Abstract

The objective was to estimate the prevalence and factors associated with prehypertension and hypertension among health workers who work in high-complexity services for critically-ill and chronic patients. An epidemiological, cross-sectional study was carried out with 490 health workers in the macroregional region of Northern Minas Gerais, Brazil. The dependent variable blood pressure (BP) was categorized as normal BP, prehypertension and hypertension. Multinomial Logistic Regression was used for the multiple analysis. The prevalence of arterial hypertension was 21.8% and that of prehypertension was 25.9%. The chances of developing arterial hypertension and prehypertension were higher in male professionals, aged ≥40 years, in civil servant workers and those who were obese or overweight. The use of continuous medication and night shift work were associated with hypertension and prehypertension, respectively. The prevalence of arterial hypertension in the group of workers was lower than that of the Brazilian population. It is necessary to carry out studies with workers from this group and investments are required in preventive measures that encourage a change to a healthy lifestyle.

Key words:
Prehypertension; Arterial Hypertension; Health worker; Prevalence

Introduction

Arterial hypertension (AH) represents the main risk factor for the development of cardiovascular diseases and mortality worldwide. It is a multifactorial disease, characterized and diagnosed by elevated and sustained blood pressure (BP) levels, of which clinical criterion in individuals over 18 years of age comprises BP levels ≥140 mmHg × 90 mmHg¹1 Sociedade Brasileira de Cardiologia (SBC). 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol 2016; 107(Supl. 3):1-83..

The World Health Organization (WHO) estimates that approximately 600 million people have AH worldwide, with a global increase of 60% of cases by 2025²2 Malta DC, Gonçalves RPF, Machado IE, Freitas MIF, Azeredo C, Szwarcwald CL. Prevalência da hipertensão arterial segundo diferentes critérios diagnósticos, Pesquisa Nacional de Saúde. Rev Bras Epidemiol 2018; 21(1):1-15., in addition to about 7.1 million deaths annually³3 Moxotó GFA, Malagris LEN. Raiva, stress emocional e hipertensão: um estudo comparativo. Psicol Teoria Pesq 2015; 31(2):221-227.. In Latin America, the prevalence is 30 to 40%, ranging from 25% to 35% according to the region⁴4 Sabio R, Valdez P, Turbay YA, Belgeri REA, Morvil GAAO, Arias C. Recomendacioneslatinoamericanas para el manejo de lahipertensión arterial en adultos (RELAHTA 2). Rev Virtual Soc Parag Med Int 2019; 6(1):86-123.. In Brazil, population surveys have shown a prevalence of 32.3%⁵5 Attarchi M, Dehghan F, Safakhah F, Nojomi M, Mohammadi S. Effect of exposure to occupational noise and shift working on blood pressure in rubber manufacturing company workers. Ind Health 2012; 50(3):205-213.. A study conducted in China with 29,924 physicians showed a prevalence of 63.9% in this group of professionals⁶6 Hou L, Jin X, Ma J, Qian J, Huo Y, Ge J. Perception and selfmanagement of hypertension in chinese cardiologists (CCHS): a multicenter, large-scale crosssectional study. BMJ Open 2019; 9(9):1-8.. According to this same perspective, an investigation carried out in the African continent estimated the AH prevalence of 52.6%⁷7 Osei-Yeboah J, Kye-Amoah KK, Owiredu WKBA, Lokpo SY, Esson J, Johnson BB, Amoah P, Aduko RA. Cardiometabolic risk factors among healthcare workers: a cross-sectional study at the sefwi-wiawso Municipal Hospital, Ghana. Bio Med Res Int 2018; 9(1):1-9.. In Brazil, the mean prevalence of AH in health workers is 20.8%, ranging from 12.7% to 28.9% according to some prevalence surveys⁸8 Domingues JG, Silva BBC, Bierhals IO, Barros FC. Doenças crônicas não transmissíveis em profissionais de enfermagem de um hospital filantrópico no Sul do Brasil. Epidemiol Serv Saude 2019; 28(2):e2018298.

9 Nascimento JOV, Santos J, Meira KC, Pierin AMG, Souza-Talarico JN. Shift work of nursing professionals and blood pressure, burnout and common mental disorders. Rev Esc Enferm USP 2019; 53:e03443.

10 Ulguim FO, Renner JDP, Pohl HH, Oliveira CF, Bragança GCM. Trabalhadores da saúde: risco cardiovascular e estresse ocupacional. Rev Bras MedTrab 2019; 17(1):61-68.^-1111 Rodrigues C, Silva JP, Cabral CVS. Fatores de risco para o desenvolvimento de hipertensão arterial (HAS) entre a equipe de enfermagem. R Interd 2016; 9(2):117-126..

