Does Hypertension Knowledge Influence Levels of Physical Activity in Hypertensive Patients From a Southern Brazilian Community?

Abstract

Background

Increased level of physical activity (PA) and health education are known as non-pharmacological treatments of hypertension (HP). There is a lack of studies investigating the influence of HP knowledge on the level of PA among hypertensive patients.

Objective

To examine the influence of patient’s knowledge about HP on PA level and the relationship between these variables.

Methods

A cross-sectional study was conducted in in a primary care center located in a city in the southern Brazil. A total of 199 hypertensive patients (median 61.2 [13] years; body mass index (BMI) 21.9 (7.5) kg/m2; 72.4% women) were included. The level of PA was assessed by measuring the number of steps taken daily. The knowledge about HP was assessed by a standardized questionnaire (HIPER-Q). The Kruskall-Wallis test was used to compare age, BMI and PA level between HP knowledge categories, and the Spearman test was used to assess correlations (p <0.05).

Results

The median score of knowledge about HP for patients categorized as insufficient (n=6, 3%), poor (n=24; 12.1%), acceptable (n=101; 50.8%) and good (n=68; 34.2%) was 11.0 (8.0), 20.0 (4.0), 26.0 (5.0) and 38.0 (2.0), respectively. No patient has achieved an “excellent” level of knowledge. There was no significant difference in PA level (p = 0.341), BMI (p = 0.510) or age (p = 0.073) between these categories. Age was negatively correlated with knowledge about HP (p <0.05 and rho = 0.02).

Conclusions

Patient’s knowledge about HP did not influence the level of PA in hypertensive patients. Age, number of steps per day and BMI were not significantly different between the categories of knowledge. Public policies and organizational strategy should be addressed to improve health education and avoid sedentary behavior in this population. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

Hypertension; Health Programs and Plans; Health Education; Exercise; Physical Activity; Epidemiology; Quality of Life; Blood Pressure

Introduction

Hypertension (HP) contributes significantly to the high prevalence of cardiovascular diseases (CVD), which are the main causes of mortality in the world.11. Roth GA, Forouzanfar MH, Moran AE, Barber R, Nguyen G, Feigin VL, et al. Demographic and epidemiologic drivers of global cardiovascular mortality. N Engl J Med. 2015;372(14):1333-41. It is believed that HP accounts for up to 7.6 million (12.8%) of total number of deaths each year.22. Carey RM, Whelton PK, 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, detection, evaluation, and management of high blood pressure in adults : synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Ann Intern Med. 2018;168(5):351-8.

Despite recent advances in the prevention and treatment of HP, the economic and health impacts of this condition have increased, with significant repercussions on public health worldwide.33. Oori MJ, Mohammadi F, Norozi K, Fallahi-khoshknab M, Ebadi A, Gheshlagh RG. Prevalence of HTN in Iran: meta-analysis of published studies in 2004- 2018. Curr Hypertens Rev. 2019;15(2):113-22. , 44. Ibrahim MM, Damasceno AA. Hypertension in developing countries. Lancet. 2012;380(9841):611-9. In this regard, strategies for the mitigation and control of hypertension, such as moderate to high levels of physical activity (PA), are recommended as important non-pharmacological approaches in the management of the disease.44. Ibrahim MM, Damasceno AA. Hypertension in developing countries. Lancet. 2012;380(9841):611-9.

A systematic review evaluated 96,073 hypertensive patients and showed that all-causes of mortality were inversely related to PA, and that walking was the most common mode of exercise.88. Pillay JD, Ploeg HP, Kolbe-alexander TL, Proper KI, Stralen M, Tomaz SA, et al. The association between daily steps and health , and the mediating role of body composition : a pedometer-based , cross-sectional study in an employed South African population. BMC Public Health. 2015;15(1):174. The practice of this exercise modality, complemented with the use of measurement tools, such as pedometers, has increased, as these are easy-to-handle and cheap devices.88. Pillay JD, Ploeg HP, Kolbe-alexander TL, Proper KI, Stralen M, Tomaz SA, et al. The association between daily steps and health , and the mediating role of body composition : a pedometer-based , cross-sectional study in an employed South African population. BMC Public Health. 2015;15(1):174. , 99. Hart TL, Swartz AM, Cashin SE, Strath SJ. How many days of monitoring predict physical activity and sedentary behaviour in older adults? Int J Behav Nutr Phys Act. 2011 Jun 16;8:62.

