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The Knowledge and Awareness of Hypertension Among Patients With

Hypertension in Central Poland: A Pilot Registry

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DOI: 10.1177/0003319713489166 · Source: PubMed

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Hypertension

Angiology
2014, Vol. 65(6) 525-532
The Knowledge and Awareness of ª The Author(s) 2013
Reprints and permission:
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Hypertension Among Patients With DOI: 10.1177/0003319713489166
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Hypertension in Central Poland:
A Pilot Registry

Marta Michalska, PhD1, Jacek Rysz, MD, PhD, FASN2,

Michael J. Pencina, PhD3, Tomasz Zdrojewski, MD, PhD4,
and Maciej Banach, MD, PhD, FAHA, FESC, FASA1

Abstract
We assessed the differences in the knowledge and level of awareness of hypertension among patients with hypertension from
Central Poland; 248 (57.6% females) patients diagnosed with hypertension completed a questionnaire. Most (79%) of the patients
were unaware of the optimal blood pressure (BP) range. The elderly patients did not know the symptoms of hypertension
(23.7%), were not willing to make lifestyle changes (57%-65%), and had a poor awareness of hypertension therapy in the absence
of symptoms (28.7%). Poor BP control occurred mainly in rural residents (10.7%) and in people with higher education (39.3%).
Untreated patients with hypertension did not know the symptoms of hypertension (29.2%), rarely measured BP (37.5%), but were
more likely to engage in regular physical activity (70.8%). Efforts should be made to improve knowledge of hypertension, especially
among the rural population, the elderly patients, those with a low-education level, and in young males who had the highest BP.

Keywords
awareness, blood pressure, compliance, hypertension, knowledge, therapy

Introduction Interesting results were obtained in the United States and

Canada. The percentage of patients aware of their condition
Hypertension, as one of main risk factors for adverse cardio-
in the United States oscillates around 80.7%; hypotensive treat-
vascular (CV) and cerebrovascular events, is a serious medical,
ment is used in 72.5% of the patients and 50.1% of whom
social, and economic problem worldwide.1,2 Despite progress
achieve adequate BP control.7
in the therapy of hypertension and improvement in detectability An important reason behind the failure of hypotensive treat-
of this condition, the number of patients with hypertension is
ment is the lack of cooperation between the patient and the
still increasing (the so-called hypertension paradox), and the
doctor (compliance phenomenon),8,9 the patient’s insufficient
percentage of patients with adequate control of blood pressure
knowledge of causes, treatment, and complications of the
(BP) is still unsatisfactory.1-4 Currently, there are 10.5 million
disease (awareness) as well as failure to follow the doctor’s
patients with hypertension in Poland, including 9.5 million
recommendations regarding lifestyle modification, the way of
people aged 18 to 79 and almost 1 million people older than
using hypotensive agents as well as frequency of follow-up
80 years .2,4,5 Data from the nationwide study of the occurrence
of risk factors for CV diseases (NATPOL 2011) indicate that,
in the last 10 years, efficiency of hypertension treatment has
1
increased approximately 2-fold, currently amounting to Department of Hypertension, Medical University of Lodz, Poland
2
26%.4 However, despite this, over 1 (36%) of the 3 patients Department of Nephrology, Hypertension and Family Medicine, Medical
University of Lodz, Poland
diagnosed with hypertension are treated ineffectively, and 3 3
Department of Biostatistics, Boston University, Harvard Clinical Research
million Poles have the condition undiagnosed or are unaware Institute, Boston, MA, USA
that they have hypertension (4% less than in 2002).4 Signifi- 4
Department of Hypertension and Diabetology, Medical University in Gdansk,
cantly better efficiency of hypertension treatment is seen in Poland
Western European countries as well as in the United States
Corresponding Author:
and Canada.6 Recent findings indicate that therapeutic effi- Maciej Banach, Department of Hypertension, WAM University Hospital in
ciency has considerably increased in Italy to 32%, in the Lodz, Medical University of Lodz, Zeromskiego 113, 90-549 Lodz, Poland.
United Kingdom to 36%, and in Spain and Germany to 40%.7 Email: [email protected]
526 Angiology 65(6)