There are several factors responsible for the development of the disease. Among them are the behavioral ones, such as an unhealthy diet, obesity, physical inactivity, alcohol and tobacco consumption. However, work-related factors such as stress and shift work/night work have also been implicated in the etiology of hypertension¹²12 Monakali S, Goon TD, Seekoe E, Owolabi EO. Prevalence, awareness, control and determinants of hypertension among primary health care professional nurses in Eastern Cape, South Africa. Afr J Prm Health Care Fam Med 2018; 10(5):1-5..

Therefore, the work environment definitively influences the worker’s health. Thus, health workers who work in high-complexity services, such as hemodialysis, oncology, emergency department and intensive care units, have daily contact with stressful situations, such as other people’s pain, tragedy, and suffering, as well as the fine line between life and death¹³13 Magalhães FJ, Mendonça LBA, Rebouças CBA, Lima FET, Custódio IL, Oliveira SC. Fatores de risco para doenças cardiovasculares em profissionais de enfermagem: estratégias de promoção da saúde. Rev Bras Enferm 2014; 67(3):394-400.. Moreover, the nature of the work in these services requires continuous assistance to patients, compliance with strict rules, routines and regulations, fragmented activity division, hierarchical rigidity and insufficient human resources. Together, these factors generate a high load of exhaustion and physical and emotional stress, increasing the risk of developing AH¹⁴14 Souza VS, Silva DS, Lima LV, Teston EF, Benedetti GMS, Costa MAR, Mendonça RR. Qualidade de vida dos profissionais de enfermagem atuantes em setores críticos. Rev Cuid 2018; 9(2):2177-2186.. Therefore, in addition to the direct and indirect costs, this disease results in situations such as absenteeism, loss of working hours or work abandonment among health workers¹⁰10 Ulguim FO, Renner JDP, Pohl HH, Oliveira CF, Bragança GCM. Trabalhadores da saúde: risco cardiovascular e estresse ocupacional. Rev Bras MedTrab 2019; 17(1):61-68..

Workers’ health represents an area of knowledge that correlates the interfaces of work, health, disease and their consequences, thus evidencing a public health issue. The prevalence of prehypertension and AH in health workers has been studied for a few decades and, therefore, further investigations are required on the health and working conditions of professionals who work specifically with critically-ill and chronic patients and the association with the disease. What demonstrates the relevance of this study is the need to expand the research on the disease and its factors associated with this group of professionals, aiming to identify the factors, improve health and working conditions and job satisfaction, which may consequently reflect directly on the quality of care provided to the patient. Therefore, the present study aimed to estimate the prevalence and factors associated with prehypertension and arterial hypertension among health workers who work in high-complexity services for critically-ill and chronic patients.

Methods

This was an epidemiological, cross-sectional and analytical study carried out with health workers from hemodialysis, oncology, emergency room and neonatal intensive care units in nine hospitals in the macro-region of Northern Minas Gerais, Brazil. The total study population consisted of 910 professionals, represented by nursing assistants/technicians, nurses, pharmacists, physiotherapists, physicians, nutritionists and psychologists, who provided direct assistance to patients. The research group, from which this study originated, has ‘compassion fatigue’ as its main research axis, which is a little explored event in the scientific sphere.

The sample size was established aiming to estimate population parameters with a prevalence of 50% (to maximize the sample size and due to the fact that the project contemplates several events), a 95% confidence interval (95%CI) and an accuracy level of 5.0%. A 20-percent addition was established to compensate for possible non-responses and losses. The calculations showed the need for a sample size of at least 450 health professionals. For the sample calculation, a simple random sampling with replacement was used, utilizing the Excel for Windows® software.

This sample size allowed the identification of a minimum prevalence ratio equal to 2.0, with a confidence level of 95%, power of 80% and an unexposed/exposed ratio of 2:1 for the gender variable.

Sample selection was performed based on the simple random sampling technique with replacement. All workers with more than six months of experience in the abovementioned services were included in the study, and professionals on medical leave or on vacation at the time of data collection were excluded.

Calibration was performed using the parameters of reliability and reproducibility, regarding the measurement of blood pressure levels, weight, height and waist circumference values. The examiners performed the measurements in triplicate for each of the aforementioned variables in a group of 20 volunteers consisting of nursing students. The measurements were compared two by two, using the intraclass correlation coefficient (ICC). In this study, the intra-rater ICC was ICC≥0.61 (satisfactory) for all variables, and the inter-rater ICC was ICC≥0.5 (satisfactory) for systolic and diastolic blood pressure measurements; ICC=1 (perfect agreement) for weight and height measurements and ICC≥0.89 (satisfactory) for waist circumference¹⁵15 Fleiss JL, Levin B, Paik M. Statistical methods for rates and proportions. New Jersey: John Wiley & Sons; 2003..