Some studies have shown that walking between 10,000 and 13,000 steps/day contributes to blood pressure lowering.1010. Iwane M, Arita M, Tomimoto S, Satani O, Matsumoto M, Miyashita K, et al. Walking 10,000 steps/day or more reduces pressure and sympathetic nerve activity mild essential hypertension. Hypertens Res. 2000;23(6):573-80. Thus, increases in PA are an important strategy in the prevention and treatment of HP,77. Rossi A, Dikareva A, Bacon SL, Daskalopoulou SS. The impact of physical activity on mortality in patients with high blood pressure: a systematic review. J Hypertens. 2012;30(7):1277-88. , 1313. Paula TP, Viana LV, Neto ATZ, Leitão CB, Gross JL, Azevedo MJ. Effects of the DASH diet and walking on blood pressure in patients with type 2 diabetes and uncontrolled hypertension : a randomized controlled trial. J Clin Hypertens. 2015;17(11):895-901.

14. Lee PH, Nan H, Yu Y, Mcdowell I, Leung GM, Lam TH. For non-exercising people , the number of steps walked is more strongly associated with health than time spent walking. J Sci Med Sport. 2013;16(3):227-30.
- 1515. Oka M, Yamamoto M, Mure K, Takeshita T, Arita M. Relationships between lifestyle , living environments , and incidence of hypertension in Japan (in men): based on participant’s data from the Nationwide Medical Check-Up. PLoS One. 2016;11(10):e0165313. although there is still a lack of studies investigating the effect of the use of pedometer-assessed PA in hypertensive patients.

Understanding lifestyle behaviors among individuals with HP is important to achieve hypertension control and to determine contributing factors to knowledge and treatment.66. Malachias MVB, Souza W, Plavnik F, Rodrigues C, Brandão A, Neves M, et al. 7a Diretriz Brasileira de Hipertensão Arterial: Capítulo 1 - conceituação, epidemiologia e prevenção primária. Arq Bras Cardiol. 2016;107(3 supl 3):1-103. , 77. Rossi A, Dikareva A, Bacon SL, Daskalopoulou SS. The impact of physical activity on mortality in patients with high blood pressure: a systematic review. J Hypertens. 2012;30(7):1277-88. Although significant progress has been made in HP detection and control, up to 70% of diagnosed hypertensive patients do not have adequate blood pressure control.55. Guimarães Filho GC, Sousa ALL, Jardim TSV, Souza WSB, Jardim PCBV. Progression of blood pressure and cardiovascular outcomes in hypertensive patients in a reference center. Arq Bras Cardiol. 2015;104(4):292-8.

Knowledge of hypertension is associated with and considered co-responsible for treatment success. Patients participating in educational procedures can take better care of their own health.1616. Kayaniyil S, Ardern C, Winstanley J, Parsons C, Brister S, Oh P, et al. Degree and correlates of cardiac knowledge and awareness among cardiac inpatients. Patient Educ Couns. 2009;75(1):99-107.

Maruf et al.1717. Maruf FA, Ojukwu CC, Akindele MO. Perception, knowledge, and attitude toward physical activity behaviour: implications for participation among individuals with essential hypertension. High Blood Press Cardiovasc Prev. 2018;25(1):53-60. demonstrated that hypertensive patients had good knowledge about PA behavior, positive attitude in terms of benefits, importance and involved risk, in addition to a high level of participation. There were significant correlations between knowledge about PA, attitude towards PA and participation in PA.1717. Maruf FA, Ojukwu CC, Akindele MO. Perception, knowledge, and attitude toward physical activity behaviour: implications for participation among individuals with essential hypertension. High Blood Press Cardiovasc Prev. 2018;25(1):53-60. However, to the best of our knowledge no study investigated whether hypertension knowledge influences the level of PA. Thus, the aim of this study was to examine the influence of hypertension knowledge on PA level and the relationship between these variables in hypertensive patients in a primary care center in southern Brazil.

Methods

In this cross-sectional study, 199 hypertensive individuals attending a primary care center in a city of southern Brazil were included in the study. In 2015, 921 hypertensive patients, representing 16.5% of the city’s total population, were enrolled in this primary care unit. The sample size estimation was performed by proportion approximation, based on the work of Lwanga and Lemeshow.1818. Lwanga S, Lemeshow S. Sample size determination in health studies: a practical manual. vol. 20, Statistics in Medicine. Geneva: World Health Organization; 2001. p. 859-66.

