Abstract

Objectives:

Evaluate the prevalence of self-reported hypertension in adults aged 20 to 59 years as well as identify associated factors, the use of health services and disease control practices according to the possession or not of a private healthcare plan.

Methods:

A population-based, cross-sectional study was conducted in the city of Campinas, Brazil, involving 957 adults.

Results:

The prevalence of self-reported hypertension was 14.1%, with greater frequencies found among women, individuals aged ≥ 40 years, those who declared their skin color to be black, those with less schooling, those who did not practice active leisure activities, ex-smokers, overweight or obese individuals and those who rated their own health as not being excellent/very good. No inequalities were detected between individuals with hypertension covered by a private healthcare plan or the Brazilian public healthcare system with regard to access to services, the use of disease-controlling medications and having received counseling on how to manage the disease. However, differences were found regarding the practice of physical activity and diet.

Conclusion:

Despite the equity disclosed in access to health care, the present findings demonstrate that an insufficient proportion of adults adopt changes in lifestyle to control hypertension, underscoring the central role of public health administrators.

Key words
Hypertension; Adult health; Epidemiological surveys; Population groups

Introduction

Chronic non-communicable diseases account for 72% of deaths in Brazil, with 30.4% related to cardiovascular diseases¹1. Malta DC, Moura L, Prado RR, Escalante JC, Schmidt MI, Duncan BB. Mortalidade por doenças crônicas não transmissíveis no Brasil e suas regiões, 2000 a 2011. Epidemiol Serv Saúde 2014; 23(4):599-608.. The prevalence of hypertension in the Brazilian population is 22 to 44% for adults and increases with age, reaching as high as 68% of older adults²2. Sociedade Brasileira de Cardiologia (SBC). VI Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol 2010; 95(Supl.1):1-51.^,33. Picon RV, Fuchs FD, Moreira LB, Fuchs SC. Prevalence of hypertension among elderly persons in urban Brazil: a systematic review with meta-analysis. Am J Hypertens 2013; 26(4):541-548.. On a global scale, hypertension is estimated to be responsible for 13% of deaths worldwide⁴4. World Health Organization (WHO). Global status report on noncommunicable diseases 2010 Geneva: WHO; 2011..

According to the Brazilian National Health Survey conducted in 2013, 21.4% of the population aged 18 years or older reported having a medical diagnosis of hypertension, which corresponds to 31.3 million Brazilians⁵5. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas. Rio de Janeiro: IBGE; 2014.. Data from the National Home Survey conducted in 2008 indicate that the prevalence of hypertension was 38% higher among individuals with a lower level of schooling and 6% higher among those with no private health insurance, after controlling for age, sex and place of residence⁶6. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cien Saude Colet 2011; 16(9):3755-3768..

The greater life expectancy, nutritional transition and contemporary lifestyle, which translate to unhealthy behaviors, have contributed to the increasing frequency of hypertension in the population⁷7. Brasil. Ministério da Saúde (MS). Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis (DCNT) no Brasil 2011-2022. Brasília: MS; 2011.^,88. Veras R. Envelhecimento populacional contemporâneo: demandas, desafios e inovações. Rev Saude Publica 2009; 43(3):548-554..

Despite the scientific consensus on the magnitude and impact of hypertension, which is considered a serious public health problem, control rates of the disease remain low⁹9. Brasil. Ministério da Saúde (MS). Estratégias para o cuidado da pessoa com doença crônica: hipertensão arterial sistêmica. Brasília: MS; 2013.. Such rates range from 1 to 15% in Latin America and Africa. In contrast, the hypertension control rate among individuals at primary care units in Germany is 64% of the total number of individuals with this disease and 18.5% among elderly individuals. A longitudinal study conducted in Italy reports a rate around 52%. Canada has the best control rate in the world (66%), which is attributed to primary care follow up and a continued educational program for healthcare professionals¹⁰10. Sharma AM, Wittchen HU, Kirch W, Pittrow D, Ritz E, Göke B, Lehnert H, Tschöpe D, Krause P, Höfler M, Pfister H, Bramlage P, Unger T; HYDRA Study Group. High prevalence and poor control of hypertension in primary care: cross-sectional study. J Hypertens 2004; 22(3):479-486.^–1212. Campbell NR, McAlister FA, Brant R, Levine M, Drouin D, Feldman R, Herman R, Zarnke K; Canadian Hypertension Education Process and Evaluation Committee. Temporal trends in antihypertensive drug prescriptions in Canada before and after introduction of the Canadian Hypertension Education Program. J Hypertens 2003; 21(8):1591-1597..

