely on self-
administration from the respondents, it is much easier, practical and cost-effective to be used in
large scale population study. However, the IPAQ still relies on recall which limits true
assessment of physical activities.

2.5.4 Ecological Momentary Assessment (EMA)

The EMA, also known as Experience Sampling Method (ESM), is another method to measure
physical activity and sedentary behaviours of the population. It measures behaviours and
experiences in more natural settings (Shiffman et al., 2008). During EMA, users are repeatedly

28
asked to report on their daily activities and/or behaviour at fixed and/or random times per day
(time-sampling), or the prompt is being triggered by a specific event (event-sampling) (Maher et
al., 2018). EMA is less capable to recall bias because of a lower dependence on the memory of
the participants(Toledo et al., 2019) . It provides more relevant data (Shiffman et al., 2008).
However, EMA faces some challenges. First, the validity of the items used to measure certain
constructs needs careful consideration. Important forms of validity to consider in EMA are
construct and content validity.

For a research outcome and its conclusion to be well accepted, tools used to measure the
variables must be reliable and valid. It should be able to capture the true status of the variable
concept. In regard to sedentary behaviours, as the level of physical activity is considered as its
main domain, it relies on either using objective or subjective measures. Both carry their own
advantages and disadvantages. To assess a larger population size and to ensure an efficient
management of resources, subjective measures are more appropriate for assessing sedentary
behaviours. Of the types of self-administered measures available for sedentary behaviours, the
Malay version of the IPAQ is deemed the best measure to be used for the current study.

29
2.6 Conceptual Diagram

Conceptual framework of sedentary behaviours and prehypertension

30
CHAPTER 3: MATERIALS AND METHODS

3.1 Study Design

In order to achieve the objectives of this study, a cross sectional study design will be used. A
cross sectional study design is deemed appropriate because it can provide information on the
prevalence of prehypertension and the possible association between sedentary behaviour and
prehypertension among the population of SAFTI. The strengths of this design are it is
economical, quick to complete and easy to perform. It can determine the prevalence of disease
and risk factor of prehypertension among the studied population. Current health status and
planning of health services also can be determined using this study design. The limitations of this
design are that it is unable to determine causal relationship between sedentary behaviours and
prehypertension.

3.2 Setting
This study will be conducted at the SAFTI in Seremban, Negeri Sembilan. The training institute
caters various types of training that includes training school for administrative staff and non-
administrative such as physical trainer and support staff. Its population is approximately 4000
which consists of 350 staff and a maximum of 3000 students from all over the Royal Malaysian
Air Force (RMAF) communities. In general, it represents the characteristics of RMAF training
schools or institutes. This study will focus on the management and training staff only. This study
will be conducted from September 2022 and will end in December 2022. The centre point of this
project will be located at the 814 Armed Forces Sick Quarters (AFSQ).

3.3 Study Populations

The population for this study will be the staff of SAFTI. To be included in the study the potential
participants should satisfy the following inclusion criteria – all military staff working in
Pangkalan Udara Sendayan for at least 12 months prior to the commencement of study period.
Those with these criteria will be excluded in this study:

1. Staff who have been diagnosed with primary or secondary hypertension.

31
 2. Staff with any chronic diseases – kidney, thyroid, hormonal diseases.

3. Staff who are pregnant.

4. Staff who are on any prolonged medications (hormonal therapy) that will affect
the blood pressure.

3.4 Sampling Method

This study will use the simple random sampling (SRS) method. The whole SAFTI staff will be
enumerated and applied for the exclusion criteria. The remaining staff will be given a unique
code. A random number generator will be used to select the potential participants up to the
required sample size. The selected potential participants will be contacted and offered to join the
study.

3.5 Sample Size

The proposed sample size for this study is 335. The estimated sample size is calculated based on
the needs for a prevalence study (Thomas & Rao, 1987). A margin of error of 5%, confidence
interval of 95% and the estimated population of 4000 data were selected for the calculation. The
given sample size was 278. However, accounting for possible non-responder of 20%, 335
samples are needed.

