Abstracts

Introduction

Arterial hypertension (AH) plays a completely recognized role in the genesis of health conditions resulting from target organ injuries, with great individual and collective impact, such as the coronary disease, stroke and chronic kidney disease¹1. Whelton PK, Beevers DG, Sonkodi S. Strategies for improvement of awareness, treatment and control of hypertension: results of a panel discussion. J Hum Hypertens 2004; 18: 563-5.. The condition has other possible consequences, with potential repercussion in the daily life of the patient. Besides the possibility of clinical symptoms directly related to high blood pressure (BP) values, the use of pharmacological antihypertensive therapy can worsen the quality of life of the user²2. Lawrence WF, Fryback DG, Martin PA, Klein R, Klein BEK. Health status and hypertension: a population based-study. J Clin Epidemiol 1996; 49: 1239-45. due to the effects induced by the used drugs.

Another mechanism that can cause the patient with AH to suffer repercussions in activities of daily living is the adoption of specific behaviors or different perceptions about health status, simply due to the fact that this patient is aware of having this condition. Among these behaviors, it is possible to mention: amplification of symptoms, missing work days, deterioration of social relations, and more frequent use of health services³3. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999; 130: 910-21.. The first study designed specifically to approach this phenomenon in relation to AH was conducted by Haynes et al.⁴4. Haynes RB, Sackett DL, Taylor W, Gibson ES, Johnson AL. Increased absenteeism from work after detection and labeling of hypertensive patients. New Engl J Med 1978; 299: 741-4., who observed an 80% increase in missed work days among workers who had been diagnosed with hypertension in a tracking program, without relating it to drug therapy or BP levels. In a study that analyzed quality of life, Mena-Martin et al.⁵5. Mena-Martin FJ, Martin-Escudero JC, Simal-Blanco F, Carretero-Ares JL, Arzua-Mouronte D, Herreros-Fernandez V. Health-related quality of life of subjects with known and unknown hypertension: results from the population-based Hortega study. J Hypertens 2003; 21: 1283-9. observed better scores of general health perception, functional capacity, vitality and mental health among normotensive individuals in comparison to hypertensive ones who were aware of their condition, but there was no difference in these parameters between normotensive individuals and hypertensive ones who were not aware of the disease.

There are few studies analyzing if the consequences of being aware of the condition are homogeneous in the several sociodemographic population strata. The reactions of the individuals to the presence of physical symptoms or to the fact of perceiving themselves as being sick can be influenced, for instance, by attributes such as gender⁶6. Van Wijk CMTG, Huisman H, Kolk A. Gender differences in physical symptoms and illness behavior. A health diary study. Soc Sci Med 1999; 49: 1061-74., age and socioeconomic position. Older people, in response to acute or chronic physical conditions, can become more vigilant as to the observation of changes in their health status⁷7. Stein EM. When is hypochondriasis not hypochondriasis? Emotional and behavioral adaptations to aging and illness. Geriatrics 2003; 58: 41-2.. Barger and Muldoon⁸8. Barger SD, Muldoon MF. Hypertension labelling was associated with poorer self-rated health in the Third US National Health and Nutrition Examination Survey. J Hum Hypertens 2006; 20: 117-23. used data from the National Health and Nutrition Examination Survey (NHANES) and found a relationship between the awareness of AH and the worst self-reported health among participants of NHANES, however, they did not detect effective changes according to gender or ethnical group.

In Brazil, it was not possible to locate studies addressed to this phenomenon specifically in literature. One analysis conducted in São Pauo identified behaviors and reactions in individuals after being diagnosed with AH, which ranged from absence of changes in life until the feeling of "a tragedy... too much suffering... I can no longer do what I used to do"⁹9. Castro VD, Car MR. O cotidiano da vida de hipertensos: mudanças, restrições e reações. Rev Esc Enferm USP 2000; 34: 145-53.. Firmo et al.¹⁰10. Firmo JOA, Lima-Costa MF, Uchoa E. Projeto Bambuí: maneiras de pensar e agir de idosos hipertensos. Cad Saúde Pública 2004; 20: 1029-40. investigated how elderly people classified as hypertensive thought and identified that "generally, interviewees say that the fact of having a blood pressure condition does not bring major disturbances into their lives"; however, many participants mentioned they were obliged to change their routine since they are not able to perform their daily living activities "when the pressure goes up".