Data related to the dependent variable (BP) and the following independent variables were also analyzed: sociodemographic (gender, age, marital status and economic class), anthropometric (weight, height and waist circumference), biochemical (fasting blood glucose (FBG), triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c) and low-density lipoprotein cholesterol (LDL-c)), working conditions (sector, time in the profession, job function in the sector, workload, employment relationship, work shift, number of work contracts and medical leave due to occupational stress, depression or anxiety), lifestyle (physical activity practice, consumption of fruits and vegetables, smoking status, alcohol consumption, sleep and use of psychotropic medication), physical health conditions (type of access to health services, previous diseases, use of continuous medication and self-perception of health), mental health conditions (symptoms of a anxiety, stress at work, symptoms of depression, internet addiction and quality of life).

Data collection took place from January 2017 to April 2018, using a self-applied questionnaire, with measurement of the anthropometric data and blood collection for the biochemical analysis.

For data collection of the dependent variable, the guidelines of the 7^th Brazilian Guidelines on Arterial Hypertension were followed, and the validated device Pulse Control (HEM-6123) Automatic Blood Pressure Monitor - Omron® was used¹1 Sociedade Brasileira de Cardiologia (SBC). 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol 2016; 107(Supl. 3):1-83.. BP measurements were obtained when the workers were approached and handed the questionnaire, and also at the time of the collection of anthropometric data and blood samples. Three measurements were made on each occasion. The mean of the last two measurements was considered for the statistical analysis, disregarding the first measurement. The blood pressure levels of the participants were classified as normal, for systolic blood pressure (SBP) level ≤120 mmHg and ≤80 mmHg for diastolic blood pressure (DBP), as prehypertension, for mean SBP values from 121 to 139 mmHg and between 81 and 89 mmHg for DBP, and as hypertension, for those with mean SBP values ≥140 mmHg and DBP ≥90 mmHg and for professionals who reported continuous use of antihypertensive medication, regardless of the measured BP values. Hypertension was further classified as stage 1 hypertension (SBP between 140 and 159 mmHg and DBP between 90 and 99 mmHg); stage 2 hypertension (SBP and DBP values of 160 to 179 mmHg and 100 to 109 mmHg, respectively); and stage 3 hypertension (SBP≥180 mmHg and DBP≥110 mmHg). When SBP and DBP were located in different categories, the highest measure was used to classify the BP¹1 Sociedade Brasileira de Cardiologia (SBC). 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol 2016; 107(Supl. 3):1-83..

The biochemical variables glucose, total cholesterol, HDL-cholesterol, LDL-cholesterol and triglycerides were collected in a single sample through antecubital venous blood after 12 hours of fasting, with laboratory analysis using the enzymatic colorimetric method, in a Labmax Plenno® device. For the reference value of cholesterol, HDL-cholesterol, LDL-cholesterol and triglycerides, those recommended by the Brazilian Guideline on Dyslipidemia and Prevention of Atherosclerosis¹⁶16 Sociedade Brasileira de Cardiologia (SBC). Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose. Arq Bras Cardiol 2017; 109(2):1-91. was used, according to which the following were classified as desirable or undesirable, respectively, Cholesterol (<190 mg/dL and ≥190 mg/dL), LDL-cholesterol (<130 mg/dL and ≥130 mg/dL), HDL-cholesterol (>40 mg/dL and ≤40 mg/dL) and triglycerides (<150mg/dL and ≥150 mg/dL). The reference values of the Guidelines of the Brazilian Society of Diabetes¹⁷17 Oliveira JEP, Montenegro-Junior RM, Vencio S. Diretrizes da Sociedade Brasileira de Diabetes 2017-2018. São Paulo: Editora Clannad; 2017. was used for glucose, which considers fasting blood glucose <100 mg/dL as normal and blood glucose ≥100 mg/dL as altered.

During the procedure for the collection of anthropometric variables, the Body Mass Index (BMI) was determined by the weight (in kilograms) and height (in meters) measured using a digital electronic scale and a stadiometer. The professionals were classified according to the WHO¹⁸18 World Health Organization (WHO). Physical status: the use and interpretation of anthropometry. Geneva: WHO; 1995. criteria as underweight (<18.5 kg/m²), normal weight (18.5 to 24.9 kg/m²), overweight (25 to 29.9 kg/m²) and obese (≥30 kg/m²). To determine the abdominal circumference, an inelastic measuring tape with a precision of 0.1 centimeter adjusted to the body was used, being considered normal a circumference value ≤80 cm for women and ≤90 for men, whereas values >80 cm for women and >90 cm for men were considered altered¹⁸18 World Health Organization (WHO). Physical status: the use and interpretation of anthropometry. Geneva: WHO; 1995.. The waist-to-height ratio (WHtR) was defined by dividing waist circumference (cm) by height (cm). A ratio ≤0.54 for men was considered normal and a ratio >0.54 was considered altered. For women, the ratio ≤0.55 and >0.55 was considered normal and altered, respectively¹⁹19 Castanheira M, Chor D, Braga JU, Cardoso LO, Griep RH, MCB, Fonseca MJM. Predicting cardiometabolic disturbances from waist-to-height ratio: findings from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline. Public Health Nutrition 2018; 21(6):1028-1035..

