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(Stroke. 2007;38:1304.)
© 2007 American Heart Association, Inc.
Original Contributions |
From the Department of Neurology (D.S., S.G., E.A., W.L.), Medical University of Vienna, Austria; and the Department of Neurology (W.L.), Hospital Barmherzige Brueder, Vienna, Austria.
Correspondence to Wolfgang Lalouschek, MD, Medical University of Vienna, Department of Neurology, Waehringer Guertel 18-20, 1090 Vienna, Austria. E-mail wolfgang.lalouschek{at}meduniwien.ac.at
| Abstract |
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Methods Five hundred ninety-one consecutive patients with stroke with a medical history of hypertension were interviewed about knowledge concerning hypertension within a multicenter hospital-based stroke registry. We analyzed answers in relation to educational level with multivariate logistic regression adjusted for age and sex.
Results Seventy-seven percent of the patients stated to have known about hypertension being a risk factor for stroke, but only 30% felt at increased risk of stroke. Less than half (47%) could identify 140 mm Hg or less as the maximum tolerated systolic blood pressure, and 53% had their blood pressure only controlled monthly or less often. Knowledge of possible consequences of myocardial infarction, nephropathy, peripheral vascular disease, and retinopathy was 64%, 20%, 11%, and 16%, respectively. Approximately half of patients were acquainted with the nonpharmacologic treatment options of physical activity (49%), reduction of salt intake (54%), and reduction of caloric intake (48%), whereas relaxation techniques were only known to 17%. Adherence to those treatment options ranged from 42% to 67%. Educational level was significantly associated with knowledge of increased risk, possible consequences of hypertension, and knowledge about nonmedication treatment options.
Conclusion Knowledge in our population was insufficient and partly associated with educational level, leaving much room for improvement by educational campaigns. Furthermore, we found a gap between knowledge of the increased risk for stroke in patients with hypertension and awareness of their own risk.
Key Words: education hypertension ischemic socioeconomic status stroke
| Introduction |
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In hypertensive subjects, awareness about their increased risk for stroke is connected to higher compliance in stroke prevention practices.9 However, patients at risk for cerebrovascular disease tend to underestimate their risk, especially if they are currently without symptoms and lack direct experience with the questioned event. Previous studies showed that only a minority of individuals at an increased risk for stroke or already under investigation for possible stroke were aware of their increased risk.9,10 In these reports, socioeconomic status was an independent predictor of awareness, a higher education being linked with increased awareness. We sought to assess awareness for hypertension and individual knowledge about it in a patient population with transient ischemic attack (TIA) or ischemic stroke and a history of arterial hypertension. We also investigated whether socioeconomic status is associated with knowledge about hypertension.
| Methods |
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Educational Level
We chose education as a marker of socioeconomic status, because it is reliably recalled, can be easily quantified in terms of numbers of years, and reverse causation does not confuse interpretation.12 We divided patients into five categories: no basic school education, secondary school graduation, apprenticeship, upper secondary school graduation, and university or college graduation.
Assessment of Awareness and Knowledge About Hypertension
The questions for assessment of awareness and knowledge about hypertension are given in Table 1.
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Statistical Analysis
Statistical analysis was conducted with SPSS 11.0. Continuous data are given as means. Categorical data are given as counts and percentages. Binary and categorical data were analyzed using contingency tables and a
2 statistic. To assess the influence of socioeconomic status on knowledge, we applied multivariate logistic regression and adjusted for age and sex. Probability values of <0.05 were considered statistically significant. Apprenticeship was used as the reference category in the logistic regression model. The Hosmer-Lemeshow test was used to assess the model fit; probability values >0.1 indicate an agreeable model fit.
| Results |
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Awareness of and Knowledge About Arterial Hypertension
Results of assessing awareness and knowledge about arterial hypertension are summarized in Table 4. Seventy-seven percent of patients claimed to be aware of hypertension as a risk factor for stroke, but knowledge was highly significantly correlated with educational level (P<0.001). Only 30% had considered themselves at increased risk for stroke and 34% felt themselves at increased risk for myocardial infarction. There was no difference between educational groups. Less than half of the patients with hypertension (47%) stated a systolic blood pressure of or below 140 mm Hg as the upper limit but only 20% of patients stated this without a basic school education (P<0.05 compared with the reference category). Knowledge of the maximum tolerated diastolic blood pressure was the same throughout the groups and comparably high with 81% of patients stating a value of 90 mm Hg or below. Fifty-three percent had their blood pressure controlled at least weekly, whereas the remaining 47% controlled it monthly or less often. Patients without a basic school education had a significantly lower frequency of blood pressure measurements than the others (P<0.05 compared with the reference category). Three fourths (76%) of the patients stated they owned a blood pressure meter, but only 63% used it.