It is therefore necessary to highlight the role of healthcare services and health professionals as promoters of effective prevention and health recovery practices. In a review study conducted by Toledo et al.¹³13. Toledo MM, Rodrigues SC, Chiesa AM. Educação em saúde no enfrentamento da hipertensão arterial: uma nova ótica para um velho problema. Texto Contexto Enferm 2007; 16(2):233-238., the authors found that educational practices directed at individuals with hypertension are insufficient and most (80.4%) adopt normative protocols rather than employing a more liberating approach. According to Rabetti & Freitas¹⁴14. Rabetti AP, Freitas SFT. Avaliação das ações em hipertensão arterial sistêmica na atenção básica. Rev Saude Publica 2011; 45(2):258-268., such practices result in actions with little impact on the control of hypertension.

Considering the challenges regarding the prevention and control of hypertension, the following were the aims of the present study: estimate the prevalence of self-reported hypertension among adults residing in the city of Campinas, Brazil; identify associations with socio-demo-graphic characteristics, health-related behaviors, ailments, health status and the body mass index; and analyze the use of healthcare services and disease control practices adopted by Brazilian adults with hypertension.

Methods

A population-based, cross-sectional study was conducted involving data from the Campinas Municipal Health Survey (ISACAMP 2008/09). This survey was conducted between February 2008 and April 2009 by the Cooperating Center for the Analysis of the Health Situation of the Collective Health Department of Campinas State University for the analysis of health status among adolescents (10 to 19 years), adults (20 to 59 years) and elderly individuals (60 years or older). The target population was community-dwelling residents of urban areas in the city of Campinas. For the present study, the adult population was analyzed.

Independent samples of 1000 individuals in each age domain were selected, taking into account the estimate of a proportion of 0.50, sampling error between 4 and 5 percentage points, a 95% confidence interval and a 2.0 design effect.

ISACAMP 2008/09 employed two-stage cluster sampling. In the first stage, 50 census sectors were systematically selected, with the probability proportional to the number of residences. Sectors defined by the Brazilian Institute of Geography and Statistics were used and the addresses of the selected sectors were updated considering the time elapsed since the census. The second stage involved the definition of the number of residences to be selected in order to reach the desired sample size based on the ratio of individuals/residences for each age group. Thus, 700 residences were selected for interviews with adults, taking into account possible losses and an 80% response rate. All residents between 20 and 59 years of age at the selected homes were interviewed.

Information was collected using a structured questionnaire with 14 themes. The questionnaire had been tested in a pilot study and was administrated by trained, supervised interviewers.

The dependent variable was self-reported hypertension, which was determined by the answer to the following question: Has any doctor or other health professional even told you that you have high blood pressure?

Three sets of independent variables were selected for the analysis of factors associated with hypertension. A fourth set of variables on the use of healthcare services and disease control practices was analyzed in a descriptive fashion according to the possession or non-possession of a private health insurance plan.

▪ Socio-demographic variables: sex, age, ethnicity/self-reported skin color, conjugal situation, number of children, schooling (in years of study), monthly household income, possession of a health insurance plan and number of appliances in the home (freezer, vacuum cleaner, washing machine, air conditioner, dishwasher, computer, etc.).