Estimates of proportions were made as follows: n= (1- α)2 (p) (1-p)/(d)X(d), where “p” indicates the prevalence of the disease in the population (16.5%); 1-p is the proportion of individuals without the disease (83.5%); 1- α is the level of confidence (95%; z=1.96), and “d” is the required accuracy (0.05). Therefore, the calculated sample was 211 hypertensive patients. A total of 302 individuals were invited to participate in the study, but 105 were excluded because of missing data (n=82) or because they did not meet the inclusion criteria (n=23). Therefore, the number of volunteers was lower than the calculated value, also because the researchers had a limited time to assess these patients.

The inclusion criteria were a) diagnosis of hypertension; b) age older than 18 years; and c) clinical follow-up lower than three months in the primary care center. The diagnosis was defined according to the VII Brazilian Guidelines on Hypertension (systolic and diastolic blood pressure levels, respectively): (1) office blood pressure ≥ 140 and/or 90 mmHg; ambulatory blood pressure ≥ 130 and/or 80 mmHg; (3) home blood pressure ≥ 135 and/ or ≥ 85 mmHg.77. Rossi A, Dikareva A, Bacon SL, Daskalopoulou SS. The impact of physical activity on mortality in patients with high blood pressure: a systematic review. J Hypertens. 2012;30(7):1277-88. Individuals with cognitive impairment to answer the questionnaire, or musculoskeletal and neurological impairments to walk were excluded.

The study was conducted for six months, and all the study procedures and patient inclusion being performed weekly. The study design followed 466/12 resolution of the Brazilian National Health Council and was approved by the Ethics Committee on research involving human beings of Santa Catarina State University, under the protocol n. 689798/2014. All patients signed an informed consent form.

Sociodemographic and personal data were collected using a specific form. Anthropometric evaluations were also performed; body mass was measured using a digital scale (Filizola PL 180) with a resolution of 0.1kg, and height was measured using a wall-mounted stadiometer (ate the nearest 1.0 cm). These measurements were performed as described by Alvarez and Pavan.1919. Alvarez B, Pavan A. Alturas e comprimentos. In: Antropometria: técnicas e padronizações. 5a ed. Várzea Paulista: Fontoura; 2011. p. 31-44. Body Mass index (BMI) was classified based on the World Health Organization (WHO) recommendations: normal weight (BMI < 25 kg/m2), overweight (25 kg/m2 ≤ BMI < 30 kg/m2) and obesity (BMI ≥ 30 kg/m2).2020. World Health Organization. Physical status: the use and interpretation of anthropometry. vol. 854, World Health Organization technical report series. Geneva: WHO; 1995. p. 1-452.

To assess the level of knowledge about hypertensive disease, the HIPER-Q instrument was applied. It consists of 17 questions that encompass seven areas regarding patient education: self-care, treatment, diagnosis, PA, concept and pathophysiology, signs and symptoms and risk factors. For each item, one answer is considered the "most correct" and receives a score of 3, and another answer is considered "partially correct" and receives a score of 1. The other two options - the incorrect and the "I don't know" option – are assigned a score of 0. After completion of all questions, the sum of the scores obtained represent the average total knowledge, and the maximum score of 51 points represents the “perfect” knowledge.2121. Santos RZ, Bonin CDBB, Martins ETC, Pereira Junior M, Ghisi GLM, Macedo KRP, et al. Development and psychometric validation of HIPER-Q to Assess knowledge of hypertensive patients in cardiac rehabilitation. Arq Bras Cardiol. 2018;110(1):60-7.

Finally, the level of PA was assessed using a pedometer (Power Walker TM® Model PW-610/611). The equipment was programmed to store the number of steps taken for 24 hours. The number of steps were registered for four days, and the mean was used for analysis. A number <5,000 steps per day indicated a "sedentary" lifestyle; between 5,000 and 9,999 steps per day indicated "low-active"; ≥10,000 steps per day "active", and >12,500 steps per day "very active".2222. Tudor-Locke C, Bassett Jr DR. How many steps/day are enough? Sport Med. 2004;34(1):1-8.

Statistical Analysis

Data were analyzed descriptively using Statistical Package for the Social Sciences (SPSS), version 20.0. The Kolmogorov-Smirnov test was used, which showed that the data did not follow a normal distribution. Absolute and relative frequencies were used for categorical variables and median and interquartile range for continuous variables. The Spearman's correlation was used to test the correlation of knowledge about HP with age, BMI and PA level. To compare PA level, age and BMI between different categories of HP knowledge, the Kruskall-Wallis test was used. All statistical tests adopted a significance level of 5% (p<0.05).”