The temporary inability to perform activities of daily living, defined as a temporary restriction in the usual functional capacity of the individual¹¹11. World Health Organization. Health interview surveys: towards international harmonization of methods and instruments. Copenhagen; 1996. (WHO Regional Publications, European Series, 58. ., is health status indicator recommended by the World Health Organization (WHO) for population studies, and it can be useful to assess the impact of a disease or condition on the daily life of a person. It can be analyzed with regard to different periods of time, but it is recommended that it does not make reference to more than two weeks earlier, since it is possible that the person cannot remember an episode that took place many days ago¹¹11. World Health Organization. Health interview surveys: towards international harmonization of methods and instruments. Copenhagen; 1996. (WHO Regional Publications, European Series, 58. .. ITAH has been used in our context for investigations about health conditions in the National Household Sample Survey (PNAD), and it can be considered as a broader health indicator. The number of days with restricted activities is considered to be an important measure for the individual's functional state and well-being¹²12. Kosorok MR, Omenn GS, Diehr P, Koepsell TD, Patrick DL. Restricted activity days among older adults. Am J Public Health 1992; 82: 1263-7.. The compromise of activities of daily living due to health problems is a more prominent indicator of quality of life tan specific diseases¹³13. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saúde Pública 2003; 19: 745-57.. Considering the other possible mechanisms mediating consequences of AH in the daily life of a patient, we observed the association between the use of antihypertensive medication and the occurrence of temporary incapacity for 8 to 14 days in a previous study¹⁴14. Goffredo Filho GS, Faerstein E. Incapacidade para atividades habituais: relação com pressão arterial e terapêutica anti-hipertensiva. Arq Bras Cardiol 2010; 94: 472-6., probably because of the adverse effect of the drugs. On the other hand, we observed an inverse association between the reported systolic BP value and the occurrence of ITAH for a seven day period, and we possibly attributed this finding to a hypoalgesia mechanism associated to AH¹⁵15. Zamir N, Shuber E. Altered pain perception in hypertensive humans. Brain Res 1980; 201: 471-4. ^{, 16}16. Hagen K, Zwart JA, Holmen J, Svebak S, Bovim G, Stovner LJ. Does hypertension protect against chronic musculoskeletal complaints? The Nord-Trøndelag Health Study. Arch Intern Med 2005; 165: 916-2..

In this study, we investigated if the self-reported history referring to the previous diagnosis of AH is associated with the frequency and the duration of temporary incapacity for usual activities, and if this relationship changes according to gender, age or socioeconomic position.

Methods

Study design and population

We analyzed data from the Pró-Saúde Study, a longitudinal investigation of technical and administrative staff of a university located in the state of Rio de Janeiro. The target population was identified by the combination of lists provided by the human resources department of the institution, by the sector in charge of payroll and directly by their units and sectors. Employees conceded to other institutions and on leave for reasons unrelated to health were excluded. The whole data collection process was conducted by trained teams of researchers, supervisors and field coordinators. Every day, questionnaires were revised and double-typed independently.

In our sectional study, we used data concerning the employees who participated in the first two stages of data collection (1999 and 2001). Out of the 4,177 eligible workers to participate in the cohort, we obtained information about 3,253 employees. After the exclusion of two workers aged more than 80 years old and of participants with missing or inconsistent data with regard to having received a prior diagnosis of AH or about ITAH, our study population consisted of 2,666 participants (63.8% of the eligible ones).

Measures

The previous diagnosis of AH, our exposure variable, was assessed by the following questions: "Has a DOCTOR or another HEALTH PROFESSIONAL ever informed you had or have hypertension, that is, high blood pressure?". The response options were: "no"; "yes, only once" and "yes, more than once", whose participants were grouped together; and "yes, only during pregnancy", whose individuals were excluded from the study population. A test-retest reliability assessment of this information was obtained in an additional study to this investigation, conducted in 1999 with 192 participants¹⁷17. Faerstein E, Chor D, Lopes CS. Reliability of the information about the history of diagnosis and treatment of hypertension. Differences in regard to sex, age, and educational level. The Pró-Saúde study. Arq Bras Cardiol 2001; 76: 301-4., which estimated a 0.75 kappa coefficient (95%CI 0.73 - 0.77) after the repetition of the questionnaire with a two-week interval.

