Promoção , prevenção e cuidado da hipertensão arterial no Brasil Promotion , prevention and arterial hypertension care in Brazil

MÉTODOS: Estudo epidemiológico transversal de base populacional realizado por meio de entrevista com 12.324 adultos, de 20 a 59 anos, em 100 municípios brasileiros. As variáveis independentes, consideradas como promoção, prevenção e cuidado, foram: ter recebido orientações sobre a manutenção do peso ideal e sobre atividade física; ter consultado um médico e ter realizado eletrocardiograma no último ano. Pressão arterial acima de 140/90 mmHg foi considerada estado descompensado, sendo a variável dependente para a avaliação da qualidade do cuidado.


INTRODUCTION
The increase in blood pressure is a sign of manifestation of a specifi c disease in secondary hypertension (HTN), corresponding to 5% of cases.In the case of primary or essential HTN, it is a sign that a set of factors is affecting the cardiovascular system, corresponding to the remaining 95% of HTN cases.In these cases, its manifestation and severity are infl uenced by factors such as the amount of salt in the diet, physical activity pattern, body weight control, smoking and co-morbidities such as diabetes mellitus. 15Thus, health promotion actions, disease prevention and clinical care are required to approach this condition. 10The directives that guide these initiatives are well-established and widely disseminated.][8][9]13 A recent study pointed to the following quality indicators to approach HTN: measuring blood pressure at least once a year and providing guidance on body weight control, physical activity and a low-salt diet. 1 The directives recommended by the Brazilian national policy a and by authors who represent the British Hypertension Society 15 were considered to assess HTN care for adults in Brazil.A previous study found a significant association between diastolic blood pressure and the variables that represent the care process and concluded that, despite the efforts made to develop methods that assess medical care quality, none of them was fully satisfactory. 9Care provided by the same doctor throughout time is a variable significantly associated with compensated blood pressure. 11apacity building and sensitization of primary health care professionals increase the adoption of practices such as guidance on risk factors and assessment of target HTN services, variables considered to be health care qualifi ers. 3 The present study aimed to estimate the prevalence of promotion, prevention and hypertension care actions for adults in Brazil and to identify its association with decompensated hypertension.

METHODS
A population-based cross-sectional epidemiological study was conducted between 2008 and 2009.The target population was representative of the Brazilian population, comprised of adults aged between 20 and 59 years, living in private homes in the urban area of 100 cities in Brazil.
The sample was obtained in a complex process on multiple levels: a) population in fi ve categories: 1) < 10,000 inhabitants; 2) 10,000 < 20,000 inhabitants; 3) 20,000 < 100,000 inhabitants; 4) 100,000 < 1.1 million inhabitants; and 5) more than 1.1 million inhabitants; b) census tracts; and c) households. 14The territorial division and network of census tracts used in the 2000 Demographic Census of the Instituto Brasileiro de Geografi a e Estatística (IBGE -Brazilian Institute of Geography and Statistics) was adopted to select cities and urban census tracts.The number of sectors selected in each city was proportional to the number of valid sectors and population size.Individuals who were not legally free or who lived in long-term institutions were excluded from this study.
The parameters for the association tests used a power of 80%, 95% confi dence level and ratio of exposure of 1:4; prevalences of outcome from 15% to 60% in the non-exposed group, prevalence ratio of 1.3 and an additional 10% for losses and 15% for confounding factors.Considering the design effect of 2.4, a sample comprised of 10,200 adults was estimated to be sufficient to meet the needs.
The defi nition of the number of individuals to be located in each urban census tract (standard unit of population group) considered a mean concentration of 1.94 adults aged from 20 to 59 years per urban household.d Households were selected in all sectors by systematically ignoring 30 households with a random beginning.All eligible adults were studied in each household.
The inclusion criterion for the category of participant having HTN was to have received a medical diagnosis of this condition, whose predictive positive value is 73.9%, 6 when compared to the diagnosis performed by measuring blood pressure, considered to be the gold standard.The mean to defi ne the outcome was obtained in different moments during the interview using two blood pressure measurements made with a Geratherm Wristwatch Medical AG blood pressure monitor, considering mean blood pressures higher than 140/90 mmHg to be decompensated. 15x, age, place of residence, economic classifi cation e and level of education were used in the analysis of quality of care behavior.The independent variables considered as promotion, prevention and care were as follows: to have consulted a doctor in the previous year, to have received guidance on ideal weight maintenance; to have received guidance on physical activity; and to have had an electrocardiogram (EKG) performed in the previous year.A blood pressure higher than 140/90 mmHg was considered to be decompensated, being the dependent variable used to assess quality of care (Figure).

