LETTER TO THE EDITOR. The hypertension-related organ damage: a poorly perceived danger in subjects with low education. Journal of Human Hypertension.
Journal of Human Hypertension (2002) 16, 449–451 2002 Nature Publishing Group All rights reserved 0950-9240/02 $25.00 www.nature.com/jhh
LETTER TO THE EDITOR The hypertension-related organ damage: a poorly perceived danger in subjects with low education Journal of Human Hypertension (2002) 16, 449–451. DOI: 10.1038/ sj/jhh/1001397 Human hypertension (HT) is the end result of various influences, and typically develops gradually over many years. The epidemiology of HT and its correlated risk factors have been studied extensively.1,2 Potential risk factors have included biological variables, psychological and environmental influences,1 such as the level of education. HT and its organ damage are major risk factors for atherosclerotic disease, but is frequently ignored by patients with little education.3–5 Increasing the awareness and detection of HT and its organ damage is one of the public health challenges set forth by recent guidelines.6 We recently confirmed that the awareness of HT and its organ damage is education-related.3 After establishing the educational level of 812 consecutive outpatients in our unit, we found that almost all (91%) had a high level of education. Because patients from our institution may be a selected cohort that is very aware of health care, we decided to establish the awareness of HT and the importance of evaluating the possible hypertension-related organ damage in a cohort of workers, with low educational level, not followed by our institution. We analysed data from 424 sanitation engineers (399 men and 25 women, mean age 40 ± 8 years), working as street sweepers in the suburb of Caserta. Patients Correspondence: MA Tedesco, MD, PhD, Salita Due Porte 14, 80136 Naples, Italy. E-mail: tedesco얀napoli.pandora.it Received 20 November 2001; revised and accepted 10 January 2002
were employed for at least 10 years. All lived in the Campania region of Italy. All had low educational level (primary education and illiterates), measured as the highest completed grade at school. They were subdivided into two groups based on blood pressure (BP) (group A, subjects with HT; and group B, subjects without HT). Subjects with normalised BP after treatment were included in the HT group. HT was defined by international guidelines on the management of HT.6 Our study was based on the clinical visit and biochemical parameters evaluated during the periodic work-ups by occupational health care providers. For each patient we evaluated age, sex, body mass index (BMI), smoking habit, systolic BP (SBP), diastolic BP (DBP), glycaemia, total cholesterol and triglycerides. Blood chemistry after an overnight fast was analysed by standard methods. Three consecutive BP readings were obtained with the subject sitting, after a rest of at least 10 minutes. The average of three readings was used for the analyses. Measurements were carried out by two trained health care professionals who had previous experience with BP measurement in similar surveys. The clinical examination included questions on living conditions, lifestyle, and prescribed medication. To evaluate how much each subject knew about hypertension, we invited them to define it. Those with HT were questioned about their awareness of cardiovascular complications by evaluating their perception of health care needs, and to have an overall check up in a tertiary centre. If they were on treatment we evaluated the effective control of arterial pressure. The questions
were posed by the same physician using an oral interview. Statistical analysis was carried out by Stat View software (SAS Institute, Cary, NC, USA). The Student’s t-test for unpaired data was used to estimate the difference between mean values. Qualitative data were expressed as percentage and were compared using Fisher’s exact test (two tailed). The data were expressed as mean ± s.d.; P ⬍ 0.05 was considered statistically significant. There were 74 hypertensives, equal to 18% of the whole sample (Table 1). None lived alone; all were married with an average of two children. None had regular physical activity during leisuretime. In this group a large number of subjects (71%) knew that their BP was high. A low percentage (20%) was informed about the risks of HT and of the importance of an effective and continuous treatment. In fact, only 15 subjects were already in therapy, and of these, only four patients had wellmanaged BP. None had ever consulted a referral centre. The majority continued to ignore their health even after medical pressure to change their lifestyle, take medication or periodically reach a medical centre. Only 30% of subjects without HT knew anything about HT and the normal upper limits of BP. This is the first European study that has evaluated the awareness of HT and its organ damage in a large sample of workers with low educational level. We recently established the educational level in a large sample of hypertensive outpatients in our hypertension unit, where we found that almost all had a high standard of education.3 Here we have established the awareness of
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Table 1 Comparison of general characteristics between patients with and without hypertension Group A (n = 74) Age (years) Men (%) Body mass index (kg/m2) Smokers (%) Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) Cholesterol (mmol/l) Triglycerides (mmol/l) Glycaemia (mmol/l)
Group B (n = 350)
P-value
43 ± 7.5 100 30 ± 4 59 153 ± 9
40 ± 8 93 27 ± 4 57 127 ± 9
0.004 0.01 0.0001 0.79 0.0001
93 ± 9
78 ± 5
0.0001
5.37 ± 0.82 1.38 ± 0.41 5.28 ± 0.94
5.48 ± 1.01 1.31 ± 0.44 5.02 ± 1.22
0.75 0.27 0.10
Data are expressed as mean ± s.d.
