Risk factors for systemic arterial hypertension: Evaluation of the effectiveness of health education actions

ARTIGO ORIGINAL

COSTA, Edinaldo Siqueira da ^[1], SILVA, Silvana Rodrigues da ^[2]

COSTA, Edinaldo Siqueira da. SILVA, Silvana Rodrigues da. Risk factors for systemic arterial hypertension: Evaluation of the effectiveness of health education actions. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 05, Ed. 08, Vol. 12, pp. 171-193. August 2020. ISSN: 2448-0959, Access link: https://www.nucleodoconhecimento.com.br/health/arterial-hypertension, DOI: 10.32749/nucleodoconhecimento.com.br/health/arterial-hypertension

SUMMARY

Systemic Arterial Hypertension is the most frequent of cardiovascular diseases and responds as the main risk factor for the most common complications, such as stroke and acute myocardial infarction, in addition to end-stage chronic kidney disease. Health education is the main tool for changes in habits and lifestyle, fundamental in the preventive process for this pathology. The aim of this research was to analyze the influence of educational actions in health on systemic arterial hypertension in the change of lifestyle of the servants of the Court of Justice of the State of Amapá. The study had the participation of 255 servers and a questionnaire was used for data collection, which were analyzed through SPSS version 22 (IBM SPSS, USA). It was observed that 54.1% were female, 66.3% brown, 33.7% aged between 40 and 49 years, 47.8% had higher education and 59.6% were married or lived in a stable union. The Body Mass Index showed that 48.2% were overweight, 64.7% had increased abdominal circumference and 10.6% had capillary blood glucose values ≥ 99 mg/dL. Regarding blood pressure, 33.3% of men and 21.7% of women had PA ≥ and 140 and/or 90 mmHg. Regarding participation in some preventive or educational activity, 76.1% stated that yes, of which 60.4% considered them satisfactory and 44.7% considered that there was no influence on lifestyle change. It was concluded that health education actions are partially impacting on the change in the habits of employees, because the indexes of risk factors still raise concern.

Keywords: Health education, systemic arterial hypertension, risk factors.

1. INTRODUCTION

Numerous issues deserve to be highlighted in the area of health and systemic arterial hypertension is undoubtedly part of this list, as it is characterized both as a disease and as a risk and aggravation factor for other diseases, being responsible for damage to the quality of life of the population worldwide, causing thousands of hospitalizations and deaths.

Systemic arterial hypertension (SAH) is one of the risk factors for cardiovascular diseases, which have been the main causes of mortality worldwide in the last decade, being responsible for about 30% of all deaths (SILVA et al., 2016a). The World Health Organization (WHO) estimated that about 600 million people had SAH and that there would be 7.1 million annual deaths resulting from this disease (MALTA et al., 2017).

According to Zangirolani et al. (2018), SAH has a high prevalence in Brazil, occurring between 22% and 44% in adults, increasing with age and reaching 68% in the elderly. Malachias et al. (2016) state that SAH affects 32.5% (36 million) of adult individuals and more than 60% of the elderly, contributing directly or indirectly to 50% of deaths from cardiovascular disease. In the city of Macapá, data from the 2017 Ministry of Health Surveillance Survey for Risk and Protective Factors for Chronic Diseases estimated that 21.4% of the population had a medical diagnosis of hypertension.

Risk factors for systemic arterial hypertension are age, gender and ethnicity, overweight and obesity, salt intake, alcohol intake, sedentary lifestyle, socioeconomic and genetic factors (MALACHIAS et al., 2016). Silva et al. (2016a) also add, based on the National Heart Lung and Blood Institute (NHLBI), overweight, smoking and stress.

Regarding the therapeutic process and prevention of hypertension, lifestyle changes are of fundamental importance for medications to result in adequate blood pressure levels (SILVA et al., 2016b). Thus, it is necessary to ensure the implementation of guidelines for the treatment of SAH involving education actions, lifestyle change and guarantee of access to medicines (OLIVEIRA et al., 2017).

Health education is an important tool in the spheres of health promotion and disease prevention, especially when dealing with chronic diseases such as hypertension, morbidity whose progress is increasing and leads to the risk of health problems (GUERRA et al., 2016). Therefore, health education is an important instrument in combating risk factors and/or control of systemic arterial hypertension.