As outcome, the occurrence and the duration of temporary incapacity episodes to perform usual activities in the 14 previous days were considered. This information was obtained by the questions: "In the PAST TWO WEEKS, were you prevented from doing any of your usual activities (for instance, work, leisure or household chores) because of a health condition you had or have?". The participants who reported temporary incapacity were then asked: "In the PAST TWO WEEKS, for HOW MANY DAYS, in total, were you prevented from doing any of your usual activities (for instance, work, study, leisure or household chores) due to this or these health problem(s) you have or had?". A test-retest reliability study of the questionnaire was conducted with 94 employees who were not hired by the university. The result of this study estimated the reliability of the response about the non-interruption of usual activities in 0.73 (95%CI 0.71 - 0.75) (kappa coefficient). Based on the observed distribution, our outcome variable was built with the categorization of the participants in three strata: those who did not report incapacity, the ones who reported it for up to 7 days, and the ones who reported incapacity between 8 and 14 days.

Some variables were considered as potential confusion factors. Age, body mass index (BMI, in kg/m²⁾, measured systolic and diastolic BP value at the time of data collection and per capita household income (in the minimum wages at the time) were treated as continuous variables, and we applied a logarithmic transformation to the latter, since its distribution presented great asymmetry to the right. Specifically concerning the measurement of BP, field researchers were trained by a material produced by the British Medical Journal¹⁸18. Beevers G, Lip GYH, O'Brien E. ABC of hypertension. Blood pressure measurement. Part II - Conventional sphygmomanometry: technique of auscultatory blood pressure measurement. Brit Med J 2001; 322: 1043-7.. Several strategies were used for the quality control of BP measures: observation of field measurements by 2 supervisors, randomly, approaching all of the measurers; maintenance of the equipment used for measurements; monthly evaluation of BP reports with individual records of measurers, in order to look for the occurrence of bias in digital terminals; fortnightly assessment of the proportion of missing data and identical BP measures.

Categorical variables were: gender; presence of comorbidities (participants who declared to have been informed by a doctor to have "diabetes" and/or "high cholesterol" were considered as a person with comorbidity); the use of antihypertensive medication and schooling, with three categories of stratification: participants with complete elementary school, complete high school and with a college degree.

Statistical procedure

After the descriptive data evaluation, we conducted an initial bivariate analysis between exposure and outcome. Afterwards, we performed a multivariate analysis by means of a multinomial logistic regression to evaluate the influence of potential confusion factors, by using the odds ratio to measure the magnitude of the association. The use of this model was based on the absence of intrinsic ordering between the outcome categories¹⁹19. Ananth CV, Kleinbaum DG. Regression models for ordinal responses: a review of methods and applications. Int J Epidemiol 1997; 26: 1323-33..

Regression models were conducted at first in the study population as a whole, involving all of the mentioned co-variables, and afterwards in the gender, age, per capita household income and schooling strata. Since the population did not present a large number of older individuals, we divided the participants into two groups: those aged until 54 years old, and from 55 years old on. Concerning the per capita income, participants were grouped in: less than 3, between 3 and 6, or more than 6 minimum wages at the time. With regard to schooling, strata were defined by: participants with complete elementary school, those with complete high school and the ones with college degree or more. In the subgroups of gender, per capita household income and schooling, models exclude only the co-variable whose strata were under investigation, while in the different age groups age was maintained as a co-variable in the model, as a strategy against residual confusion.

All of the regression procedures were conducted only with observations that did not present absent values in none of the co-variables, and the mentioned analyses were repeated after the interviewees who reported a previous diagnosis of myocardial infarction (MI), angina or stroke were excluded. The statistical procedures were conducted with the software Stata 9.1.

These protocols were submitted and approved by the Research Ethics Committee of the university where the study was conducted. Participants were informed about the Pró-Saúde Study and its objectives and signed the informed consent form.

Results

Table 1 shows the distribution of co-variables among the 2,666 participants, with small prevalence of female participants, the group with per capita household income of up to 3 minimum wages and individuals with higher schooling. The frequencies of previous diagnosis of comorbidities (diabetes mellitus or dyslipidemia) and angina, MI or stroke are in the same table. The mean age of participants was of 41.6 years old (ranging from 24 and 69 years old), and 196 individuals were 55 years old or more (7.4%). BMI ranged from 15 and 64, with mean of 26.2 (data not shown in the table). The mean value of systolic pressure was 116.8, and 73.5 mmHg for diastolic pressure.