Results

Sociodemographic data, BMI, PA level, and patient’s knowledge about HP are described in Table 1 . Of the 199 patients included, 144 (72.4%) were women and 55 were men (27.6%). Median knowledge about HP was 32 (10) points, which means acceptable knowledge according to HIPER-Q.2121. Santos RZ, Bonin CDBB, Martins ETC, Pereira Junior M, Ghisi GLM, Macedo KRP, et al. Development and psychometric validation of HIPER-Q to Assess knowledge of hypertensive patients in cardiac rehabilitation. Arq Bras Cardiol. 2018;110(1):60-7.

Table 1
– Sociodemographic data, body mass index, physical activity level, and patient’s knowledge about hypertension (n=199)

The correlation tests of knowledge about HP with age, BMI and level of PA are illustrated in Table 2 . Age was negatively related to HP knowledge, but the correlation found was very weak and the correlation coefficient between the variables was rho=0.02.

Table 2
– Correlation of knowledge about hypertension with age, body mass index and physical activity level (n=199)

Comparison of PA level, BMI and age between different HP knowledge categories are presented in Table 3 . No significant difference was found between KHP groups.

Table 3
– Levels of patient’s knowledge about hypertension by age, body mass index, and level of physical activity

Discussion

The present study examined the influence of HP knowledge on PA level and the relationship between these variables in hypertensive patients. The results showed that there was no significant difference between different levels of HP knowledge and the number of steps taken per day, which means that the knowledge about the disease does not seem to be determinant to increase PA level in these individuals.

Despite the well-established literature on the importance of knowledge about the disease as a strategy to promote better blood pressure control and cardiovascular prognosis, there is still a lack of studies correlating this knowledge with other variables, such as PA. Some authors found that only 13.6% of hypertensive patients evaluated in cardiology outpatient clinics identified physical inactivity as a risk factor for HP. This could result from the perception of these patients that changes in lifestyle have no impact on high blood pressure management.2323. Bilal M, Haseeb A, Lashkerwala SS, Zahid I, Siddiq K, Saad M, et al. Knowledge , awareness and self-care practices of hypertension among cardiac hypertensive patients. Glob J Health Sci. 2015;8(2):9-19.

Iyalomhe and Iyalomhe 2424. Iyalomhe GBS, Iyalomhe SI. Hypertension-related knowledge , attitudes and life-style practices among hypertensive patients in a sub-urban Nigerian community. J Public Health Epidemiol. 2010;2(4):71-7. demonstrated a low level of knowledge on HP, ineffective attitudes towards treatment and adoption of inappropriate lifestyles in a study with 108 patients undergoing antihypertensive treatment. In addition, only 10 patients (9.3%) reported practicing physical exercises regularly.2424. Iyalomhe GBS, Iyalomhe SI. Hypertension-related knowledge , attitudes and life-style practices among hypertensive patients in a sub-urban Nigerian community. J Public Health Epidemiol. 2010;2(4):71-7. On the other hand, qualitative research exploring the knowledge of hypertensive patients about cardiovascular risk factors showed that even though patients were aware of the importance of PA for their health, the majority declared to be insufficiently active.2525. Espejo M, Magabo S, Rivera-Castro A, Faiz M, Ramirez L, Robles C, et al. Qualitative Study of knowledge, perception , and behavior related to hypertension and cardiovascular disease risk reduction among hypertensive african-americans in urban inner city of South Bronx , New York. J Racial Ethn Health Disparities. 2019;6(1):197-206. A possible reason for this is a gap in the knowledge about effective strategies for modifying cardiovascular risk factors. Furthermore, resistance to the adoption of healthy lifestyles, even by patients with good knowledge on the disease, may indicate that the expectations about the results are relatively low, that is, these patients are not confident that PA actually improves health.2626. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the health belief model. Health Educ Q. 1988;15(2):175-83.

An educational program intervention had a significant impact on both mean levels of knowledge and adherence to healthier habits by patients with coronary artery disease (CAD) .2727. Tawalbeh LI, Ahmad MM. The effect of cardiac education on knowledge and adherence to healthy lifestyle. Clin Nurs Res. 2014;23(3):245-58.