3.6 Variables, Data Sources and Measurement

The dependent variable for this study is physician-diagnosed prehypertension. The operational
definition of prehypertension is when the respondent’s systolic blood pressure is above 119
mmHg, and/or the diastolic blood pressure is above 79 mmHg. The blood pressure status will be
treated as a categorical variable (Prehypertensive vs. Non-Prehypertensive). The blood pressure
will be measured using a standardised digital sphygmomanometer. The brand and model of the
sphygmomanometer is OMRON HEM 7121J/7124. The digital sphygmomanometer will be
calibrated daily prior to usage with a mercury sphygmomanometer. The procedure for blood
pressure measurement is as planned:

32
 1. The respondent will be asked to rest 10 minutes before his or her blood pressure is
taken.

2. The measurement will be at a sitting position.

3. An appropriately sized cuff will be used.

4. Three readings will be taken and recorded at a five-minute interval.

5. The average of the three readings will determine the respondent’s prehypertension
status.

6. The respondent is prohibited from eating, smoking, drinking coffee or doing any
strenuous physical activity for at least 1 hour prior to the blood pressure measurement
taking place.

The independent variable of this study is sedentary behaviour. The operational definition of
sedentary behaviour is the level of physical activity scored using the International Physical
Activity Questionnaire in Malay (IPAQ-M). The IPAQ-M is a validated sedentary behaviour
measurement tool adapted for the Malay-speaking population. The IPAQ-M is suitable for adults
between 15 and 69 years of age and is primarily used for population surveillance (Chu & Moy,
2015). The IPAQ-M is scored “high”, “moderate” or “low”. The explanation of activities
associated with the scoring is as noted:

1. Scoring a "high” level of physical activity on the IPAQ-M means the respondent’
s physical activity levels equate to approximately one hour of activity per day or more at
least a moderate intensity activity level.

2. Those who score “high” on the IPAQ-M engage in vigorous intensity activity on
at least 3 days achieving a minimum total physical activity of at least 1500 MET minutes
a week or 7 or more days of any combination of walking, moderate intensity or vigorous

33
 intensity activities achieving a minimum total physical activity of at least 3000 MET
minutes a week.

3. Scoring a “moderate” level of physical activity on the IPAQ-M means the

respondent is doing some activity more than likely equivalent to half an hour of at least
moderate intensity physical activity on most days.

4. Those who score "moderate” on the IPAQ-M engage in 3 or more days of

vigorous intensity activity and/or walking of at least 30 minutes per day or 5 or more
days of moderate intensity activity and/or walking of at least 30 minutes per day or 5 or
more days of any combination of walking, moderate intensity or vigorous intensity
activities achieving a minimum total physical activity of at least 600 MET minutes a
week.

5. Scoring a "low” level of physical activity on the IPAQ-M means that the
respondent is not meeting any of the criteria for either "moderate” or “high” levels of
physical activity.

Other than the mentioned independent variable, there are other variables that will be obtained or
measured. These variables will be treated as confounders for this study. The variables, their
operating definition and their measurements are as follow:

1. Age. Age is defined as the biological age of the respondent. It is calculated by

subtracting the date of measurement from the respondent’s date of birth. The
respondent’s age will be recorded as a continuous variable and to be categorised into age
groups.

2. Gender. Operationally, gender is the distinction between “male” and “female” as

reported by the respondent. It will be treated as a categorical variable.

34
3. Marital Status. The operational definition of respondent’s marriage status is the
status given (“single”, “married”, “divorced/widowed”) by the respondent. This variable
will be treated as a categorical variable.

4. Rank. The respondent’s rank is his or her officially conferred rank at the time the
questionnaire is filled. The rank will be then re-coded into “senior officer”, “officer” and
“other rank”. This variable will be treated as a categorical variable.

5. Occupational Position. The respondent’s occupational position is the type of

work 5ostly performed and reported by them. These are coded either “command”,
“administrative”, “logistics”, “engineering”, “transport”, “training”, “health” or “others”.
This variable is treated as a categorical variable.

6. Years of Service. Respondent’s service years are measured by subtracting the

present date with the date they enter the service. An absolute year will be recorded. This
variable is treated as a continuous variable.

7. Education. The respondent’s education level is the maximum official education

certification obtained by them to date. The options are “SPM”, “diploma”, “bachelor
degree”, “master degree” or “doctorate degree”. This is treated as a categorical variable.

8. Household Income. Operationally, this is the total income received and reported
by the respondent and those who live with him or her each month. The reported income
will be categorised into “below 40”, “middle 40” or “top 20” based on the present
national income level cut off points.