In this population, 828 individuals (31.1%) had already been informed about having AH by health professionals. Temporary incapacity for usual activities in the 2 previous weeks was reported by 623 participants (23.4%), with mean duration of 2.9 days and median of 2 days. Among those who reported time of incapacity, it lasted up to 7 days in 488 cases (83%), and for 99 participants (16.9%), from 8 to 14 days.

Table 2 shows the proportion of participants who reported ITAH in the subgroups of individuals who had been diagnosed with AH or not. In both groups it is possible to observe great prevalence of participants who did not report ITAH, and a small proportion of individuals reporting ITAH for more than 7 days.

In the regression analysis, considering the adjusted odds ratio for the co-variables, no association was observed between the awareness of a previous diagnosis of AH and the occurrence of ITAH, be it in the general population, among men and women, or in the strata of per capita household income and schooling (Table 3). There was an effect modification according to age group: in individuals aged more than 54 years old, we observed more chances of ITAH among participants who had been diagnosed with AP, with adjusted odds ratio of 9.5 (Table 3).

Results remained practically unaltered when analyses were repeated with the exclusion of individuals who reported previous angina, MI or stroke (data not shown).

Discussion

After the adjustment for gender, age, per capita household income, schooling, BMI, systolic and diastolic BP, report of comorbidities and use of antihypertensive medication, our results do not suggest the presence of association between the previous diagnosis of AH and the occurrence of temporary incapacity for usual activities in almost all of the studied groups (total population, men and women, different levels of per capita income and schooling) and in the two assessed periods of duration of incapacity (up to 7 days, and 8 to 14 days). However, among individuals aged more than 54 years old, the association between previous information of AH and ITAH up to 7 days presented a remarkable and statistically significant magnitude, even after the adjustment by the described variables (OR = 9.50).

ITAH can be seen as a specific modality of the so called illness behavior²⁰20. Alves PC. A experiência da enfermidade: considerações teóricas. Cad Saúde Pública 1993; 9: 263-71.. This concept comes from the early descriptions by Sigerist (1929) about the "special position of the sick person", and especially from the theoretical construction of Talcott Parsons (1951) about the "sick role"²¹21. Mechanic D. Sociological dimensions of illness behavior. Soc Sci Med 1995; 41: 1207-16., in which specific attitudes and wishes considered to be socially adequate for a person who is seen as being sick are described²²22. Segall A. The sick role concept: understanding illness behavior. J Health Soc Behav 1976; 17: 163-70.. Mechanic and Volkart first used the term illness behavior in 1961²³23. Mechanic D, Volkart EH. Stress, illness behavior, and the sick role. Am Sociol Rev 1961; 26: 51-8., in order to approach the great variability of reactions in relation to the presence of symptoms or the perception of the disease, and to identify social, cultural, environmental and psychological components that could influence these reactions²¹21. Mechanic D. Sociological dimensions of illness behavior. Soc Sci Med 1995; 41: 1207-16.. This conceptual elaboration indicates a change in focus: from a global "macro-sociological" analysis, it begins to focus on behaviors of specific social groups²⁰20. Alves PC. A experiência da enfermidade: considerações teóricas. Cad Saúde Pública 1993; 9: 263-71.. Afterwards, Mechanic defines the sick behavior more broadly, as the "several forms in which individuals react to physical symptoms, how they monitor their internal status, define and interpret symptoms, attributing values to them, adopting attitudes with therapeutic objective, and looking for formal or informal health care"²¹21. Mechanic D. Sociological dimensions of illness behavior. Soc Sci Med 1995; 41: 1207-16..

From this amplification of the conceptual field, it is possible to find several investigations approaching different modalities of illness behavior and their determinants. Young mentions examples of different behaviors associated with ethnical and cultural factors: in New York, individuals descending from Italians expressed more concern in response to painful symptoms, while those descending from the Irish were more optimistic and satisfied in their relationship with the assisting doctor²⁴24. Young JT. Illness behavior: a selective review and synthesis. Sociol Health Ill 2004; 26: 1-31.. By assessing patients with celiac disease in the remission period, Rosa et al. detected attitudes considered to be of disproportional fear in relation to the disease in 24% of the individuals²⁵25. Rosa A, Troncone A, Vacca M, Ciacci C. Characteristics and quality of illness behavior in celiac disease. Psychosomatics 2004; 45: 336-42..