Self-reporting hypertension based on an informed medical diagnosis was validated by
Brazilian authors in a recent study. 6Likewise, the variables adopted to indicate health promotion, prevention and care were similar to those used by authors in North America in the last decade as well. 1 In addition to the questionnaire application and blood pressure measurements, weight (Geratherm digital scale) and height (WISO T87 measuring tape) were assessed, thus enabling objective and standardized measurements.All pieces of equipment were of proven quality and their use was authorized by the Agência Nacional de Vigilância Sanitária (Anvisa -National Health Surveillance Agency) and Instituto Nacional de Metrologia, Qualidade e Tecnologia (Inmetro -National Institute of Metrology, Quality and Technology).
Data were recorded electronically in a Personal Digital Assistant (PDA).At the end of each day of research, PDA data were stored into a portable computer and subsequently sent to the server located at the research headquarters via Internet.This technology also enabled participants' homers to be located by Global Positioning System (GPS), used as fi eld work quality control.Data were stored and analyzed in Stata 10.0.
Bivariate analysis was performed to compare proportions, using the chi-square test with a 5% signifi cance level.Crude and adjusted prevalence ratios with 95% confi dence intervals were calculated using Poisson regression, 5 according to a hierarchical analysis model (Figure).The following variables were included at the most distal level: sex, age, geographic region, socioeconomic class and level of education; at the second level: to have consulted a doctor about HTN and to have received guidance on health promotion; and at the third level: to have had an EKG performed.
This study was approved by the Research Ethics Committee of the Universidade Federal de Pelotas, according to protocol number 152/07 of November 23 rd , 2007.All participants signed an informed consent form.

RESULTS
A total of 12,324 adults were interviewed in the 100 cities of the sample, of which 16.3% (2,004) reported a medical diagnosis of HTN.There were no differences in the distribution of hypertensive individuals by sex among Brazilian regions.The distribution by age showed higher proportions of hypertension in the 50 to 59 year age group, concentrated in the Southeast and Central-West regions, whereas the lower frequency The proportion of individuals with hypertension who had no formal education in the Northeast region was higher than that found in the remaining regions, followed by the North and Central-West regions.In the latter region, the lowest proportion of adults with hypertension who had not completed one year of school was observed (Table 1).
Among this sample comprised of 1,995 individuals with hypertension, 1,318 (66.1%) had consulted a doctor about HTN in the previous year.Of these, 682 (52.4%) had had an EKG performed to monitor the heart as a target organ of HTN.The blood pressure of 1,495 participants with HTN (74.6%) of this sample was measured in this study, of which 634 (42.4%) had values higher than the normal limits and were thus considered to be decompensated.
The proportion of adults with HTN who had consulted a doctor in the previous year was signifi cantly higher (p < 0.000) among women (69.0%) than men (61.5%).
When stratifi ed by age, the proportion of adults who had consulted a doctor in the previous year was 59.9% in the 20 to 29 year age group, 56.8% in the 30 to 39 year age group, 64.4% in the 40 to 49 year age group, and 72.1% in the 50 year and more age group, and these differences were signifi cant (p < 0.000).In addition, the results of this study also showed signifi cant regional differences (p= 0.03), with higher frequencies in the North (76.3%) and Central-West regions (70.5%), whereas the overall sample had a lower value (66.1%).
The stratifi cation of this variable by socioeconomic classes did not show signifi cant differences.When the stratifi cation was performed by level of education in number of years of school completed, those with 12 or more years of school had consulted a doctor with a signifi cantly higher frequency (p = 0.01) (72.0%) than the overall sample (66.0%).
The majority (87.2%) of adults with hypertension monitored their weight.Almost half (45.4%) received guidance on ideal weight maintenance, of which 77.8% attempted to follow this guidance.One third of them (31.6%) reported having had problems with excessive weight in the previous year; an even higher proportion (38.5%) had a body mass index that indicated obesity.
Guidance on ideal body weight did not show signifi cant difference in prevalence (p = 0.37) between men and women, nor among the different age groups (p = 0.10  To have consulted a doctor about systemic arterial hypertension