The sociodemographic variables, physical health conditions and working conditions were assessed using a form prepared by the project team. To investigate the variables related to lifestyle, the instrument validated in Brazil “Fantastic Lifestyle Questionnaire” was used, which considers the behavior of individuals in the last 30 days²⁰20 Añez CRR, Reis RS, Petroski EL. Versão Brasileira do questionário "Estilo de vida Fantástico": Tradução e validação para Adultos Jovens. Arq Bras Cardiol 2008; 91(2):102-109.. This study used only the questions of interest that encompassed aspects of the variables related to the practice of physical activity, diet, smoking status, alcohol consumption and sleep.

Variables relevant to mental health conditions and quality of life were measured using instruments validated in Brazil: Beck Anxiety Inventory²¹21 Cunha JA. Manual da versão em português das Escalas Beck. São Paulo: Casa do Psicólogo; 2001., Beck Depression Inventory²¹21 Cunha JA. Manual da versão em português das Escalas Beck. São Paulo: Casa do Psicólogo; 2001., General Work Stress Scale²²22 Paschoal T, Tamayo A. Validação da escala de estresse no trabalho. Estud Psicol 2004; 9(1):45-52., Internet Addiction Test²³23 Young KS. Internet addiction: The emergence of a new clinical disorder. Cyber Psychol Behav 1996; 1(3):237-244. and the WHOQOL-BREF²⁴24 Fleck MPA, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, Pinzon V. Aplicação da versão em português do instrumento de avaliação de qualidade de vida da Organização Mundial da Saúde (WHOQOL-100). Rev Saude Publica 1999; 33(2):198-205., respectively.

Since no theoretical model was identified that contemplated the potential influence of sociodemographic characteristics, lifestyle, physical, mental, and working health conditions, anthropometric and biochemical measurements on AH in health workers who attended to critically-ill and chronic patients, a model was proposed, which was built after extensive literature review, addressing the topic and based on a previous model²⁵25 Pimenta AM, Assunção AA. Estresse no trabalho e hipertensão arterial em profissionais de enfermagem da rede municipal de saúde de Belo Horizonte, Minas Gerais, Brasil. Rev Bras Saude Ocup 2016; 41(6):1-11.. This model establishes the hierarchical grouping of variables at the distal, intermediate and proximal levels (Figure 1) according to the interaction of these levels in the development process of the expected outcome, i.e., arterial hypertension. The distal level consisted of sociodemographic variables; the intermediate level consisted of variables related to lifestyle, working conditions, physical health conditions, mental health conditions; and the proximal level included anthropometric and biochemical variables²⁶26 Silveira MF, Freire RS, Nepomuceno MO, Martins AMEBL, Marcopito LF. Cárie dentária e fatores associados entre adolescentes no norte do estado de Minas Gerais, Brasil: uma análise hierarquizada. Cien Saude Colet 2015; 20(11):3351-3364..

The data were entered in duplicate, organized and analyzed using the statistical software Statistical Package for Social Sciences (SPSS®) for Windows, version 23.0. The investigated variables were described through their absolute and percentage frequency distribution. Then, a bivariate analysis was performed between the outcome variable (blood pressure) and each independent variable using the chi-square test with robust variance, in which the variables with a descriptive level of p≤0.25 were selected for the multiple analysis.

In the multiple analysis, the Multinomial Logistic Regression model was used, and the outcome was categorized into three groups: normal, prehypertension and hypertension, with professionals being classified as having hypertension stages 1, 2 and 3 in this last group. Odds Ratio with 95% confidence intervals and p≤0.05 were estimated. In this model, the “normal” category of the blood pressure variable was considered as the reference category. The goodness-of-fit of the model was adequate (Deviance Test p=0.620) and this result explained 28.9% of the outcome variability (Pseudo-R²=0.289).

The study complied with the ethical principles of the National Health Council (Conselho Nacional de Saúde - CNS) Resolution No. 466/2012 and the research project was approved by the Research Ethics Committee of Universidade Estadual de Montes Claros. All participants signed the Free and Informed Consent Form (FICF).