Other studies observed changes in behavior and in valorization of the symptoms among individuals diagnosed with AH. Mold et al. observed that the estimated time by the patients to recover their health status from a high respiratory infection was practically twice as high among hypertensive individuals when compared to normotensive people²⁶26. Mold JW, Hamm RM, Jafri B. The effect of labeling on perceived ability to recover from acute illnesses and injuries. J Fam Practice 2000; 49: 437-40.. Bloom e Monterossa observed that patients who had claimed to be hypertensive, and, however, after a new assessment presented with normal pressure values with no specific treatment, reported more depressive symptoms and worse health perception than normotensive people²⁷27. Bloom JR, Monterossa S. Hypertension labeling and sense of well-being. Am J Public Health 1981; 71: 1228-32.. Leynen et al. observed more missed work days among hypertensive or dyslipidemic individuals who were aware of having these conditions when compared to unaware workers²⁸28. Leynen F, Backer G, Pelfrene E, Clays E, Kittel F, Moreau M, et al. Increased absenteeism from work among aware and treated hypertensive and hypercholesterolaemic patients. Eur J Cardiov Prev R 2006; 13: 261-7..

There was no association between the awareness of a previous AH diagnosis and the occurrence of ITAH in the group of our study population. It is possible to speculate that the studied population, for some specific demographic characteristic, would not be prone to adopting such behavior. It could be assumed that specific individuals would have the tendency to underestimate or voluntarily omit the occurrence of temporary incapacity, since the information was collected in the work environment. Even if it is not possible to completely rule out the aforementioned situations, we believe its occurrence was very rare because of the emphasis manifested by the collection teams as to data secrecy, the explanation in the question that it was about any of the usual activities of the interviewee, and because of a certain "dilution" effect, since the question was in the middle of the questionnaire together with other data without a direct relation with this one. Another possibility is that this specific modality of illness behavior is not commonly adopted by the individuals. We cannot confirm or refuse this hypothesis, since this outcome (ITAH) was mostly used in previous investigations as a health indicator, and not in the context of investigating illness behavior. Finally, we can speculate as to the lack of a direct correspondence between the fact that the individual had already been informed about the AH but, finally, really considering to have this condition. It is possible that part of the interviewees who had already received this information took it for granted, and did not see themselves as hypertensive patients, which would make their perceptions and actions similar to those of someone who did not receive such information.

We did not observed the influence of gender in the relationship between being aware of a previous AH diagnosis and the occurrence of ITAH. The difference between genders when it comes to the reaction to the presence of feelings possibly interpreted as symptoms or diseases is remarkable. Adult women tend to report physical symptoms more often and more intensively than men²⁹29. Van Wijk CMTG, Kolk AM. Sex differences in physical symptoms: the contribution of symptom perception theory. Soc Sci Med 1997; 45: 231-46., and they also look for health care services more often³⁰30. Macintyre S, Ford G, Hunt K. Do women 'over-report' morbidity? Men's and women's responses to structured prompting on a standard question on long standing illness. Soc Sci Med 1999; 48: 89-98.. Banegas et al. observed that the fact of being aware of the hypertensive condition among women was associated with reduced quality of life in several dimensions; among men, such fact was detected in fewer domains³¹31. Banegas JR, Guallar-Castillón P, Rodríguez-Artalejo F, Graciani A, Lopéz-García E, Ruilope LM. Association between awareness, treatment, and control of hypertension, and quality of life among older adults in Spain. Am J Hypertens 2006; 19: 686-93.. However, this more frequent perception of symptoms does not necessarily translate into the more frequent adoption of some modalities of illness behavior. In the investigation by Van Wijk et al.⁶6. Van Wijk CMTG, Huisman H, Kolk A. Gender differences in physical symptoms and illness behavior. A health diary study. Soc Sci Med 1999; 49: 1061-74., women reported physical symptoms more often and more intensively than men; however, there was no difference between genders as to the restriction of activities and use of medications. On the other hand, Reis et al.³²32. Reis JR, Rocca PF, Silveira AM, Bonilla IML, Giné AN, Martin M. Fatores relacionados ao absenteísmo por doença em profissionais de enfermagem. Rev Saúde Públ 2003; 37: 616-23. detected more proportion of short term work leave among women, in a sample of nurse professionals. It is important to notice that the aforementioned studies approach outcomes that can even be characterized as illness behavior, but they have differences in relation to each other.