HT and the importance to evaluate the possible hypertensionrelated organ damage in a cohort of workers, with low educational level, not followed by our institution (with the disadvantage of a very low number of women). The awareness of HT and of its organ damage was investigated in all hypertensives, by evaluating their perception of health care needs and to have an overall check up in a tertiary centre. Despite a large proportion of subjects who knew that their BP was high, only 20% were already in therapy and none underwent examinations to detect target organ damage. These findings confirm the hypothesis of our first study that many low educated hypertensives are unaware of hypertension-related organ damage and either not treated or inadequately managed. Taken together, our two studies demonstrate that the awareness of HT and of its organ damage is education-related in our region. Education plays an important role in guarding against disease influenced by lifestyle. Many population studies have attempted to explain the inverse relationship between education (and indirectly of socioeconomic status) and BP.7–8 HT and its risk factors are relatively unknown by people with little education: low perception of health care needs as a priority, and inadequate information regarding prevention, diagnosis and treatment of the HT may impede access to health care Journal of Human Hypertension
structures.9 Generalising our findings to other countries is likely to be dependent on the nature of their health care delivery. There might be other reasons for this poor control. HT is largely asymptomatic, treatment is generally life-long and may be associated with dose-related side effects. Symptomless patients, especially the uneducated, are often unwilling to change their lifestyle, take medication or periodically reach a medical centre to forestall some far-off, poorly perceived danger. Patients with higher educational level know that the available treatment is effective, especially after a complete and periodic evaluation in a tertiary centre. Cardiovascular risk stratification only based on a simple routine work-up can often underestimate overall risk.10 The recommended approach for initiation of treatment and for decision-making is not only based on BP level, but also on the presence or absence of target organ damage or other risk factors, allowing a much more accurate identification of high risk patients.10 Many of the problems associated with lower socio-educational status can be eliminated with systems that overcome social and educational barriers to health care and to adoption of healthier lifestyles. We emphasise the importance of a sound sanitary policy using all possible screening programmes able to reach the uneducated,11–12 to eliminate social
inequalities when managing HT. A recent study showed a positive short and long-term impact of a structured educational intervention on the patient’s knowledge of HT and related complications in patients with educational level higher than primary school.13 Our findings suggest the opportunity to extend this approach to the general population with little education and with inadequate health literacy, particularly through the collaboration between general practitioners, tertiary centres, medical scientific societies and regional political institutions. This decision can only be implemented when appropriate arrangements are all in place. MA Tedesco1 S Caputo1 G Di Salvo1 F Natale1 G Ratti1 D Sortino2 A Iacono1 R Calabro`1 1 Medical Surgical Department of Cardio-Thoracic Sciences, Second University of Naples, Naples, Italy 2 Occupational Medicine, ASL CE/1, Caserta, Italy References 1 Dyer AR, Stamler J, Shekelle RB, Schoenberger J. The relationship of education to blood pressure. Findings on 40,000 employed Chicagoans. Circulation 1976; 54: 987–992. 2 Pappas G, Gergen PG, Carroll M. Hypertension prevalence and the status of awareness treatment, and control in the Hispanic Health and Nutrition Examination Survey (HHANES). Am J Public Health 1990; 80: 1431–1436. 3 Tedesco MA et al. Educational level and hypertension: how socioeconomic differences condition health care. J Hum Hypertens 2001 15: 727–731. 4 Zdrojewski T, Pienkowski R, Szynkiewicz M, Krupa-Wojciechowska B. Have rapid socioeconomic changes influenced awareness of blood pressure in Poland? J Hum Hypertens 2001; 15: 247–253. 5 Burt VL et al. Trends in the prevalence, awareness, treatment and control of hypertension in the adult US population. Data from the health examin-
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ation surveys. Hypertension 1995; 26: 60–69. 6 Word Health Organization – International Society of hypertension guidelines for the management of hypertension. Guidelines Subcommittee. J Hypertens 1999; 17: 151–183. 7 Vargas CM, Imgram DD, Gillum RF. Incidence of hypertension and educational attainment: the NHANES I epidemiologic follow-up study. First National Health and Nutrition Examination Survey. Am J Epidemiol 2000; 152: 272–278. 8 Winkleby MA, Jatulis DE, Frank E,
Fortmann SP. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health 1992; 82: 816–820. 9 Marceca M, Fara GM. Socio-economic determinants in conditioning Health Care access. Ann Ig 2000; 12: 49–57. 10 Cuspidi C et al. Influence of different echocardiographic criteria for detection of left ventricular hypertrophy on cardiovascular risk stratification in recently diagnosed essential hypertensives. J Hum Hypertens 2001; 15: 619–625.
11 Earle KA, Taylor P, Wyatt S, Burnett Ray J. A physician-pharmacist model for the surveillance of blood pressure in the community: a feasibility study. J Hum Hypertens 2001; 15: 529–533. 12 Martin RM et al. Elevated blood pressure in men accompanying patients to obstetrician’s office. Am J Hypertens 2000; 13: 1042–1044. 13 Cuspidi C et al. Short and long-term impact of a structured educational program on the patient’s knowledge of hypertension. Ital Heart J 2000; 1: 839–843.
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