Results

A total of 490 health workers participated in the study, most of them female (65.9%), aged between 30 and 39 years (68.6%). Regarding the lifestyle, most professionals practiced physical activity less than 3 times a week (63.9%), reported preserved sleep quality (55.8%), did not consume alcohol and tobacco (53.2% and 97, 3%, respectively).

Regarding the working conditions, more than half of the interviewees had been working in the health area for less than 10 years (52.9%), mostly nursing assistants/technicians (66.3%), working less than 44 hours/week (56.5%) and had only one job (63.1%). It was observed that 10.6% of professionals had moderate/severe symptoms of anxiety; 97.2% were considered mild internet addicts. Regarding the anthropometric variables, 64.2% had elevated waist circumference and 40.9% were classified as overweight. As for the biochemical variables, more than half of the professionals had levels considered adequate for cholesterol (58.4%), LDL-cholesterol (67.4%), HDL-cholesterol (53%) and triglycerides (69.9%), and blood glucose was considered normal in 87.1% of the professionals.

The prevalence of AH among health workers was 21.8% [21.3%-29.3%] and that of prehypertension was 25.9% [17.8%-25.8%]. Table 1 shows the classification of blood pressure stages in the professionals.

Concerning the bivariate analysis, when analyzing the association of the disease in the studied population with the study variables, it was observed that gender (p<0.001), age range (p=0.001), marital status (p=0.216), consumption of fruits and vegetables (p=0.241), smoking status (p=0.056), sleep (p=0.105), time working in the profession (p=0.002), work shift (p<0.001), employment relationship (p=0.001), medical leave (p=0.244), number of employment contracts (p=0.250), symptoms of depression (p=0.203), quality of life: psychological domain (p=0.232), WC (p=0.002), BMI (p< 0.001), WHtR (p<0.001), Total Cholesterol (p=0.016), LDL-Cholesterol (p=0.112), Triglycerides (p=0.007) and Blood Glucose (p=0.016) were significant at the 25% level.

Table 2 shows the results of the multiple analysis for the prehypertension and hypertension categories of the outcome variable, using the normal category as a reference. Male gender (OR=3.1; CI: 1.9-5.1), age (OR=2.6; CI: 1.3-5.0), civil servants (OR=2.3; CI: 1.1-4.7), use of continuous medication (OR=2.7; IC: 1.5-5.0), were associated with AH at the distal level, (OR=2.7; CI: 1.5-5.0); and at the proximal level, overweight and obesity (OR=3.1; CI: 1.6-6.1 and OR=8.3; CI: 3.8-18.1, respectively). Male gender (OR=2.7; CI: 1.7-4.3), age range ≥40 years and between 30 and 39 years (OR=3.0; CI: 1.5-5.9 and OR =2.4; CI: 1.3-4.3, respectively), night work (OR=2.8; CI: 1.6-5.0), civil servants (OR=2.7; CI: 1.4-5.0), obesity and overweight (OR=4.3; CI: 2.1-8.6 and OR=1.9; CI: 1.1-3.3 respectively) were associated to prehypertension.

Discussion

The prevalence of AH in the studied group was similar to that found in a study carried out with health workers from Spain, of 22.9%²⁷27 Sobrino J, Domenech M, Camafort M, Vinyoles E, Coca A. Prevalence of masked hypertension and associated factors in normotensive healthcare workers. Blood Pressure Monit 2013; 18(6):326-331.. Higher results were found in a survey carried out with cardiologists in China⁶6 Hou L, Jin X, Ma J, Qian J, Huo Y, Ge J. Perception and selfmanagement of hypertension in chinese cardiologists (CCHS): a multicenter, large-scale crosssectional study. BMJ Open 2019; 9(9):1-8., with a prevalence of 63.9%, and in a general hospital in Ghana⁷7 Osei-Yeboah J, Kye-Amoah KK, Owiredu WKBA, Lokpo SY, Esson J, Johnson BB, Amoah P, Aduko RA. Cardiometabolic risk factors among healthcare workers: a cross-sectional study at the sefwi-wiawso Municipal Hospital, Ghana. Bio Med Res Int 2018; 9(1):1-9. with 52.6%. However, lower prevalence rates, of 11.1%, 14%, 16.7% and 19%, were observed in Thailand²⁸28 Angkurawaranon C, Wisetborisut U, Jiraporncharoen W, Likhitsathian S, Uaphanthasath R, Gomutbutra P, Jiraniramai S, Lerssrimonkol C, Aramrattanna A, Doyle P, Nitsch D. Chiang Mai University health worker study aiming toward a better understanding of noncommunicable disease development in Thailand: methods and description of study population. Clin Epidemiol 2014; 6(1):277-286., Malaysia²⁹29 Hazmi H, Ishak WRW, Jalil RA, Hua GS, Hamid NF, Haron R, Shafei MN, Ibrahim MI, Bebakar WM, Ismail SB, Musa KI. Traditional cardiovascular risk-factors among healthcare workers in kelantan, Malaysia. J Intern Med 2015; 261(3):285-292., Iran³⁰30 Jahromi MK, Hojat M, Koshkaki SR, Nazari F, Ragibnejad M. Risk factors of heart disease in nurses. Iran J Nurs Obstetrícia Res 2017; 22(4):332-337. and Mexico³¹31 Orozco-González CL, Sanabria LC, Franco JJV, Márquez JJR, Manzanoa AMC. Prevalencia de factores de riesgo cardiovascular em trabajadores de lasalud. Rev Med Inst Mex Seguro Soc 2016; 54(5):594-601., respectively.