In the same manner, significant associations were found between some aspects of health literacy and increased levels of PA in patients diagnosed with acute myocardial infarction, stroke or angina pectoris.2828. Aaby A, Friis K, Christensen B, Rowlands G, Maindal HT. Health literacy is associated with health behaviour and self-reported health : a large population-based study in individuals with cardiovascular disease. Eur J Prev Cardiol. 2017;24(17):1880-8. Significant positive correlations were also found between the level of knowledge about risk factors for coronary disease and PA level in patients who underwent cardiovascular procedure or event.2929. Alm-Roijer C, Stagmo M, Udén G, Erhardt L. Better knowledge improves adherence to lifestyle changes and medication in patients with coronary heart disease. Eur J Cardiovasc Nurs. 2004;3(4):321-30. On the other hand, a recent research conducted in China showed that patients with a higher level of knowledge about cardiovascular disease were more likely to not adhere to a healthy lifestyle, including the practice of PA.3030. Lu M, Xia H, Ma J, Lin Y, Zhang X, Shen Y, et al. Relationship between adherence to secondary prevention and health literacy , self-efficacy and disease knowledge among patients with coronary artery disease in China. Eur J Cardiovasc Nurs. 2020;19(3):230-7. The authors attributed these findings to the possibility that patients with a lower level of knowledge may have followed physicians’ advice without questioning, which may also have been influenced by socioeconomic factors.

In our study, the median of steps/day was 9,138, without difference between men and women. Although these patients were classified as low-active,2222. Tudor-Locke C, Bassett Jr DR. How many steps/day are enough? Sport Med. 2004;34(1):1-8. these findings exceed those found in another study where, after four weeks of dietary changes and increase in PA levels, the hypertensive and diabetic patients had a median of 4,043 steps,1313. Paula TP, Viana LV, Neto ATZ, Leitão CB, Gross JL, Azevedo MJ. Effects of the DASH diet and walking on blood pressure in patients with type 2 diabetes and uncontrolled hypertension : a randomized controlled trial. J Clin Hypertens. 2015;17(11):895-901. the half of the daily steps registered in the present study. Another study, in which 75% of the respondents were women, reported that diabetics and hypertensive patients submitted to a health literacy program walked 11,686 daily steps,3131. Leung AYM, Chau PH, Leung ISH, Tse M, Wong PLC, Tam WM, et al. Motivating diabetic and hypertensive patients to engage in regular physical activity : a multi-component intervention derived from the concept of photovoice. Int J Environ Res Public Health. 2019;16(7):1219. a similar quantity to that found in males in our study. Other researchers demonstrated that women performed a mean of 7,453 steps per day.3232. Santos M, Araújo T, Cruciani F, Silva L, Andrade E, Matsudo V. Standard steps of hypertension women in strategy family health program. Rev Bras Ci e Mov. 2011;19(1):5-10.

Another study conducted in Hong Kong showed that physically inactive people used to walk 8,147 steps daily, and the number of steps taken was negatively associated with health complications, such as HP.1414. Lee PH, Nan H, Yu Y, Mcdowell I, Leung GM, Lam TH. For non-exercising people , the number of steps walked is more strongly associated with health than time spent walking. J Sci Med Sport. 2013;16(3):227-30. These results became relevant since the number of daily steps seems to be inversely correlated with the incidence of HP and, possibly, other cardiovascular outcomes.1414. Lee PH, Nan H, Yu Y, Mcdowell I, Leung GM, Lam TH. For non-exercising people , the number of steps walked is more strongly associated with health than time spent walking. J Sci Med Sport. 2013;16(3):227-30. , 1515. Oka M, Yamamoto M, Mure K, Takeshita T, Arita M. Relationships between lifestyle , living environments , and incidence of hypertension in Japan (in men): based on participant’s data from the Nationwide Medical Check-Up. PLoS One. 2016;11(10):e0165313.

Hypertensive patients with low level PA are a concern, since insufficient PA represents the fourth risk factor for mortality worldwide, with more than 3.2 million deaths per year and 32.1 million quality-adjusted life years (QALYs).3333. World Health Organization. Prevalence of insufficient physical activity [Internet]. Global Health Observatory data. [acesso 5 fev 2020]. Disponível em: https://www.who.int/gho/ncd/risk_factors/physical_activity_text/en/#
https://www.who.int/gho/ncd/risk_factors...
Therefore, the benefits of regular PA are significant for individuals with cardiovascular risk factors, such as HP, as it can reduce mortality by up to 16%.3434. Wen CP, Wai JPM, Tsai MK, Yang YC, Cheng TYD, Lee M, et al. Minimum amount of physical activity for reduced mortality and extended life expectancy : a prospective cohort study. Lancet. 2011;378(9798):1244-53.