visits.8,9 As regards, the causes associated with failure to follow The questionnaire included also questions concerning
doctors’ recommendations, the most often cited factors are demographic data: age, sex, place of residence, education, type
those directly dependent upon the patient, resulting from lack of profession, material status, and socio-professional status.
of knowledge of one’s condition, its chronic nature and
possible consequences, low motivation for continuation of Statistical Analysis
treatment, and necessity to modify one’s lifestyle.9-11
Data gathered using the questionnaire were grouped and
Therefore, the aim of our study was to analyze the knowl-
entered into a previously created Excel form, and then statisti-
edge and awareness of hypertension among patients with
cally analyzed using STATISTICA 7.0 PL Software. In the
hypertension in different age groups, depending on sex, place
case of single-choice questions, the assessed qualitative vari-
of residence, education, socio-professional status, type of ables were expressed as a number of observations with a given
profession, or level of wealth. An additional aim of the study
variant (category) of the variable (N) and corresponding
was to distinguish a group of patients with hypertension, whose
percentage in relation to the number of available observations.
level of knowledge and awareness is insufficient and who
As regards the multiple-choice questions, a number of choices
require further education on this matter, thereby constituting
of a certain category were given (N), followed by percentage in
a high-risk group for hypertension-related organ complications.
relation to the number of answers (percentage of answers) and
to the number of respondents (percentage of cases). Relation-
ships between the variables were assessed using Pearson chi-
Materials and Methods square test of independence. Results characterized by P < .05
(2-sided) were considered significant. In addition, contingency
Study Population index (C) and phi index (f) were calculated as measures of the
A survey study was carried out among patients hospitalized at strength of correlation.
the Department of Nephrology, Hypertension and Family Med-
icine and patients of Outpatient Clinic of Hypertension and
Metabolic Disorders at the WAM University Hospital in Lodz, Results
Poland between March 1, 2011 and November 30, 2011. A
group of 252 randomly selected patients were included in the General Population
study, all living in Central Poland (Lodz Province) and diag- The final study analysis included 248 people (4 patients were
nosed with hypertension according to the European Hyperten- excluded as they answered <50% of the questions), 143
sion Society guidelines of 2009,12 both treated and untreated (57.6%) women and 105 (42.4%) men. The highest percentage
for that condition. The following exclusion criteria were used: was represented by patients aged 56 to 65 (33.2%) and above
lack of consent for participating in the study, patient’s 66 (32.4%) years old . The largest (56.1%) social group were
condition making it impossible to take part in the survey or retired seniors and pensioners. Of all the respondents, 71.1%
complete the questionnaire, and failure to answer at least half were dwellers of cities, over 5 00 000 residents (mostly Lodz).
of the questions in the questionnaire. The highest number (37.8%) of responders declared secondary
People consenting to take part in the study were asked to education. Detailed characteristics of the patients are shown in
complete on their own an anonymous questionnaire containing Table 1.
25 questions, assessing the level of the patients’ knowledge and
awareness of hypertension and its complications. The study Knowledge of the Normal and One’s Own BP Values and
was approved by bioethics committee of the Medical Univer- Frequency of Taking Measurements
sity of Lodz; approval number: RNN/412/11/KB.
The participating patients did not know the normal BP values.
The highest number (79%) of respondents stated that only val-
ues under 120/80 mm Hg are normal, and only 17.74% of the
Questionnaire patients selected the expected answer—<140/90 mm Hg.
The questionnaire used in the study was prepared based on the Patients in the study group were characterized by very high
surveys previously used in other countries13 and adjusted for awareness of their own BP. Only <2% of the population admit-
the specificity of Polish patient’s population. The questionnaire ted that they did not know their BP. More than half of the
contained both single- and multiple-choice questions, closed respondents stated that they had a high BP, while 24.7% found
and half open, concerning, among other things, the following: their BP to be normal. In addition, it was demonstrated that
knowledge of the normal BP and frequency of taking measure- among patients declaring high BP, the biggest group were
ments; knowledge of hypertension complications; type of young people aged 25 to 39 (85.71%; P ¼ .003) and men
hypotensive treatment used, including regularity of taking (66.7%; P ¼ .043). The results are summarized in Table 2.
medications, necessity to change lifestyle and dietary habits; High awareness of BP is often accompanied by high
knowledge of complications of treated and untreated hyperten- frequency of taking measurements. The study results revealed
sion; knowledge of factors leading to hypertension; and assess- that over 88% of the patients had measured their BP within
ment of quality (comfort) of life. a week before the day of performing the study survey. A
Michalska et al 527