▪ Health-related behaviors and nutritional status: smoking; alcohol intake frequency; alcohol dependence evaluated using the Alcohol Use Disorder Identification Test (AUDIT) with a cutoff point of ≥ 8 on a scale of 0 to 40 points¹⁵15. Lima CT, Freire ACC, Silva APB, Teixeira RM, Farrel M, Prince M. Concurrent and construct validity of the AUDIT in an urban Brazilian sample. Alcohol and Alcoholism 2005; 40(6):584-589.; physical activity during leisure, categorized as active (at least 150 minutes per week distributed among at least three days), insufficiently active (less than 150 minutes per week or 150+ minutes per week but distributed among less than three days per week) and inactive (no type of physical activity on any day of the week); nutritional status, evaluated based on the body mass index (BMI) calculated using weight and height and classified as underweight (< 18.5 kg/m²), ideal range (18.5 to 24.9 kg/m²), overweight (25.0 to 29.9 kg/m²) and obesity (≥ 30 kg/m²)¹⁶16. World Health Organization (WHO). Physical status: the use and interpretation of anthropometry. Geneva: WHO; 1995..

▪ Ailments and health status: Number of chronic diseases and number of health complaints among those included on two checklists and self-rated health status; 1) chronic disease checklist – arterial hypertension, diabetes mellitus, heart disease, cancer, rheumatism/arthritis/arthrosis, osteoporosis, asthma/bronchitis/emphysema, tendinitis/repetitive strain injury/work-related musculoskeletal disorders and circulation problems; 2) health complaint checklist – headache/migraine, back pain/problem, allergy, emotional problem, dizziness/vertigo, insomnia and urinary problem.

▪ Use of healthcare services and disease-control practices: time elapsed since the diagnosis, visits to a physician for follow up of hypertension, reasons for not regularly visiting the physician, last visit to a physician for follow up of hypertension, participation in hypertension groups, having received medical counseling related to hypertension and measures taken to control the disease.

Data analysis initially involved estimates of the prevalence of hypertension according to the independent variables. Associations were tested using the chi-squared test with a 5% significance level. Prevalence ratios (crude and adjusted for sex and age) were calculated with 95% confidence intervals. A multiple Poisson regression model was employed in three steps. First, demographic and socioeconomic variables with a p-value < 0.20 in the univariate analysis were incorporated and only those with a p-value < 0.05 after adjustments remained in the model. Second, health-related behaviors and BMI were incorporated using the same cutoff points (p < 0.20 in the univarite analysis and p < 0.05 following adjustments for other variables). In the third, step, ailment and health status variables were incorporated with the same cutoff points as in the previous steps. Proportions were estimated using the chi-square test with a 5% significance level for the analysis of associations between possession/non-possession of a private insurance plan and both the use of health services and disease-control practices.

The data from the interview were entered in a blinded fashion in the Epidata program, version 3.1 (Epidata Assoc., Odense, Denmark). Statistical analysis were performed with the aid of the svy module of the Stata 11.0 program (Stata Corp., College Station, USA), which enables the consideration of weights and sampling design.

The ISACAMP 2008/09 program received approval from the human research ethics committee of the School of Medical Sciences of Campinas State University (Brazil).

Results

Data from 957 adults were analyzed. The female sex accounted for 51.3% of the sample. Mean age was 37.5 years (men: 37.0 years; women: 37.9 years).

The prevalence of self-reported hypertension was 14.1% (95% CI: 12.3 to 16.1%) and was significantly higher among women, those who self-declared their ethnicity/skin color to be black, those with one or more children and those with a lower level of schooling. An increase in the frequency of hypertension occurred with the advance in age, as the prevalence was nearly tenfold higher among individuals aged 50 to 59 year in comparison to those aged 20 to 29 years. With regard to conjugal status, hypertension was more prevalent among separated and widowed individuals and lower among single individuals (Table 1).