In the national scenario, a study⁹9 Nascimento JOV, Santos J, Meira KC, Pierin AMG, Souza-Talarico JN. Shift work of nursing professionals and blood pressure, burnout and common mental disorders. Rev Esc Enferm USP 2019; 53:e03443. carried out in an Oncology Hospital in the city of Rio de Janeiro was identified, showing a similar design to that of the present study, whose estimated prevalence was 25.5%. However, the need for more studies to assess the prevalence of AH in this specific group of workers is highlighted, as most studies were conducted by professionals working in hospital services with general practice care, which limited the comparison of data. Also in the national context, the prevalence of the disease among health workers varied between 20.6%⁸8 Domingues JG, Silva BBC, Bierhals IO, Barros FC. Doenças crônicas não transmissíveis em profissionais de enfermagem de um hospital filantrópico no Sul do Brasil. Epidemiol Serv Saude 2019; 28(2):e2018298., 28.9%¹⁰10 Ulguim FO, Renner JDP, Pohl HH, Oliveira CF, Bragança GCM. Trabalhadores da saúde: risco cardiovascular e estresse ocupacional. Rev Bras MedTrab 2019; 17(1):61-68. and 12.7%¹¹11 Rodrigues C, Silva JP, Cabral CVS. Fatores de risco para o desenvolvimento de hipertensão arterial (HAS) entre a equipe de enfermagem. R Interd 2016; 9(2):117-126..

The prevalence of prehypertension in the present investigation was lower than that found in a Ghanaian study, whose result was 52.6%⁷7 Osei-Yeboah J, Kye-Amoah KK, Owiredu WKBA, Lokpo SY, Esson J, Johnson BB, Amoah P, Aduko RA. Cardiometabolic risk factors among healthcare workers: a cross-sectional study at the sefwi-wiawso Municipal Hospital, Ghana. Bio Med Res Int 2018; 9(1):1-9.. Moreover, a longitudinal study³²32 Egan BM, Stevens-Fabry S. Prehypertension-prevalence, health risks and management strategies. Nat Rev Cardiol 2015; 12(5):289-300. demonstrated that prehypertension increases the risk of incident hypertension, with annual rates ranging from 8% to 20%. A prospective cohort conducted by Jardim et al.³³33 Jardim TDSV, Jardim PCBV, Araújo WEC, Jardim LMSS, Salgado CM. Cardiovascular risk factors in a cohort of healthcare professionals - 15 Years of evolution. Arq Bras Cardiol 2010; 95(3):332-338., in Brazil, observed a similar result, with an increase in the prevalence of hypertension from 4.6% to 18.6% after 20 years of follow-up. Pre-hypertensive individuals are more likely to become hypertensive and have a higher risk of developing cardiovascular complications, when compared to individuals with normal BP, requiring periodic follow-up¹1 Sociedade Brasileira de Cardiologia (SBC). 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol 2016; 107(Supl. 3):1-83..

The male population in this study had a greater chance of developing pre-hypertension and AH when compared to the female population. Studies carried out in China⁶6 Hou L, Jin X, Ma J, Qian J, Huo Y, Ge J. Perception and selfmanagement of hypertension in chinese cardiologists (CCHS): a multicenter, large-scale crosssectional study. BMJ Open 2019; 9(9):1-8. and Iran³⁰30 Jahromi MK, Hojat M, Koshkaki SR, Nazari F, Ragibnejad M. Risk factors of heart disease in nurses. Iran J Nurs Obstetrícia Res 2017; 22(4):332-337. showed a significant association between male gender and hypertension. Moreover, men are more affected by this disease up to 50 years of age. On the other hand, as women produce female hormones, which are protective factors, they tend to have a low incidence before menopause, with the risk increasing from the sixth decade of life onwards³⁴34 Machado MC, Pires CGS, Lobão WM. Concepções dos hipertensos sobre os fatores de risco para a doença. Cien Saude Colet 2012; 17(5):1365-1373.. Moreover, there is a stronger association between male gender and other factors associated with AH, such as smoking, alcohol consumption, obesity and sedentary lifestyle³⁵35 Dantas RCO, Paes NA, Silva ANTC, Valenti VE, Mora JAO, Chambrone JZ, Abreu LC, Farias MCAD. Determinantes do controle da pressão arterial em homens assistidos na atenção primária à saúde. Mundo Saude 2016; 40(2):249-256..