Table 1. Characteristics of the Study Group (N, %). Table 2. Knowledge of One’s Own Blood Pressure Values by Age and
Sex (Percentage of Responses).
Category N (%)
Blood Pressure Values
Age
24 10 (4) High Normal Low Unstable Do not Know
25–39 28 (11.3)
40–55 47 (19.1) Total 55.9 24.7 6.9 10.9 1.6
56–65 82 (33.2) Agea
66 80 (32.4) 24 80.00 20.00 0.00 0.00 0.00
Sex 25–39 85.71 10.71 0.00 3.57 0.00
Female 143 (57.6) 40–55 68.09 17.02 8.51 6.38 0.00
Male 105 (42.4) 56–65 51.90 29.11 8.86 10.13 0.00
Place of residence 66 39.24 30.38 6.33 18.99 5.06
City > 5 00 000 residents 177 (71.7) Sexb
City < 5 00 000 residents 42 (17.0) Female 47.48 28.06 7.91 14.39 2.16
Rural 28 (11.3) Male 66.67 20.95 4.76 6.67 0.95
Education a
P ¼ .003 (f ¼ .3829153, C ¼ 0.3575957).
Primary 29 (11.6) b
P ¼ .043 (f ¼ .2005886, C ¼ 0.1966710).
Vocational 38 (15.3)
Secondary 94 (37.8) that the regularity of medication use was affected by their
Incomplete higher 26 (10.4)
financial situation—0.81% and memory—1.6%, while 11.7%
Higher 62 (24.9)
Socio-professional status of the respondents stated this question did not concern them.
Employed 89 (36.2) It was also shown that 70% of the respondents were not aware
Retired senior/pensioner 138 (56.1) of the necessity to treat hypertension in spite of the lack of
Student 7 (2.8) ailments or symptoms related to this disease. It was demon-
Unemployed 12 (4.9) strated that the lowest awareness in this regard was seen in
patients older than 66 years (28.7%) who statistically more
frequently discontinued treatment (P ¼ .006; Figure 2).
significant relationship was observed between the place of resi-
dence (P ¼ .004) and education (P ¼ .04) and frequency of taking Awareness of Symptoms, Complications, and Risk Factors
BP measurements. Groups taking least frequent measurements
were village residents (10.7%) and people with more education
for Hypertension
(39.3%; in the last 12 or 3 months, respectively). In the present study, 85% of the respondents admitted to be
aware of the symptoms of hypertension. It was noted that
among people not knowing the hypertension symptoms, elderly
Treatment of Hypertension people older than 66 years (P ¼ .035) were statistically signif-
We showed that in the group of respondents who answered the icantly more common. Almost 1 in 4 of such patients admitted
question concerning the hypotensive therapy used (pharmaco- lack of knowledge (23.7%; Figure 3).
logical and nonpharmacological), 84.7% of the patients took The awareness of the hypertension complications were as fol-
antihypertensive medications, 40.3% had reduced table salt lows: cerebral stroke (74.8%) and myocardial infarction (65.4%)
consumption, 29.4% had reduced their weight, 23.8% had as well as heart failure (49.6%), while atherosclerosis (36.6%)
increased physical activity, and 2.8% respondents admitted to and renal failure (38.2%) were listed a little less frequently. The
use no hypertensive therapy at all. It was also noted that more relatively smallest proportion of the answers concerned hyper-
educated respondents more often used physical activity as an tensive angiopathy of the eye—25.2%. Of all the respondents,
element of treatment (P ¼ .021). Most reluctant to changing 6.9% admitted lack of knowledge. Taking into account the rela-
their lifestyle were retired seniors and pensioners. Of all the tionships between each of the assessed parameters and knowl-
responders, they least frequently declared body mass normaliza- edge of the consequences and complications of hypertension,
tion (P ¼ .002) and increased physical activity (P ¼ .049; it was demonstrated that less-educated patients, the unemployed
Table 3). Additionally, in this group as well as among men (P ¼ .040), and village residents (P ¼ .023) have the lowest
(P ¼ .035), the elderly individuals (P ¼ .013), less-educated awareness of risks associated with the disease. The best results
people (P ¼ .005), and village residents (P ¼ .047) a significant were observed in patients with incomplete higher and higher
lack of knowledge of proper dietary habits was demonstrated education, who more frequently cited renal failure (P ¼ .042),
(Figure 1). myocardial infarction (P ¼ .031), atherosclerosis (P ¼ .005), and
Among 85.3% of the responders who declared hypotensive hypertensive angiopathy of the eye (P ¼ .001) as complications
medication use, 77.4% stated they take hypotensive agents of untreated hypertension (Figure 4).
regularly. On the other hand, 10.8% of the patients used antihy- According to the respondents, the factors most strongly
pertensive therapy based on their physical state and depending contributing to the development of hypertension were over-
on their BP level. Only a small proportion of patients declared weight (80%), strong emotions, stress, and worries (74%),
528 Angiology 65(6)