Although our results indicated a weak correlation between the level of knowledge about HP and age of patients, there was no significant difference in age between different categories of knowledge. This result could be explained by the high percentage of patients in the same age group (70% were between 50 and 70 years old). Conversely, a study based on WHO data regarding global aging and adult health, examined patterns of prevalence of HP in low and middle-income countries and found that awareness of the disease was associated with older age.3535. Lloyd-Sherlock P, Beard J, Minicuci N, Ebrahim S, Chatterji S. Hypertension among older adults in low-and-middle-income countries: prevalence, awareness and control. Int J Epidemiol. 2014;43(1):116-28. Another study demonstrated that knowledge and awareness about HP are different between the elderly and high school students, suggesting that there might exist a generational difference in knowledge about the disease.3636. Sanagawa A, Ogasawara M, KuHPara Y, Yasumoto M, Iwaki S, Fujii S. Investigation into differences in level of knowledge about hypertension between high school students and elderly people. Yakugaku Zasshi. 2017;137(6):783-9. Besides, the fact that HP increases with age may contribute to the relationship between age and HP knowledge.

It is well established that obesity and a sedentary lifestyle are associated with cardiovascular risk factors, including HP.66. Malachias MVB, Souza W, Plavnik F, Rodrigues C, Brandão A, Neves M, et al. 7a Diretriz Brasileira de Hipertensão Arterial: Capítulo 1 - conceituação, epidemiologia e prevenção primária. Arq Bras Cardiol. 2016;107(3 supl 3):1-103. , 3737. Luz RH, Barbosa AR, d’Orsi E. Waist circumference, body mass index and waist-height ratio: are two indices better than one for identifying hypertension risk in older adults? Prev Med. 2016 Dec;93:76-81. This was confirmed by characteristics of our study population, with a high percentage of inactive individuals (42.7%) and even higher percentage of overweight or obese hypertensive patients (72.4%).

However, no significant differences were found in BMI between the categories of knowledge about HP. Corroborating our findings, Knuth et al.,3838. Knuth AG, Bielemann RM, Silva SG, Borges TT, Duca GF, Kremer MM, et al. Public knowledge on the role of physical activity in the prevention and treatment of diabetes and hypertension: a population-based study in southern Brazil. Cad Saude Publica. 2009;25(3):513-20. demonstrated an association between knowledge about the effects of PA on hypertension prevention and BMI; however, BMI was not associated with knowledge of the effects of PA on the treatment of HP and type 2 diabetes. This may have been due to the prevalence of these diseases be higher in individuals with a higher BMI.3838. Knuth AG, Bielemann RM, Silva SG, Borges TT, Duca GF, Kremer MM, et al. Public knowledge on the role of physical activity in the prevention and treatment of diabetes and hypertension: a population-based study in southern Brazil. Cad Saude Publica. 2009;25(3):513-20.

With respect to knowledge about HP, most patients (50.8%) were classified in the category of “acceptable knowledge”. These results are similar to those of other studies2121. Santos RZ, Bonin CDBB, Martins ETC, Pereira Junior M, Ghisi GLM, Macedo KRP, et al. Development and psychometric validation of HIPER-Q to Assess knowledge of hypertensive patients in cardiac rehabilitation. Arq Bras Cardiol. 2018;110(1):60-7. , 3939. Dawes MG, Kaczorowski J, Swanson G, Hickey J, Karwalajtys T. The effect of a patient education booklet and BP “tracker” on knowledge about hypertension. a randomized controlled trial. Fam Pract. 2010;27(5):472-8. and reflect the importance of assessing knowledge about health and formulating hypotheses that may elucidate the determining factors for information gaps. It is also noteworthy that no patient presented an optimal level of knowledge about the disease, according to the classification of the instrument.2121. Santos RZ, Bonin CDBB, Martins ETC, Pereira Junior M, Ghisi GLM, Macedo KRP, et al. Development and psychometric validation of HIPER-Q to Assess knowledge of hypertensive patients in cardiac rehabilitation. Arq Bras Cardiol. 2018;110(1):60-7.