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Knowledge of other possible consequences of hypertension, namely myocardial infarction, nephropathy, peripheral vascular disease, and retinopathy, were significantly associated with educational attainment. Knowledge about these consequences ranged from 64% for myocardial infarction to 11% for peripheral vascular disease. Concerning nonpharmacologic options for lowering blood pressure, there were significant differences defined by educational level as well; the higher the educational level, the more patients were likely to know about physical activity, reduction of salt intake, reduction of caloric intake, and relaxation techniques. Knowledge about these options ranged from 17% (relaxation techniques) to 54% (reduction of salt intake). When asking about adherence to these lifestyle modifications, 37% to 66% affirmed to do so.
| Discussion |
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Educational level markedly influenced knowledge of hypertension as a risk factor of stroke. It steadily increased from 54% in patients without a basic school education to 89% of patients with a college degree. Interestingly, missing awareness of being at an increased risk for stroke and myocardial infarction was the same throughout the groups. Because patients with higher education were more likely to know about the connection between stroke and hypertension, this implies that they also more often denied this fact for themselves. To our knowledge, we are the first to investigate "knowledge" and "awareness" separately, but our results indicate that these are not necessarily linked to each other.
Notably, only half of the patients were able to state the maximum tolerated systolic blood pressure (or a value below), which seems surprisingly low but is consistent with a survey in the United States in 2005, where 49% could name the target values of blood pressure.14
Questioning about consequences of hypertension revealed another deficit: myocardial infarction was known by 64% of the patients followed by nephropathyknown by one of fivewhereas peripheral vascular disease and retinopathy reached only 11% and 16%, respectively. Compared with knowledge in older Americans in a recent report, in which 86% could identify heart disease and 49% kidney failure as a consequence of hypertension, this is clearly lower.15 Again, there were highly significant differences between the different educational groups.
Nonpharmacologic treatment options by adoption of healthy lifestyles have been recommended as an indispensable part of management in patients with hypertension.16 Weight reduction was shown to lower blood pressure with a 5 to 20-mm Hg systolic blood pressure reduction per 10-kg weight loss,17,18 as does reduction of sodium intake (2 to 8 mm Hg)1921 and regular physical activity (4 to 9 mm Hg).22,23 All named treatment options were known by approximately half of our population with exception a fourth option we askedpracticing relaxing techniqueswhich was only familiar to 17% of patients. Again, there were clear differences between the educational groups. Consecutively asking about adherence to these lifestyle modifications showed that better knowledge is not necessarily related to a better practice; the only statistical significance according to educational level concerned reduction of salt intake, whereas the other three options were adopted by a maximum of nearly 40% of patients in all educational levels.
In summary, there is much room for improvement in hypertensive patients awareness of and knowledge about hypertension, its consequences, and nonpharmacologic ways to control it. Moreover, it seems to be important to help patients transfer their knowledge adequately into practice. Perceived risk is one of the key factors for promoting behavioral changes; a person perceiving risk for some adverse event as high is more likely to take preventive action to reduce the risk.10 For our patients, this could, for example, mean providing individualized risk feedback, which was shown to be effective in increasing perceived stroke risk among patients who had underestimated their stroke risk.10 For better adherence to lifestyle modifications, Burke et al found a structured "modification program" to be effective.24
Our results do not only point out a strong need for improvement of knowledge in people at increased risk for cerebrovascular disease, but also the need of increasing awareness of their individual risk. Because the drugs for effective lowering of blood pressure exist, education of affected patients is an important target to convert the possible 40% risk reduction into reality for all patients with hypertension.
| Acknowledgments |
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None.
Received June 22, 2006; revision received October 20, 2006; accepted October 30, 2006.
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