Table 3. Type of Treatment Depending on the Socio-Professional Status (Percentage of Patients).

Types of Treatment Used

Hypotensive Agents Salt-Restricted Diet Weight Reduction Increased Physical Activity None Other

Total 84.68 40.32 29.44 23.79 2.82 3.23

Socio-professional status
Employed 85 42 43 33 1 5
Retired senior/pensioner 85 42 20a 18b 4 3
Student 71 14 29 14 14 0
Unemployed 83 25 41 33 0 0
a
P ¼ .002.
b
P ¼ .049

[%] 70
P = 0.013 P = 0.035

60

50

40 yes

rather yes than no

30
rather no than yes
20

10

0
≤ 24 25-39 40-55 56-65 ≥66 Female Male
Age Sex

[%] 60
P = 0.005 P = 0.005
50
40 yes
30 rather yes than no
20
rather no than yes
10
0

Place of residence Education

Figure 1. Knowledge of dietary habits in patients with hypertension by age, sex, place of residence, and education.

alcohol and tobacco smoking (67%) as well as renal diseases Quality of Life
(58%). It was noted that women, retired seniors, and pensioners
The present study indicates that the quality of life of patients
as well as young, working, and studying people had the highest
with hypertension decreases with age. In the analyzed group
awareness of the risk factors for hypertension; this included renal
of patients, complaints concerning bothersome ailments and
diseases (ie, a secondary form of hypertension), tobacco
limitation of physical activity were most frequently expressed
smoking, and overweight as well as vitamin insufficiency and
by the elderly patients (P ¼ .018) as well as by the retired
physical fatigue.
Michalska et al 529

age age
≥66 63.75
≥66 76.25
56-65 73.75 YES
56-65 88.89
40-55 71.11 NO
YES
25-39 82.14 HARD TO SAY 40-55 93.33
NO
≤24 90
25-39 82.14
0 20 40 60 80 100 120 [%]
≤24 100
Figure 2. Awareness of the necessity to treat hypertension despite
0 20 40 60 80 100 120 [%]
disease-related ailments/symptoms in different age groups (P ¼ .006; f
¼ .2963666; C ¼ 0.2841503). C indicates contingency index; f, phi
index. Figure 3. Knowledge of the hypertension symptoms among patients
in different age groups (P ¼ .035; f ¼ .203; C ¼ 0.201).

higer
incomplete higer
Renal failure* secondary
vocational
primary
higer
incomplete higer
Myocardial infarction** secondary
vocational
primary
higer
incomplete higer
secondary
vocational
Heart failure primary
higer
incomplete higer YES
secondary
vocational
primary NO
Cerebral stroke
higer
incomplete higer
secondary
vocational
primary