9. Household Members. The reported number of household members living

together with the respondent. If the respondent is single and living in a communal
barracks, he or she will be instructed to report only “1”. This variable is an integer and
will be coded as a continuous variable.

35
 10. Smoking. Smoking status information will be obtained using self-administered
questions which include “current tobacco smoking status”, “past daily smoking status”
for current less than daily smoker and “past smoking status” for current non-smoker.
These variables will be coded as categorical variables.

11. Body Mass Index (BMI). The BMI will be calculated from respondent’s weight
in kilogram and height in meter, weight divided by height-squared (Kg/m2). Height (to
the nearest mm) and weight (to the nearest 100g) will be measured using a stadiometer
(SECA 213) and electronic scale SECA 786 respectively. Respondents will be measured
without shoes and while wearing light clothing. This variable will be treated as
continuous variable, and will also be re-coded and categorised using WHO BMI
Category (Prentice & Jebb, 2001).

12. Body Fat. The respondent’s body fat will be ascertained using a standardised
bioelectrical impedance analyser (BIA) BC 418. The value recorded will be a percentage
fat weight of the total body weight and will be treated as a continuous variable.

3.7 Statistical Analysis

To answer the first objective, a descriptive statistic will be used. Continuous data will be
reported using the mean and standard deviation (SD), while categorical data will be reported in
frequencies and percentages. For the second objective, as it is considered as a categorical
variable, Pearson’s chi-squared statistic will be used. For the third objective, in assessing the
relationship between sedentary behaviours and prehypertension, a multiple logistic regression
method will be used. All the covariates will be included in the analysis. This will be reported as
an odd ratio. The IBM SPSS Statistics version 26 software will be used for the statistical
analysis.

3.8 Ethical Considerations

Permission will be obtained from both the Royal Malaysian Air Force Headquarters and the
Medical and Ethics Research Committee of the MAF Health Services Division. Ethical approval

36
especially in view of study protocols will be obtained from the respected university ethics
committee.

37
CHAPTER 4: DISCUSSION

4.1 Significance of Expected Results

The expected results of this proposed study will add new knowledge on prevalence of
prehypertension and level of sedentary behaviour among Air Force community working in any
training-based organisation.

This study will also provide a magnitude of association between level of sedentary behaviours
and prevalence of prehypertension among military personnel, where this type of association
study is poorly reported in the past.

4.2 Public Health Implications

The public health implication of this proposed study is providing a baseline for a new
intervention programme to further reduce the prevalence of prehypertension and at the same time
increase the level of physical activity of military personnel and their organisation.

4.3 Public Health Significance

The public health significance of this proposed study is creating a saving of health care costs on
personnel as well as organisationally, where a more healthy and ready military personnel are
created and maintained.

4.4 Study Strengths

The strengths of this proposed study are as follow:

1. A new study. This is considered a new study on prehypertension and sedentary

behaviours in military population. Based on the literature reviews, there is none were
reported so far.

2. Easy to conduct. This type of study design is easy to conduct but can achieve its
objectives.

38
 3. Cheaper. Using questionnaire-based methods is much easier and cost-effective
than using objective measures.

4. Shorter time to conduct. As we are going to see the participants at one period
and without the need to follow up, the time taken to finish the study will be shorter.

5. Well defined population. The target population of this study is well defined and
would be easier to ascertain the true population for sampling.

6. Generalisability. The proposed study will use random selection of sample and
through this sampling methodology, the study findings can be generalised to the
population.

7. Strict protocol. A strict protocol will be used measuring participant’s blood

pressure; thus the true prevalence of prehypertension can be obtained.

4.5 Study Limitations

The limitations of this proposed study are as follow:

1. Cannot ascertain causal relationship. As we are going to use cross sectional

study design, which is the best design to measure prevalence, the findings will not give
knowledge on the cause and effect between either prehypertension or sedentary
behaviour. For this, a cohort study design needs to be used.

2. Unknown confounding factors. The proposed study will include many

confounding factors based on the literature review. However, there are still many
unknown confounding factors between the two variables. Thus, the findings will always
be limited to the included confounding factors only.

39
3. Information dan recall bias. In this study, IPAQ-M is used as the measurement
tool and expected to have information and recall bias from the respondents.

40
CHAPTER 5: RESEARCH PLANNING

5.1 Budget
For the estimated 335 sample size of this proposed study, and the possible usage of digital forms,
the cost to conduct is estimated around RM10 per participants considering the need for batteries,
stationeries, token to the participants and meals for the research assistants. Thus, the total will be
approximately RM3350.