The prevalence of self-reported hypertension was higher among individuals who remained inactive during leisure activities and ex-smokers and was lower among those who ingested alcoholic beverages one to four times per month. The prevalence increased with the increase in excess weight. The diagnosis of hypertension was reported by 36.8% of obese individuals, representing a 5.08-fold higher prevalence in comparison to those in the ideal BMI range (Table 2).

With regard to comorbidities, self-reported hypertension was more prevalent among individuals with three or more health complaints as well as those who reported one or more chronic diseases. The prevalence of hypertension was significantly higher among individuals who rated their health as good or poor/very poor in comparison to those who rated their health as very good or excellent (Table 3).

Table 4 displays the results of the multiple Poisson regression model. The prevalence of hypertension was higher among women, those aged 40 years or older, those who declared their ethnicity/skin color as black, those who remained inactive during leisure activities, ex-smokers, those with overweight or obesity, those who reported two or more chronic disease and those who rated their health as being good or poor/very poor.

Table 5 lists aspects related to hypertension control practices according to the possession or non-possession of a private health insurance plan. A total of 40.2% of the adults with hypertension were diagnosed six or more years earlier, 75.3% reported visiting regularly visiting a physician or healthcare service the purposes of disease control and 71.2% reported receiving counseling on how to manage the disease. Among those who did not visit a physician, the main reason was that they did not consider it necessary (63.4%). The vast majority (96.5%) did not participate in hypertension groups and 16.2% sought a physician or healthcare service more than one year earlier. No significant differences were found between those with a private health insurance plan and those dependent on the Brazilian public healthcare system with regard to regularly visiting a physician, using routine disease-control medications or having received orientations regarding how to manage hypertension. However, having a private health insurance plan was associated with greater frequencies of physical activity and dieting to lose or maintain weight as well as a greater frequency of disease-control practices.

Discussion

The use of self-reported information on the presence of hypertension can be considered a limitation of the present study, since the prevalence is underestimated in this manner by limiting the investigation only to individuals who had access to a medical diagnosis and omitting those who are unaware of having high blood pressure. Although certain locations offer adequate medical care, individuals less attentive to their health can remain without a diagnosis even when having the disease. Nonetheless, population-based validation studies reveal that self-reported information on hypertension can be considered an appropriate indicator for estimating the prevalence of the disease¹⁷17. Lima-Costa MF, Peixoto SV, Firmo JOA. Validade da hipertensão arterial auto-referida e seus determinantes (projeto Bambuí). Rev Saude Publica 2004; 38(5):637-642.^,1818. Chrestani MAD, Santos IS, Matijasevich AM. Hipertensão arterial sistêmica auto-referida: validação diagnóstica em estudo de base populacional. Cad Saude Publica 2009; 25(11):2395-2406..

Moreover, the present findings reveal segments of the adult population with greater prevalence rates of self-reported hypertension, which enables better guidance with regard to the planning of interventions. The findings add to existing data from previous studies, reaffirming the greater frequency of the disease among socially more vulnerable segments of society beyond the increase stemming from the ageing process.

The prevalence of hypertension was 14.1% in adults aged 20 to 59 years residing in the city of Campinas, which is virtually that same as the 14.0% prevalence reported for the Brazilian population in the 2008 National Household Survey, which revealed that the prevalence increases with age from 3.2% among individuals aged 20 to 29 years to 35% among those aged 50 to 59 years⁶6. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cien Saude Colet 2011; 16(9):3755-3768.. Data from the Vigitel national telephone survey in 2008 indicate a higher figure of around 23.1% in the adult population (≥ 18 years of age), with changes accompanying the increase in age and with the highest rates among young individuals (18 to 24 years) found in the cities of Teresina and Porto Alegre (10.6%)¹⁹19. Muraro AP, Santos DF, Rodrigues PRM, Braga JU. Fatores associados à Hipertensão Arterial Sistêmica autorreferida segundo VIGITEL nas 26 capitais brasileiras e no Distrito Federal em 2008. Cien Saude Colet 2013; 18(5):1387-1398..