Atherosclerosis*** higer
incomplete higer
secondary
vocational
primary
higer
Hypertensive angiopathy incomplete higer
of the eye**** secondary
vocational
primary
0 10 20 30 40 50 60 70 80 90 100 [%]
Don’t know

Figure 4. Knowledge of complications caused by untreated hypertension depending on education level. *P ¼ .042; **P ¼ .031; ***P ¼ .005;
****P ¼ .001.

seniors and pensioners (P ¼ .032). Hypertension-related low important given the benefits of effective hypertension treat-
comfort of life was also more frequently reported by women ment: decreased risk of cerebral stroke, coronary heart disease,
than by men (P ¼ .007). Only 27% of the responders stated that congestive heart failure, or overall mortality.14,15 Currently in
hypertension had not affected their comfort of life at all, and Poland, only 26% of the people are treated efficiently despite
only 9% had to change their job because of the disease. availability of many effective and well-tolerated medications,
knowledge of nonpharmacological methods of treatment, and
measures for BP monitoring.2,4,5 The blame for insufficient
Discussion BP control is often placed on the patient, who is not aware of
One element of basic importance in treating a chronic disease, their disease and associated threats, fails to attend visits to the
such as hypertension, is good cooperation between the patient doctor, or discontinues taking medication due to lack of
and the doctor, leading to proper control of BP. It is especially symptoms.16
530 Angiology 65(6)