We did not detect differences in the association between being aware of the previous AH diagnosis and the occurrence of ITAH in the different socioeconomic strata. Once our study is basically exploratory, we chose to use one more indicator (schooling and per capita household income) in order to reach different dimensions from that construct³³33. Braveman PA, Cubbin C, Egerter S, Chideya S, Marchi KS, Metzler M, et al. Socioeconomic status in health research. One size does not fit at all. J Am Med Assoc 2005; 294: 2879-88., which could change the relation investigated through different paths. The direct association between ITAH and the worse socioeconomic condition has been observed in our field by some investigations¹³13. Lima-Costa MF, Barreto S, Giatti L, Uchoa E. Desigualdade social e saúde entre idosos brasileiros: um estudo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saúde Pública 2003; 19: 745-57. ^{, 34}34. Lima-Costa MF, Guerra HL, Firmo JOA, Vidigal PG, Uchoa E, Barreto SM. The Bambuí Health and Aging Study (BHAS): private health plan and medical care utilization by older adults. Cad Saúde Pública 2002; 18: 177-86.. However, we did not find other studies specifying the occurrence of ITAH according to social condition associated with other factors. By approaching outcomes that were somehow similar, Alexopoulos et al. observed that the low schooling was associated with a higher rate of absence at work among individuals with low back pain³⁵35. Alexopoulos EC, Konstantinou EC, Bakoyannis G, Tanagra D, Burdorf A. Risk factors for sickness absence due to low back pain and prognostic factors for return to work in a cohort of shipyard workers. Eur Spine J 2008; 17: 1185-92.. On the other hand, in the work by Barger and Muldoon⁸8. Barger SD, Muldoon MF. Hypertension labelling was associated with poorer self-rated health in the Third US National Health and Nutrition Examination Survey. J Hum Hypertens 2006; 20: 117-23., the relationship between the awareness of AH and self-reported health did not change according to ethnical group (white, black or Hispanic). In the most detailed analysis by Boltanski about the somatic culture in different social classes, the author describes how the interest and the attention conceived by the individuals to their own bodies increase when they rise in social class³⁶36. Boltanski, L. As classes sociais e o corpo. 2ª edição. Rio de Janeiro: Edições Graal; 1984.. Therefore, poorer individuals would tend to use the body mostly as an "instrument" of "maximum use", adopting more resistant actions to perceptions that would lead to the abandonment of daily tasks; it is as if these individuals, to quote the author, "accepted the sick roll less easily".

There are two factors that implicate prudence with regard to the generalization of our results in relation to socioeconomic position, and both are related to the characteristics of the researched population. Since it is composed of employees hired in a university, there are certainly not individuals from the whole spectrum of social strata, particularly very poor ones. Besides, since they worked in a specific institution, their relationship with work, and possibly with other aspects of life, can be filled with peculiarities, thus compromising their representativeness in relation to other population groups.

In our study, a strong association has been detected between previous awareness of the AH diagnosis and incapacity for up to 7 days only in the population aged 55 years old or more. This mean age of this group is of 59 years old, being 33.5% male participants, and with 8.1% of them reporting previous angina, MI or stroke. With regard to the main study variables, 64.4% of them had already been informed about having AH by health professionals, and temporary incapacity was reported by 22.3% of the participants. This finding is different from the result observed in the only study we found focused on this specific question. In the investigation by Firmo et al., the association found in the bivariate analysis between the awareness of the hypertensive condition and the occurrence of temporary incapacity in a population aged > 60 years old or more was not confirmed after the adjustment for confusion variables³⁷37. Firmo JOA, Uchoa E, Lima-Costa MF. Projeto Bambuí: fatores associados ao conhecimento da condição de hipertenso entre idosos. Cad Saúde Pública 2004; 20: 512-21.. Some factors may have contributed with this difference. Our study, unlike the mentioned one, used not only the fact of temporary incapacity, but also the time of incapacity. We used this approach due to the previous work that suggested that different incapacity times can be related to several factors¹⁴14. Goffredo Filho GS, Faerstein E. Incapacidade para atividades habituais: relação com pressão arterial e terapêutica anti-hipertensiva. Arq Bras Cardiol 2010; 94: 472-6., therefore increasing the specificity of our outcome.