5.2 Timeline
The estimated time taken to complete this study is 6 months. Below is the proposed Gannt chart:

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6

Design

Proposal
Completion
Admin & Ethical
Approval
Data Collection

Analysis

Report Writing

41
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Appendix A: Questionnaires for Data Collection

BORANG KAJI SELIDIK 

TINGKAH LAKU AKTIVITI FIZIKAL DAN RISIKO PRA-DARAH TINGGI
DARI KALANGAN ANGGOTA TENTERA

MAKLUMAT BERKAITAN KAJI SELIDIK

1. Anda dipelawa untuk menyertai satu kaji selidik secara sukarela yang melibatkan tingkah
laku fizikal dan risiko pra-darah tinggi. 
 
2. Sebelum anda bersetuju untuk menyertai kajian penyelidikan ini, adalah penting anda
membaca
dan memahami borang ini. 

3. Sekiranya anda menyertai kajian ini, anda akan menerima satu salinan borang ini untuk
disimpan sebagai rekod anda.

4. Penyertaan anda di dalam kaji seldik ini dijangka mengambil masa selama 15-30 minit. 

TUJUAN KAJIAN

5. Kajian ini bertujuan adalah untuk menentukan kaitan tingkah laku fizikal dan prevalen
pra-darah tinggi di lakangan anggota tentera. 

KESUKARELAAN

6. Penyertaan anda dalam kaji selidik ini adalah secara sukarela. Anda berhak menolak
untuk menyertai kajian ini atau anda boleh menamatkan penyertaan anda pada bila-bila masa,
tanpa sebarang hukuman atau
kehilangan manfaat yang sepatutnya anda perolehi.
49
PERSOALAN

7. Sekiranya anda mempunyai sebarang soalan mengenai prosedur kaji selidik ini atau hak-
hak anda, sila hubungi;
Mejar (Dr) Mastura binti Hamzah
Pegawai Pemerintah
814 Rumah Sakit Angkatan Tentera
Pangkalan Udara Sendayan
Emel - 

KERAHSIAAN

8. Data yang diperolehi dari kajian yang tidak mengenalpasti anda secara perseorangan
mungkin akan diterbitkan. Maklumat anda yang asal mungkin akan dilihat oleh pihak
penyelidik, 

9. Lembaga Etika kajian ini dan pihak berkuasa regulatori untuk tujuan mengesahkan data
kajian. 

PERSETUJUAN MENGIKUTI KAJI SELIDIK

10. Dengan menandatangani borang persetujuan ini, anda membenarkan penelitian rekod,
penyimpanan maklumat dan pemindahan data seperti yang dihuraikan di atas. 

TANDATANGAN :

50
NAMA :

TARIKH : 

Tarikh Borang Diisi :

________________

A. BUTIRAN ASAS RESPONDEN

Kod

1. Perkhidmatan ☐1 Darat      ☐2 Laut     ☐3 Udara

2. Tempoh Perkhidmatan

3. Nombor Tentera

4. Pangkat

5. Kategori Pangkat ☐1 Peg Kanan

☐2 Peg
☐3 PTTK      
☐4 PTTR

6. Nama

7. Pasukan

8. Jenis Pekerjaan/Kepakaran ☐1 Pemerintah      

☐2 Pentadbir
☐3 Logistik     
☐4 Kejuruteraan
☐5 Pengangkutan

51
 ☐6 Kejurulatihan
☐7 Kesihatan
☐8 Lain – sila nyatakan
__________________

9. Tahap Pendidikan ☐1 SPM      

☐2 Diploma
☐3 Sarjana Muda     
☐4 Sarjana
☐5 Doktor Falsafah

10. Jantina ☐1 Lelaki      ☐2 Perempuan

11. Tarikh Lahir

12. Tahap Perkahwinan ☐1 Bujang      

☐2 Kahwin
☐3 Duda     
☐4 Janda

13. Pendapatan Seisi Rumah (Sebulan) ☐1 Bawah RM2,500    

☐2 RM2,500 hingga RM4,849
☐3 RM4,850 hingga RM10,949     
☐4 Atas RM10,949

14. Jumlah Penghuni Seisi Rumah

52
 14. Status Merokok/Vape ☐1 Tidak Pernah      
☐2 Masih Merokok
☐3 Pernah, Lebih Setahun
☐4 Pernah, Kurang Setahun