Hypertension was more prevalent among women, which is in agreement with data reported in previous studies⁵5. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas. Rio de Janeiro: IBGE; 2014.^,66. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cien Saude Colet 2011; 16(9):3755-3768.^,1717. Lima-Costa MF, Peixoto SV, Firmo JOA. Validade da hipertensão arterial auto-referida e seus determinantes (projeto Bambuí). Rev Saude Publica 2004; 38(5):637-642.. Information from the Vigitel telephone survey demonstrate a greater prevalence rate of the disease among women between 2006 and 2011²⁰20. Andrade SSCA, Malta DC, Iser BM, Sampaio PC, Moura L. Prevalência da hipertensão arterial autorreferida nas capitais brasileiras em 2011 e análise de sua tendência no período de 2006 a 2011. Rev Bras Epidemiol 2014; 17(Supl. 1):215-226.. This gender difference may be explained by the greater perception of physical signs and symptoms of health conditions among women as well as greater concerns regarding health and seeking medical assistance⁶6. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cien Saude Colet 2011; 16(9):3755-3768.^,2121. Pinheiro RS, Viacava F, Travassos C, Brito AS. Gênero, morbidade, acesso e utilização de serviços de saúde no Brasil. Cien Saude Colet 2002; 7(4):687-707.^,2222. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios. Um Panorama da Saúde no Brasil: acesso e utilização dos serviços, condições de saúde e fatores de risco e proteção à saúde 2008. Rio de Janeiro: IBGE; 2010..

The increase in prevalence with the advance in age is also in agreement with data described in the literature⁵5. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas. Rio de Janeiro: IBGE; 2014.^,66. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cien Saude Colet 2011; 16(9):3755-3768.^,2020. Andrade SSCA, Malta DC, Iser BM, Sampaio PC, Moura L. Prevalência da hipertensão arterial autorreferida nas capitais brasileiras em 2011 e análise de sua tendência no período de 2006 a 2011. Rev Bras Epidemiol 2014; 17(Supl. 1):215-226.^,2323. Zaitune MPA, Barros MBA, César CLG, Carandina L, Goldbaum M. Hipertensão arterial em idosos: prevalência, fatores associados e práticas de controle no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2006; 22(2):285-294.. This increase is related to the longer life expectancy of the population, which leads to a greater burden of chronic diseases, disability and the demand for health services²⁴24. Barros MBA, César CLG, Carandina L, Torre GD. Desigualdades sociais na prevalência de doenças crônicas no Brasil, PNAD-2003. Cien Saude Colet 2006; 11(4):911-926..

The prevalence of hypertension was higher among adults with a lower level of schooling, as reported in other studies⁵5. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas. Rio de Janeiro: IBGE; 2014.^,2020. Andrade SSCA, Malta DC, Iser BM, Sampaio PC, Moura L. Prevalência da hipertensão arterial autorreferida nas capitais brasileiras em 2011 e análise de sua tendência no período de 2006 a 2011. Rev Bras Epidemiol 2014; 17(Supl. 1):215-226.. Analyzing data from the 2008 National Household Survey, Barros et al.⁶6. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cien Saude Colet 2011; 16(9):3755-3768. found that the chronic diseases analyzed, except tendinitis and cancer, were more prevalent among individuals with less schooling. Lima-Costa²⁵25. Lima-Costa MF. A escolaridade afeta, igualmente, comportamentos prejudiciais à saúde de idosos e adultos mais jovens? - Inquérito de Saúde da Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Epidemiol Serv Saúde 2004; 13(4):201-208. found that adults and elderly individuals with less schooling had greater frequencies of smoking and a sedentary lifestyle as well as ingested fruits, vegetables and legumes less. According to the World Health Organization⁴4. World Health Organization (WHO). Global status report on noncommunicable diseases 2010 Geneva: WHO; 2011. chronic diseases mainly affect socially more vulnerable segments of society due to greater exposure to risk factors, less access to healthcare services and a lower level of health-related information.