Aware that their employees, as well as other groups of workers, are also subject to develop hypertension and are vulnerable to their risk factors in the face of their lifestyle, as well as the importance of health education actions in the prevention and control of disease risks, the Court of Justice of the State of Amapá – CJSA, through its health section , instituted the Living Better program, which includes health education actions such as: Health Report, Periodic Exams, Health Profile and health actions for the benefit of its workers.

Health education actions are of high importance, since it is considered one of the main instruments of prevention of SAH, acting in health promotion with a focus on stimulating the adoption of healthy habits and lifestyles, reflecting on a higher quality of life. Therefore, the health education actions promoted in the CJSA need to have their effectiveness in reducing the risk factors of proven SAH or the possible causes of its ineffectiveness identified, so that their workers are not vulnerable to the risk of increased disease rates. In view of this scenario, one cannot remain inert, and it is necessary to take effective policies to combat risk factors, in order to promote a higher quality of life for employees and their families.

The response about the effectiveness of health education actions implemented in the CJSA was relevant due to the demonstration of the current problem inherent to the increase in workers’ exposure to risk factors of systemic arterial hypertension, because it contributes to the elaboration/implementation of actions to reduce exposure to the disease and promote a higher quality of health/life to these workers. Furthermore, demonstrating the importance of health education in the prevention of SAH reduces the medical and social cost of Brazil and improves the health of affected people, as well as contributes to the development of new knowledge, assisting managers, professionals and students in the health and related areas, also serving as bibliographic support for new research.

In this context, the general objective of the study was to analyze the influence of educational actions in health that are promoted within the Court of Justice of Amapá, in the change of the lifestyle of workers, in order to reduce risk factors for systemic arterial hypertension.

2. Methods

This is a descriptive study with a quantitative approach developed in the Court of Justice of the State of Amapá – CJSA, having as a population sample 680 employees crowded in the Comarcas of the cities of Macapá and Santana. Of this total, the sample was calculated to provide estimates of proportions or prevalence of the characteristics of interest of the study through the Epi info program, considering a 95% confidence interval (95% CI) and a margin of error of 5%, reaching a minimum sample size of 245 participants. However, there was a 10% increase to cover any losses and refusals. At the end of the study, a sample of 255 participants was completed.

The data collection instrument adopted for research was the structured questionnaire, elaborated from those already used by the Ministry of Health in the National Health Survey (2013) and Vigitel (2016), since they contained blocks with questions about variables that involve risk factors for hypertension, such as: sociodemographic data, smoking, physical activity, alcohol consumption and health perception , among others. However, it was adapted in order to meet the objectives of the study.

The questionnaires were individual and after completion, blood pressure, abdominal circumference, height and weight and fasting capillary glycemia were measured. Data collection was carried out with prior scheduling, where participants were instructed about the need to be fasting, wearing light clothing, without accessories and shoes, in addition to an empty bladder, not having practiced physical exercises and smoked for at least 60 minutes before collection.

The collected data were first tabulated by double scanning, for comparison and validation of the bank. They were subsequently transferred to the statistical package Statistical Package for Social Science – SPSS version 22 (IBM SPSS, USA), to perform statistical analyses of the variables in a uni variate and bivariate way.

In the descriptive analysis, a frequency distribution was observed between gender and sociodemographic variables, physical and clinical data. Pearson’s chi-square test (χ²) was used in the inferential analysis to analyze the association between hypertension and socio-demographic variables, physical and clinical data, habits and lifestyle, chronic diseases and health status and health education. A number α = 0.05 was used in all tests.

The study complied with the precepts of Resolution 466/2012 of the National Health Council, being registered in the Brazil Platform and submitted to the analysis of the Research Ethics Committee, obtaining approval under CAAE 9773318.8.0000.0003. All participants were informed about the research, its objectives and methods, guaranteeing anonymity and free participation, thus signing the free and informed consent form before the beginning of data collection.

3. Results

From the data obtained from the questionnaires applied to the 255 servers, it was possible to observe the sociodemographic and clinical profiles, lifestyle and influence of health education actions.

Regarding the sociodemographic profile, the female gender (54.1%) it was superior to the male (45.9%), 66.3% declared themselves brown, 33.7% were between 40 and 49 years old, 47.8% had higher education and 59.6% were married or living in a stable union (Table 1).

Table 1. Sociodemographic profile, research form 2019.

In the physical and clinical data, 48.2% of the individuals had BMI between 25 and 29 Kg/m² and 27.6% blood pressure greater than ≥ 140 and/or 90 mmHg, and 26.3% had fasting capillary glycemia ≥ 99 mg/dL and 64.7% had abdominal circumference ≥ 94 cm when male and 80 cm as a woman (Table 2).