Geographic region
Age Sex year age group, 56.2% in the 40 to 49 year age group and 53.9% in the 50 year and more age group.This monitoring was signifi cantly (p = 0.004) more frequent in the Southeast region (58.5%), when compared to the general prevalence of the sample (52.4%).The prevalence of monitoring was signifi cantly (p < 0.000) higher among those of socioeconomic class A (74.5%), when compared to the overall sample (52.6%).Those The proportion of individuals with decompensated HTN (p < 0.000) differed between men and women and, regardless of sex, the lowest prevalence was in the 30 to 39 year age group (31.0%) and the highest one was in the 50 year and more age group (46.4%).
The lowest prevalence of participants with decompensated HTN was found in the Southeast region (37.1%),signifi cantly (p = 0.001) lower than the overall sample (42.4%), whereas the highest prevalence (50.7%) was observed in the South region.There were no differences according to socioeconomic class.There was a signifi cantly lower prevalence (p = 0.01) of individuals with decompensated HTN among those with 12 or more years of school (32.0%) than the overall sample (42.4%), while a higher prevalence was found among those with no formal education.The relationship between having consulted a doctor in the previous year and decompensated blood pressure values did not show signifi cant differences (p = 0.789).The proportion of individuals with decompensated hypertension was signifi cantly lower among adults who had received guidance on ideal weight maintenance (p = 0.028), those who had received guidance on physical activity practice (p = 0.032) and those who had had an EKG performed (p = 0.014) (Table 2).
The crude and adjusted analyses showed an association between having decompensated HTN and the following: being male, being aged more than 40 years and living in the South region (Table 2).

DISCUSSION
The prevalence of decompensated hypertension in this study (42.4%) was lower than that found in a study conducted in the United States (58%). 2 The positive association between lower proportions of decompensated blood pressure values and ideal weight maintenance, physical activity practice and EKG identifi ed in the crude analysis suggests that these actions may represent positive clinical care markers of HTN.
In the present sample, level of education was more sensitive to the differences in HTN care than economic classification, despite the heterogeneous social composition in terms of socioeconomic class and level of education. 2Only half of the individuals with hypertension had an EKG performed in the previous year, a result similar to that found in a study conducted in Saudi Arabia that included 47% of participants with decompensated HTN and where the EKG was one of the procedures least frequently performed. 4ly half of the sample received guidance on ideal weight maintenance and physical activity practice, thus confi rming literature data and contributing to the loss of effectiveness of management of this health condition.Relatively low frequencies such as these are in agreement with the still relevant prevalences of obesity and sedentary habits which should consequently be the focus of concern for public health agents. 12Ideal weight maintenance stands out as a minor impact that these types of guidance have on the behavioral changes expected from each of them, because to have received such guidance was positively associated with the lower prevalence of decompensated blood pressure.
The lack of association between having consulted a doctor in the previous year and decompensated blood pressure values was a curious and apparently contradictory fi nding with previously published evidence. 11he independent variable in this study 11 was "to have consulted the same doctor" and that of the present study was "to have consulted a doctor", regardless of being the same one or not, which may represent a difference in adherence to the recommended measures.
Special attention should be given to the result of the multiple analysis in which the independent variables that remained associated with decompensated blood pressure were: being male, being in the 40 to 49 year age group or 50 year and more age group, and living in the South region of Brazil.Each variable represents a synthetic concept that, as such, includes several attributes.Consequently, with the study design adopted, this makes it impossible to accurately identify factors susceptible to an intervention that reduce the prevalence of decompensated blood pressure.
Finally, health prevention and promotion actions aimed at this population are small.New studies with a national scope and an appropriate design such as multicenter cohort studies are required to study the possible determinants that cause decompensated blood pressure in these conceptual components.

Figure .
Figure.Model of analysis of quality of care in systemic arterial hypertension in the adult population.Brazil, 2010.

Table 1 .
Distribution of the adult population with systemic arterial hypertension by ethnicity, sex, age, socioeconomic classifi cation and level of education, according to geographic region.Brazil, 2010.HTN in this age group was found in the Northeast region (40.7%).Almost half of the sample of Brazilians with hypertension belonged to socioeconomic class C; a higher proportion of individuals of classes D and E in the North and Northeast regions contrasted with the higher proportion of individuals of classes A and B in the South, Southeast and Central-West regions. of

Table 2 .
Measures of association between independent variables and outcome (decompensated systemic arterial hypertension).Brazil, 2010.