With regard to ethnicity, hypertension was more prevalent among individuals who declared themselves to be black, which is in agreement with data reported in previous studies and reaffirms historically and socially determined eth-no-racial inequalities²⁶26. Malta DC, Moura L, Bernal RTI. Diferenciais dos fatores de risco de Doenças Crônicas não Transmissíveis na perspectiva de raça/cor. Cien Saude Colet 2015; 20(3):713-725.^–2929. Laguardia J. Raça, genética & hipertensão: nova genética ou velha eugenia? História, Ciências, Saúde – Manguinhos 2005; 12(2):371-393.. According to Malta et al. ²⁶26. Malta DC, Moura L, Bernal RTI. Diferenciais dos fatores de risco de Doenças Crônicas não Transmissíveis na perspectiva de raça/cor. Cien Saude Colet 2015; 20(3):713-725., disparities between blacks and whites are also evidenced in rates of passive smoking in the work environment, the use of alcoholic beverages, the consumption of fatty meats, fruits and vegetables and the practice of physical activity in the workplace associated with the exercise of occupational activities that require lower qualifications.

Physical inactivity contributes to more than three million deaths annually and constitutes an important risk factor for non-communicable chronic diseases⁴4. World Health Organization (WHO). Global status report on noncommunicable diseases 2010 Geneva: WHO; 2011.. The present findings lend support to this statement, as the prevalence of hypertension was higher among individuals who were inactive during leisure activities. Data from the Brazilian Health Ministry reveal that 16.2% (95% CI: 15.6 to 16.9%) of individuals ages 18 years or older do not practice physical activity³⁰30. Brasil. Ministério da Saúde (MS). VIGITEL Brasil 2013: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2014.. Exercising at least 30 minutes per day most days of the week is recommended for the prevention of hypertension and lowering blood pressure levels³¹31. Dasgupta K, Quinn RR, Zarnke KB, Rabi DM, Ravani P, Daskalopoulou SS, Rabkin SW, Trudeau L, Feldman RD, Cloutier L, Prebtani A, Herman RJ, Bacon SL, Gilbert RE, Ruzicka M, McKay DW, Campbell TS, Grover S, Honos G, Schiffrin EL, Bolli P, Wilson TW, Lindsay P, Hill MD, Coutts SB, Gubitz G, Gelfer M, Vallée M, Prasad GV, Lebel M, McLean D, Arnold JM, Moe GW, Howlett JG, Boulanger JM, Larochelle P, Leiter LA, Jones C, Ogilvie RI, Woo V, Kaczorowski J, Burns KD, Petrella RJ, Hiremath S, Milot A, Stone JA, Drouin D, Lavoie KL, Lamarre-Cliche M, Tremblay G, Hamet P, Fodor G, Carruthers SG, Pylypchuk GB, Burgess E, Lewanczuk R, Dresser GK, Penner SB, Hegele RA, Mc-Farlane PA, Khara M, Pipe A, Oh P, Selby P, Sharma M, Reid DJ, Tobe SW, Padwal RS, Poirier L; Canadian Hypertension Education Program. The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2014; 30(5):485-501.^,3232. Brook RD, Appel LJ, Rubenfire M, Ogedegbe G, Bisognano JD, Elliott WJ, Fuchs FD, Hughes JW, Lackland DT, Staffileno BA, Townsend RR, Rajagopalan S; American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity. Beyond medications and diet: alternative approaches to lowering blood pressure. A Scientific Statement from the American Heart Association. Hypertension 2013; 61(6):1360-1383..