Therefore, patient knowledge is a central component in the treatment of HP and is associated with successful self-management of the disease and behavioral changes.1616. Kayaniyil S, Ardern C, Winstanley J, Parsons C, Brister S, Oh P, et al. Degree and correlates of cardiac knowledge and awareness among cardiac inpatients. Patient Educ Couns. 2009;75(1):99-107. , 4040. Chaves GSS, Ghisi GLM, Grace SL, Oh P, Ribeiro AL, Britto RR. Effects of comprehensive cardiac rehabilitation on functional capacity and cardiovascular risk factors in Brazilians assisted by public health care: protocol for a randomized controlled trial. Braz. J. Phys. Ther. 2016 Nov-Dec; 20(6):592-600. Health education interventions can result in significant reductions in risk factors associated with lifestyle diseases, such as HP.4141. Alves E, Costa AR, Ferreira PM, Azevedo A, Lunet N. Health-related knowledge on hypertension among the Portuguese population: results from a population-based survey. Blood Press. 2018;27(4):194-9. Thus, the WHO3333. World Health Organization. Prevalence of insufficient physical activity [Internet]. Global Health Observatory data. [acesso 5 fev 2020]. Disponível em: https://www.who.int/gho/ncd/risk_factors/physical_activity_text/en/#
https://www.who.int/gho/ncd/risk_factors...
recommends that health promotion strategies should be designed to improve knowledge about health and self-management of the disease, beyond the adoption of healthy lifestyles. Therefore, understanding the barriers to obtaining adequate knowledge on HP can contribute to the overall improvement of prevention and management of this condition, with implications for clinical practice.4141. Alves E, Costa AR, Ferreira PM, Azevedo A, Lunet N. Health-related knowledge on hypertension among the Portuguese population: results from a population-based survey. Blood Press. 2018;27(4):194-9.

We did not find longitudinal studies in the literature demonstrating the effects of the higher level of knowledge about HP on outcomes, such as worse prognosis or mortality. In this context, studies on other chronic diseases have shown promising results, suggesting that disease-related education may be determinant in the control of risk factors, such as sedentary lifestyle, smoking and continuity of treatment, which can lead to reductions in comorbidities, health costs and even mortality 4242. Schwarzer R, Lippke S, Luszczynska A. Mechanisms of health behavior change in persons with chronic illness or disability : the health action process approach (HAPA). Rehabil Psychol. 2011;56(3):161-70. , 4343. Ghisi GLM, Abdallah F, Grace SL, Thomas S, Oh P. A systematic review of patient education in cardiac patients: do they increase knowledge and promote health behavior change? Patient Educ Couns. 2014;95(2):160-74. Thus, we expect that our findings can be used as a basis for future studies.

Caution is needed with the interpretation of the results, since this work has some limitations. First, it is notable that our research presents a cross-sectional design, thus hindering the relationships of causalities and effects between the variables. Second, in our population, there were some patients that performed physical exercises on a regular basis, which was not controlled in this research. Third, the instrument used to assess the level of PA, the pedometer, does not allow detecting activities performed with upper limbs or sedentary time and does not measure the intensity and duration of PA. Although this equipment has been widely used to evaluate PA levels, these points limit the extrapolation of the results.

Conclusion

In summary, our results showed that level of knowledge about HP did not influence the level of PA in hypertensive patients from a primary care unit in the south of Brazil. Age, number of steps per day and BMI was not significantly different between four HP knowledge categories. Health education should be emphasized as a strategy to improve knowledge and promote behavior change among hypertensive patients. Public policies and organizational strategy should be addressed to improve health education and avoid sedentary behavior among hypertensive patients.

References

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  • Study Association
    This study is not associated with any thesis or dissertation work.
  • Ethics Approval and Consent to Participate
    This study was approved by the Ethics Committee of the Universidade do Estado de Santa Catarina under the protocol number 689789/2014. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study.

  • Sources of Funding: This study was funded by Fundação de Amparo à Pesquisa e Inovação do Estado de Santa Catarina.

Publication Dates

  • Publication in this collection
    09 June 2021

History

  • Received
    26 May 2020
  • Reviewed
    15 Oct 2020
  • Accepted
    15 Dec 2020
Sociedade Brasileira de Cardiologia Avenida Marechal Câmara, 160, sala: 330, Centro, CEP: 20020-907, (21) 3478-2700 - Rio de Janeiro - RJ - Brazil
E-mail: sbc@cardiol.br