15. Tinggi (Meter)

16. Berat (Kilogram)

17. Peratus Lemak Badan (%)

B. BACAAN TEKANAN DARAH

Bil Perkara Bacaan 1 Bacaan 2 Bacaan 3 Kod

1. Sistolik (mmHg)

2. Diastolik (mmHg)

C. PERNYATAAN TINGKAH LAKU AKTIVITI FIZIKAL

Fikirkan tentang semua aktiviti fizikal berat yang anda telah lakukan dalam tempoh 7 hari yang
lepas ini.  

Aktiviti fizikal berat adalah aktiviti yang menggunakan daya tenaga fizikal yang kuat dan
membuat anda bernafas jauh lebih kuat daripada biasa.  

Fikirkan hanya tentang aktiviti-aktiviti fizikal yang anda telah lakukan selama sekurang-
kurangnya 10 minit pada sesuatu masa.

53
1. Dalam tempoh 7 hari yang lepas ini, berapa harikah anda telah melakukan aktiviti
fizikal berat, contohnya mengangkat barang berat, mencangkul, senaman aerobik atau berbasikal
laju?

_______ hari seminggu

                   Tiada aktiviti fizikal berat                             Lompat ke soalan 3

2. Berapakah masa yang anda biasa gunakan untuk melakukan aktiviti fizikal berat pada
salah satu daripada hari berkenaan?

       _______jam _____minit sehari 

                  Tidak tahu / Tidak pasti 

Fikirkan tentang semua aktiviti fizikal sederhana yang anda telah lakukan dalam tempoh 7 hari
yang lepas ini.

Aktiviti fizikal sederhana adalah aktiviti yang menggunakan daya tenaga fizikal yang sederhana
dan membuatkan anda bernafas agak lebih kuat daripada biasa.  

54
Fikirkan hanya tentang aktiviti-aktiviti fizikal yang anda telah lakukan selama sekurang-
kurangnya 10 minit pada sesuatu masa.

3. Dalam tempoh 7 hari yang lepas ini, berapa harikah anda telah melakukan aktiviti
fizikal sederhana, contohnya mengangkat muatan ringan, mengelap lantai, berbasikal pada
kelajuan biasa, atau bermain badminton beregu?  Ini tidak termasuk berjalan kaki.

_______hari seminggu        

    
                  Tiada aktiviti fizikal sederhana                       Lompat ke soalan 5

4. Berapakah masa yang anda biasa gunakan untuk melakukan aktiviti fizikal sederhana
pada salah satu daripada hari berkenaan? 

  _______jam ______minit sehari 

                  Tidak tahu / Tidak pasti 

55
Fikirkan tentang masa yang anda telah gunakan untuk berjalan kaki dalam tempoh 7 hari yang
lepas ini.  

Masa ini merangkumi berjalan kaki di tempat kerja dan di rumah, berjalan kaki dari satu tempat
ke tempat yang lain, dan berjalan kaki semata-mata untuk rekreasi, bersukan, bersenam atau pada
masa lapang.

5. Dalam tempoh 7 hari yang lepas ini, berapa harikah anda telah berjalan kaki selama
sekurang-kurangnya 10 minit pada sesuatu masa? 

_______hari seminggu        

    
                  Tiada berjalan kaki                                Lompat ke soalan 7

6. Berapakah masa yang anda biasa gunakan untuk berjalan kaki pada salah satu daripada
hari berkenaan? 

 _______jam _______minit sehari 

56
                  Tidak tahu / Tidak pasti 

Soalan terakhir ini adalah berkaitan masa yang anda telah gunakan untuk duduk pada hari-hari
bekerja dalam tempoh 7 hari yang lepas ini.  

Masukkan masa yang di habiskan duduk di tempat kerja, di rumah, sewaktu belajar dan di masa
lapang.  

Masa ini juga merangkumi waktu yang di habiskan duduk di meja, menziarahi kawan-kawan,
membaca, atau duduk atau baring sambil menonton televisyen.

7. Dalam tempoh 7 hari yang lepas ini, berapakah masa yang anda telah gunakan untuk
duduk pada sesuatu hari bekerja?
 
_______jam _______minit sehari 

                  Tidak tahu / Tidak pasti 

                         
          

57