Our study provided an opportunity to assess the level of Although nonpharmacological management is an important
knowledge and awareness concerning hypertension among part of hypotensive therapy,12 lifestyle change is still not pop-
different patient groups and of distinguishing the group in the ular among patients, especially the older ones. Results gathered
greatest need of educational actions. Good control of BP is in the population of Central Poland (Lodz voivodeship) area
strictly connected to the patients’ knowledge of the normal BP indicate that retired seniors and pensioners are most reluctant
values. The results of the present study confirmed a very low to normalize their body mass and perform regular physical
percentage of people correctly stating the normal BP levels (only exercise. As often is the case with elderly people, this situation
18%). In a study by Piwonska et al,17 slightly better results were is associated with physical and motor limitations (resulting
obtained. It was demonstrated that 51% of men and 56% of from various rheumatologic conditions and diseases of the
women knew the upper limit of the normal BP range. Among motor system) and lack of belief in efficiency of such
these patients, 14% identified the correct values within the range treatment. Similar results were obtained in an Austrian study,
of high–normal BP, 35% in the range 120/80 to 129/84 mm Hg, where elderly people older than 50 years more frequently
and 1% below 120/80 mm Hg.17 The level of knowledge of BP decided to use pharmacological treatment than to change their
values among Poles dropped from 71.9% in 1994 (NATPOL I)18 lifestyle. Only 2% of them declared body mass reduction,
to 58.9% in 2002 (NATPOL Plus)19 and changed to 61% in the 8%—decreased salt consumption, and 4%—increased physical
Multicentre nationwide study of the Polish population’s health activity.13
(WOBASZ 2003-2005).17 In all these studies, better results were Poor compliance with hypotensive treatment regimen is one
seen in women than in men, among more-educated people, and of the main causes of insufficient control of hypertension.24 The
those living in cities with more than 50 000 residents. Compara- patient’s attitude toward the doctor’s recommendations is
ble awareness of one’s own BP, around 65%, was observed in a affected by many factors, such as complex treatment regimen,
population of elderly people (60 years old) living in 20 munic- long-term therapy, side effects, and high treatment costs.24-26
ipal provinces in Western China.20 In the American National The results of the present study demonstrated that more than
Health and Nutrition Examination Survey registry, the aware- 77% of the respondents took hypotensive agents regularly in line
ness of BP values was also relatively high, amounting to 70%, with their doctor’s recommendations. A similar proportion of
which of course might have resulted from a national educational patients were aware of the necessity to treat hypertension in spite
program conducted in this country, namely, the National High of lack of ailments and symptoms. On the other hand, the impor-
Blood Pressure Education Program.7 tant problem of treatment continuation was observed in the
Unlike in the presented studies, the patients participating in elderly patients, older than 66 years. Therefore, one might
our study were characterized by a very high awareness of their suppose this group includes patients who are most reluctant to
own BP values. Only less than 2% of the population included in appreciate benefits of efficient, long-term treatment.
the study did not know their BP values. It is a surprising result, Hypertension is often referred to as a ‘‘silent killer,’’
but it needs to be stressed that the study included only patients because in its initial course, it might not show characteristic
with diagnosed hypertension. Unfortunately, it was observed symptoms.27 Increased BP is usually diagnosed by accident,
that the groups of young people and men were characterized during routine measurements, or only after organ complica-
by the biggest percentage of patients declaring the highest tions have developed. Therefore, correct diagnosis and early
BP levels. This fact can reflect poor efficiency of therapeutic treatment can prevent the development of subclinical organ
actions relating to hypertension. damage and other organ complications.28,29 In order to achieve
Diagnosis of hypertension and subsequent monitoring of the good efficiency of hypotensive therapy, it is important to
course of the disease and of treatment outcomes require taking diagnose the disease as soon as possible. A quite unexpected
regular BP measurements. Usually, patients perform BP result of our study was very high (85%) awareness of the hyper-
measurements at home (ambulatory). The results of our study tension symptoms. Only among the elderly patients, older than
revealed that 88.8% of the patients had measured their BP 66 years, lack of knowledge of the hypertension symptoms was
within a week before the day of performing the study survey. observed. Steiner et al30 as well as Familoni et al31 obtained
Groups taking least frequent measurements (in the last 12 slightly lower results. Although most respondents were able
months) were village residents and people with more educa- to clearly name the symptoms of hypertension, only 19% in the
tion. It seems this might be associated with insufficient avail- former and 11.4% in the latter study were aware that hyperten-
ability of manometers among village residents, but probably sion may sometimes lack any distinct symptoms.30,31
this is more frequently a result of lack of time due to intensive The knowledge of possible complications of hypertension,
labor or reluctance, also in people with higher and incomplete and in a sense the consequences of inappropriate control, is
higher education. Different results were obtained in a study by very important for good compliance.20 Paradoxically, in the
Cuspidi et al, where it was demonstrated that among 66.6% of study group, the highest results were seen in elderly people,
the patients, regular BP measurements in a domestic setting including retired seniors and pensioners, who significantly
were more frequently taken by men, younger people, and those more frequently associated cerebral stroke and atherosclerosis
with higher education. Taking regular BP also contributed to with hypertension. Similarly, in a study by Egan et al32 con-
better control of BP, because in this group, lower levels of ducted in a group of more than 1500 adult Americans aged
systolic BP were noted.21-23 >50, as many as 94% of the respondents were convinced that
Michalska et al 531

cerebral stroke is the most common complication of hyperten- Funding

sion, 86% cited heart diseases, and 49% renal failure.32 Low The author(s) disclosed receipt of the following financial support for
level of knowledge regarding the complications of hypertension the research, authorship, and/or publication of this article: The study
was observed in our study among village residents, less-educated was funded by a grant from the Medical University of Lodz—for own
people, and unemployed. Therefore, this group should become research work contributing to young scientists’ and doctoral students’
the focus of more intense educational actions. development, no. 502-03/5-139-02/502-54-063.
A factor that considerably affects therapeutic success in
patients with hypertension is the patient’s quality of life. References
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patients’ general feeling and can also prevent them from more uncontrolled disease despite improved therapy. N Engl
performing their usual social roles, or worsen their financial J Med. 2009;361(9):878-887.
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perspective of many years, we should strive after a situation and fall of hypertension: lessons learned from Eastern Europe.
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Declaration of Conflicting Interests N, Kobus G, Dobrzycki S. Markers of kidney function in the
The author(s) declared no potential conflicts of interest with respect to elderly in relation to the new CKD-EPI formula for estimation
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