In an investigation that aimed to characterize the metabolic and cardiovascular risk profile in an asymptomatic Brazilian adult population, it was observed that prehypertension was significantly more frequent in males and in those with a sedentary lifestyle and/or overweight. These results were also found in a population-based investigation carried out in the city of Florianópolis, state of Santa Catarina, Brazil³⁶36 Nary FC, Santos RD, Laurinavicius AG, Conceição RDO, Carvalho JAM. Relevância da pré-hipertensão como categoria diagnóstica em adultos assintomáticos. Einstein 2013; 11(3):303-309..

Regarding the age range, international studies⁶6 Hou L, Jin X, Ma J, Qian J, Huo Y, Ge J. Perception and selfmanagement of hypertension in chinese cardiologists (CCHS): a multicenter, large-scale crosssectional study. BMJ Open 2019; 9(9):1-8.^,3737 Gaudemaris R, Levant A, Ehlinger V, Hérin F, Lepage B, Soulatb JM, Sobaszek A, Kelly-Irving M, Lang T. Blood pressure and working conditions in hospital nurses and nursing assistants. The ORSOSA study. Arch Cardiovasc Dis 2001; 104(1):97-103. indicate that the older the age, the greater the chance of developing AH, which corroborates the results of the present study, since professionals over 30 years old were more likely to develop prehypertension, and those over 40 years of age, to develop AH, when compared to the group of professionals aged between 20 and 29 years. There is a direct and linear association between aging and the prevalence of AH, justified by aging and vascular stiffening¹1 Sociedade Brasileira de Cardiologia (SBC). 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol 2016; 107(Supl. 3):1-83..

Professionals who worked the night shift were more likely to develop prehypertension when compared to day shift workers. A cohort study carried out with American nurses³⁸38 Gangwisch JE, Feskanich D, Malaspina D, Shen S, Forman JP. Sleep, duration and risk for hypertension in women: results from the nurses' health study. Am J Hypertens 2013; 26(7):903-911. showed that professionals who slept less than five hours a day were 1,19-fold [1.14-1.25] more likely to develop high blood pressure values, when compared to those who slept more than seven hours a day. It is known that a short sleep duration, common among night workers, is a significant etiological factor for the increase in BP and the development of AH. An investigation conducted with nurses in Italy³⁹39 Copertaro A, Bracci M, Barbaresi M. Valutazione dell'omocisteina nei lavoratori turnisti. Monaldi Arch Chest Dis 2008; 70(1):24-28. showed that, in this group of professionals, there is a greater consumption of coffee, cigarettes, alcohol, hypnotic drugs and a sedentary lifestyle. Moreover, sleep deprivation prolongs exposure to stress, increases appetite, favors obesity and increases serum total cholesterol levels, factors that are highly associated with the development of AH³⁸38 Gangwisch JE, Feskanich D, Malaspina D, Shen S, Forman JP. Sleep, duration and risk for hypertension in women: results from the nurses' health study. Am J Hypertens 2013; 26(7):903-911..

Professionals who were civil servants had a greater chance of developing prehypertension and AH, similar to the investigation carried out in the national context by Cunha et al.⁴⁰40 Cunha CLF, Moreira JPL, Oliveira BLCA, Bahia L, Luiz RR. Planos privados de saúde e a saúde dos trabalhadores do Brasil. Cien Saude Colet 2019; 24(5):1959-1970., who showed a prevalence of 21% among civil servants and 15.5% in other workers. Civil servants have better labor and economic stability and a set of labor rights that are different from those of the other workers; however, during the data collection period, the assessed Brazilian state was going through a financial crisis that resulted in delayed payment to civil servants⁴¹41 Barbosa LOS, Leal Filho RS, Oliveira Junior FA, Sousa FMP. Ideologia partidária e crise fiscal dos estados: o caso de Minas Gerais. Nova Economia 2019; 29(2):487-513.. These delays may have reflected on the physical and emotional health of these professionals, as well as arbitrated changes in lifestyle, with a direct impact on diet, physical activity, leisure and, consequently, on prehypertension and AH status.