Self-reported diagnoses of hypertension were more prevalent among ex-smokers in comparison to individuals who had never smoked. It is estimated that smoking is responsible for 9% of deaths in the world⁴4. World Health Organization (WHO). Global status report on noncommunicable diseases 2010 Geneva: WHO; 2011.. The greater prevalence of hypertension among ex-smokers in the present investigation is likely the result of reverse causality, as the emergence of hypertension may have led individuals to give up smoking. However, further studies are needed to confirm this hypothesis.

With regard to nutritional status, hypertension was more prevalent among individuals with overweight or obesity, which is similar to findings described by other researchers²⁸28. Costa JSD, Barcellos FC, Sclowitz ML, Sclowitz IKT, Castanheira M, Olinto MTA, Menezes AMB, Gigante DP, Macedo S, Fuchs SC. Prevalência de hipertensão arterial em adultos e fatores associados: um estudo de base populacional urbana em Pelotas, Rio Grande do Sul, Brasil. Arq Bras Cardiol 2007; 88(1):59-65.^,3333. Barbosa LS, Scala LCN, Ferreira MG. Associação entre marcadores antropométricos de adiposidade corporal e hipertensão arterial na população adulta de Cuiabá, Mato Grosso. Rev Bras Epidemiol 2009; 12(2):237-247.^,3434. Papathanasiou G, Zerva E, Zacharis I, Papandreou M, Papageorgiou E, Tzima C, Georgakopoulos D, Evangelou A. Association of high blood pressure with body mass index, smoking and physical activity in healthy young adults. Open Cardiovasc Med J 2015; 9:5-17.. In Brazil, the prevalence of excess weight increased from 43.2 to 51.0% between 2006 and 2012, which is an annual increase of 1.37%, and the prevalence of obesity increased from 11.6 to 17.4% (annual increase of 0.89%)³⁵35. Malta DC, Andrade SC, Claro RM, Bernal RTI, Monteiro CA. Evolução anual da prevalência de excesso de peso e obesidade em adultos nas capitais dos 26 estados brasileiros e no Distrito Federal entre 2006 e 2012. Rev Bras Epidemiol 2014; 17(Supl.1):267-276.. In a cross-sectional study involving a sample of 1584 individuals aged 18 to 64 years, Sarno and Monteiro³⁶36. Sarno F, Monteiro CA. Importância relativa do Índice de Massa Corporal e da circunferência abdominal na predição da hipertensão arterial. Rev Saude Publica 2007; 41(5):788-796. found a risk of hypertension attributable to a body mass index ≥ 25 kg/m² among 56% of men and 41% of women, confirming the increased risk of hypertension with the occurrence of excess weight.

The prevalence of hypertension was higher among individuals who reported having two or more chronic diseases. The findings of clinical studies demonstrate that 70% of individuals with diabetes also have hypertension and the coexistence of the two conditions significantly increases the risk of developing other comorbidities³⁷37. Alessi A, Bonfim AV, Brandão AA, Feitosa A, Amodeo C, Alves CR, Brasil DP, Souza DSM, Barbosa E, Consolim-Colombo FM, Borelli F, Fonseca FH, Lopes HF, Chaves H, Bortolotto LA, Martin LC, Scala LCN, Mota-Gomes MA, Malachias MVB, Izar MC, Fonseca MIH, Neves MFT, Morais NS, Passarelli Júnior O, Jardim PCV, Toscano PR, Miranda RD, Franco R, Betti RTB, Pedrosa RP, Povoa R, Carneiro SB, Jardim T, Barroso WKS. I Posicionamento Brasileiro em hipertensão arterial e diabetes mellitus. Arq Bras Cardiol 2013; 100(6):491-501.. Moreover, hypertension was more prevalent among individuals who rated their health as not being very good or excellent. In a population-based study conducted in the city of Pelotas (southern Brazil), 45.4% of adults with hypertension perceived their health as being fair or poor³⁸38. Reichert FF, Loch MR, Capilheira MF. Autopercepção de saúde em adolescentes, adultos e idosos. Cien Saude Colet 2012; 17(12):3353-3362..