Besides, there are important differences between the populations in the two studies. In our case, it is population who works and lives in a large city, while the study by Firmo et al. uses a population-based cohort from a small city in the state of Minas Gerais; there, possibly a significant part of the participants no longer works. Considering that the illness behavior globally suffers major influence from sociocultural factors, it is possible that these different population profiles justify the different results that were found. For example, we can speculate that an economically active population performs more daily activities, therefore, being more susceptible to not being able to conduct any of these activities.

It is possible that the higher occurrence of ITAH in workers aged more than 54 years old who had been diagnosed with AH is the expression of more attitudes of sensitivity and vigilance of these individuals in relation to changes that can represent the worsening of their health conditions⁷7. Stein EM. When is hypochondriasis not hypochondriasis? Emotional and behavioral adaptations to aging and illness. Geriatrics 2003; 58: 41-2.. In the process of adjustment to a new condition, one factor considered to be relevant for the motivation to adopt a specific behavior is the perception of more susceptibility³⁸38. Sharpe L, Curran L. Understanding the process of adjustment to illness. Soc Sci Med 2006; 62: 1153-66.. Due to the known changes in the physical condition at this age group, and the higher probability to develop health in general, it is possible that these individuals adopt such behavioral pattern in response to information that is interpreted as a threat to health more frequently than younger people. An alternative explanation could be based on the occurrence of ITAH in relation to target organ injuries, because most of these individuals possibly have had AH for much longer than younger people. However, the results were basically the same when the analyses were conducted after the exclusion of the participants who reported previous history of angina, MI or stroke.

Generally, our results are inconsistent with those by Taimela et al., who observed lower probability of missing work among individuals aged more than 45 years old when compared to those younger than 40 years old³⁹39. Taimela S, Llara E, Malmivaara A, Tiekso J, Sintonen H, Justén S, et al. Self-reported health problems and sickness absence in different age groups predominantly engaged in physical work. Occup Environ Med 2007; 64: 739-46.. However, Adamson et al. observed that the tendency to look for health care because of thoracic pain, especially among women, increased with age⁴⁰40. Adamson J, Donovan J, Ben-Shlomo Y, Chaturvedi N, Bowling A. Age and sex interaction in reported help seeking in response to chest pain. Brit J Gen Pract 2008; 58: 318-23., which can be interpreted as a similar attitude to that approached in our investigation.

As in the situation when the awareness of having AH cannot lead individuals to be considered as effectively hypertensive, it is necessary to emphasize the possibly ambiguous relationship between the aforementioned data and the use of hypertensive medication. We can speculate that those individuals who use this therapy are more prone to really considering themselves as hypertensive, and, therefore, to adopting specific behaviors because of that. Since the use of medication showed association with ITAH from 8 to 14 days¹⁴14. Goffredo Filho GS, Faerstein E. Incapacidade para atividades habituais: relação com pressão arterial e terapêutica anti-hipertensiva. Arq Bras Cardiol 2010; 94: 472-6. in another investigation, its inclusion was mandatory in the statistical analysis as a possible confusion variable. However, this procedure can have led to a hyper-adjustment, which on the one hand may have attenuated the association researched in the population as a whole or in some subgroups, but on the other, turns the association found in the subgroup aged more than 54 years old even more robust.

Final considerations

We characterized ITAH as a modality of illness behavior, both with the objective of contextualizing it inside a broad spectrum of reactions of individuals in relation to the health-disease question, and so we can confront our findings with other data from literature. From another point of view, we emphasize that ITAH is important, since it is a relevant indicator of health and quality of life. We understand that the simple fact of an individual being diagnosed with a specific condition, in this case, AH, may lead to consequences in his or her routine. The assessment of this process cannot only contribute with the better understanding of a broad spectrum of human reactions to the sickening process, and enable that the care to the individual who looks for health care includes more adequate orientations, with positive repercussion in on health status, especially if we consider the higher vulnerability of elderly people, among which we detected the possible consequence of mere information. Further investigations about the subject should contemplate, additionally, the reported causes of temporary incapacity.

References

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History