Furthermore, workers who used continuous medications were more likely to develop AH. Similar results were found in national surveys⁸8 Domingues JG, Silva BBC, Bierhals IO, Barros FC. Doenças crônicas não transmissíveis em profissionais de enfermagem de um hospital filantrópico no Sul do Brasil. Epidemiol Serv Saude 2019; 28(2):e2018298.^,1111 Rodrigues C, Silva JP, Cabral CVS. Fatores de risco para o desenvolvimento de hipertensão arterial (HAS) entre a equipe de enfermagem. R Interd 2016; 9(2):117-126. which showed that more than half of the professionals used continuous medication, with oral contraceptives being the most prevalent class. A study shows that women who use this medication have two-to-three fold greater chances of having AH than those who do not use this contraceptive method, as this drug causes a small increase in cardiac output⁴²42 Andrade AWL, Lima EFB. Avaliação dos efeitos dos contraceptivos orais sobre os níveis tensionais. Rev Eletr Farm 2016; 13(3):140-150..

Overweight and obesity are strong factors associated with AH. In this study, obese professionals were 8.3-fold more likely to develop AH when compared to professionals with normal weight. Lower results were found in international studies in China with OR=1.31⁶6 Hou L, Jin X, Ma J, Qian J, Huo Y, Ge J. Perception and selfmanagement of hypertension in chinese cardiologists (CCHS): a multicenter, large-scale crosssectional study. BMJ Open 2019; 9(9):1-8. and in Mexico with OR=3.6³¹31 Orozco-González CL, Sanabria LC, Franco JJV, Márquez JJR, Manzanoa AMC. Prevalencia de factores de riesgo cardiovascular em trabajadores de lasalud. Rev Med Inst Mex Seguro Soc 2016; 54(5):594-601.. Overweight and obesity can be explained by the irregular practice of physical activity and inadequate diet, being related to diabetes, cardiovascular disease and cancer. In the work environment, they are supposedly associated with occupational injuries, increased absenteeism rates, discrimination, presenteeism and reduced productivity¹⁰10 Ulguim FO, Renner JDP, Pohl HH, Oliveira CF, Bragança GCM. Trabalhadores da saúde: risco cardiovascular e estresse ocupacional. Rev Bras MedTrab 2019; 17(1):61-68..

The results of this study should be considered, as they are representative of the population of workers working in high-complexity services that care for critically-ill and chronic patients in the North of Minas Gerais, Brazil. It is expected that the dissemination of the obtained information will be considered by the managers who work with this group of professionals. Furthermore, it is appropriate to emphasize the need to expand research in the scientific community aimed at discussing the prevalence of prehypertension and AH and their associated factors among these professionals. This investigation also highlights the importance of working directly with the workers with a higher chance of developing prehypertension in a preventive manner, encouraging changes in habits and the adoption of a healthy lifestyle.

The prevalence of AH in the assessed group was lower than that found in the Brazilian population. Although the population assessed in this study has received formal education in health-related areas, the results reinforce the importance of investing in preventive measures, carried out by hospital managers, aimed at encouraging changes to a healthy lifestyle, such as adequate nutrition and regular physical activity among these professionals. It is also important to promote respect for the rest periods and adequate conditions for the professionals’ rest, as such measures contribute not only to improving the overall well-being, but also to weight and anxiety control, reduction of depressive states and disease prevention. This occurs because, by taking care of diet and physical activity in the workplace, they open up the possibility of improving the workers’ health, contributing to a positive and social image of the company, increasing the teams’ self-esteem, reducing staff turnover and work absenteeism, increasing productivity and reducing medical leave and the costs of medical care and disability among these professionals.

Some limitations of this study need to be considered. The use of a self-administered questionnaire is susceptible to misinterpretation and mistakes when filling it out, and it is also possible that the professionals have underreported behaviors considered to be negative to health, as the research took place in the hospital environment. Moreover, the small number of investigations carried out with professionals working in hospital services that deal with critically-ill and chronic patients made it difficult to compare the findings. However, the methodological rigor used in the investigation is highlighted, such as sample planning, the use of validated instruments, the training and calibration of examiners, adequate data collection techniques and entering data in duplicate. These points maintained the quality control of the instruments and ensured study validity and reliability regarding the presented analysis and strategies.

Conclusion

The prevalence of prehypertension and AH among health professionals demonstrates the need to adopt mechanisms that act on modifiable risk factors, such as encouraging physical activity, adopting healthier eating habits, as well as promoting the implementation of health policies that encourage changes inside and outside the work environment, with greater focus on workers’ health prevention and promotion. Therefore, it is necessary to engage professionals and managers of health services, in a joint and complementary manner, aiming to facilitate better health situations.

Well-informed workers who are aware that their behavior can determine the greater or lesser risk of becoming ill are certainly healthier and more productive. It is also important to emphasize the effort that must be applied to adapt the workplace to the needs of individuals, aiming to reduce public expenses arising from pathological processes directly related to labor dysfunctions.

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