The main finding of the present study regards hypertension control strategies. Adults with a private health insurance plan performed physical activity more and dieted more to lose or maintain weight, although physical activity was reported by only 17.4% and a controlled diet was reported by only 16.1% of the individuals with hypertension. Souza et al.³⁹39. Souza CS, Stein AT, Bastos GAN, Pellanda LC. Controle da pressão arterial em hipertensos do Programa Hiperdia: estudo de base territorial. Arq Bras Cardiol 2014; 102(6):571-578. report similar findings in a study conducted in Novo Hamburgo (southern Brazil), in which these figures were also low, as 22.1% and 7.4% of individuals with hypertension registered with the Hiperdia Program recognized physical exercise and the maintenance of adequate weight, respectively, as important practices for controlling the disease. The findings are also in agreement with data reported by Zaitune et al.²³23. Zaitune MPA, Barros MBA, César CLG, Carandina L, Goldbaum M. Hipertensão arterial em idosos: prevalência, fatores associados e práticas de controle no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2006; 22(2):285-294. in a study conducted in Campinas, which revealed greater recognition on the part of elderly individuals regarding the use of dieting and physical activities as strategies for controlling hypertension, despite the low rates of carrying out such practices (9.0 and 22.4%, respectively).

The present results underscore the importance of the qualification of services directed at education activities for health promotion, especially in primary care. Indeed, an experience in Canada reveals that primary care follow up combined with the continued education of healthcare professionals leads to better results regarding the control of hypertension¹²12. Campbell NR, McAlister FA, Brant R, Levine M, Drouin D, Feldman R, Herman R, Zarnke K; Canadian Hypertension Education Process and Evaluation Committee. Temporal trends in antihypertensive drug prescriptions in Canada before and after introduction of the Canadian Hypertension Education Program. J Hypertens 2003; 21(8):1591-1597..

The findings lend support to the relevance of the investments that have been made in Brazil and the rest of the world to address non-communicable chronic diseases, such as hypertension, beyond medicinal treatment, as there is consensus in the scientific community regarding the positive effects of changing one's lifestyle⁴⁰40. Organização Pan-Americana de Saúde (OPAS). Estratégia e plano de ação regional para um enfoque integrado à prevenção e controle das doenças crônicas, inclusive regime alimentar, atividade física e saúde Washington: OPAS; 2007.^,4141. Malta DC, Silva Júnior JB. O Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil e a definição das metas globais para o enfrentamento dessas doenças até 2025: uma revisão. Epidemiol Serv Saúde 2013; 22(1):151-164.. However, it is necessary to overcome the normative approach that remains dominant in health services, as Toledo et al.¹³13. Toledo MM, Rodrigues SC, Chiesa AM. Educação em saúde no enfrentamento da hipertensão arterial: uma nova ótica para um velho problema. Texto Contexto Enferm 2007; 16(2):233-238. point out in reference to educational approaches for individuals with hypertension, since the qualification of healthcare services exerts a positive impact on the efficiency of disease control practices¹⁴14. Rabetti AP, Freitas SFT. Avaliação das ações em hipertensão arterial sistêmica na atenção básica. Rev Saude Publica 2011; 45(2):258-268..

Conclusion

The possession or non-possession of a private health insurance plan among adults with hypertension was not significantly associated with the use of healthcare services or having received medical orientation regarding the management of the disease, which demonstrates equity in access to health care among such patients in the city of Campinas (southeastern Brazil). However, despite access to regular medical follow up and counseling with regard to managing the hypertension, an insufficient proportion of adults adopt changes in lifestyle to control the disease, such as the practice of physical exercise and adequate eating habits to lose or maintain weight.

This is a worrisome situation that underscores the central role of state and municipal public health administrators, who need to work in an intersectoral manner to strengthen the integrality of care through strategies outlined in the Brazilian National Plans for the Control of Chronic Diseases, in such a way that the actions can lead to the achievement of goals established by the Health Ministry.

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