Table 2. Physical and clinical characteristics, research form 2019.

Regarding the practice of physical activities, 21.6% answered that they did not practice any type of physical exercise or sport in the last three months. Among those who performed physical activity, 34.5% practiced activities for 3 to 4 days per week, where 31.4% stated that the duration was longer than 60 minutes daily and that 83.9% of the participants did not travel to work on foot or by bicycle. Regarding smoking, 97.6% reported not currently smoking, but 50.2% consumed alcoholic beverages, of which 17.3% consumed 1 to 2 days a week (Table 3).

Table 3. Habits and lifestyle, research form 2019.

Regarding the variable of health education in the CJSA, 76.1% reported having participated in some preventive or educational activity in health and 63.1% have already read and usually read the health reports published via e-mail. However, 34.5% reported that the health actions promoted were unsatisfactory and 49% claimed that the actions did not influence any change in their lifestyle (Table 4).

Table 4. Health education actions in the Court of Justice of Amapá, research form 2019.

4. Discussion

The highest female participation in the study (54.1%) corroborates with most studies conducted by random samples that are related to SAH. However, it is observed that most of these studies are conducted in places that favor their participation, such as basic health units (BHU), which have several health policies aimed at this public. Therefore, it may not serve as a comparative reference with the data found here.

In the present study, the predominance of females may be justified by the increasing participation of women in the labor market, because, according to Guimarães, Brito and Barone (2016), the composition of the economically active population has changed significantly, with a rapid inflection of female engagement in the labor market.

Policies such as that of the National Council of Justice, which published Resolution NCJ No. 255 establishing the National Policy for Encouraging Female Institutional Participation in the Judiciary, may also be a reference for a greater initiative of women in the actions that occurred in the CJSA , because even being a minority, in the universe of servants, represented a higher percentage in the survey. In addition to all these factors, we can also make a difference in the cultural heritage of being women more interested in health care than men.

The male sex, in turn, presented higher blood pressure levels, with 33.3% presenting AP ≥ 140 and/or 90 mmHg, against 21.7% of females. According to Silva et al. (2016a), regarding the prevalence of SAH between the sexes, women may have pressure influenced by some situations such as contraceptive use, polycystic ovary syndrome, pregnancy, hormone replacement and menopause, although the mechanisms responsible for the differences in pressure regulation between the sexes are not fully understood.

The Brazilian Society of Cardiology, in its 7th guideline, defines SAH as a multifactorial clinical condition characterized by sustained increase in blood pressure levels ≥ 140 and/or 90 mmHg. The values show a strong indication of the disease, which is why the percentages of the study were analyzed from this perspective (MALACHIAS et al., 2016).

The above-mentioned indexes are contrary to the data of the National Household Survey and the national telephone survey. According to Lobo et al. (2017), in this national telephone survey, the prevalence in the Brazilian population for the year 2011 was 24.8%, and 21.4% in the National Health Survey. However, Guerra et al. (2016) report that the 2013 National Health Survey (NHS) indicated that the prevalence of systemic blood pressure (SBP) in women was 19.5%, while in men it was 25.3%, showing that sex is not determinant in the prevalence of systemic arterial hypertension.

According to the 2010 Demographic Census conducted by IBGE, brown color was the second predominant race in Brazil, corresponding to 45% of the population. According to the National Health Survey in 2013, the prevalence of self-reported hypertension for the Brazilian population was 20% in browns, a lower percentage when compared to whites, which was 22.1% and blacks, with 24.2%. Chagas e Almeida (2016), performed with users of the BHU of the Federal University of Amapá, there was also a predominance of brown people, with a percentage of 61.2%.

Black individuals are considered in the literature at higher risk of developing SAH. Regarding brown color, studies that correlate the impacts of the disease are still scarce, requiring further analysis.

Regarding age, only 5.9% were 60 years old, but in addition to those aged between 50 and 59 years, the percentage rises to 33%, signaling ≥ a significant increase in elderly employees over the course of a decade in the CJSA. The scientific literature summed up in studies related to SAH is unisonas about the increase in systemic blood pressure with increasing age. Malachias et al. (2016) ensure that it is the most prevalent non-transmissible chronic disease among the elderly and that its prevalence progressively increases with aging, being considered the main modifiable cardiovascular risk factor in the geriatric population. In view of this scenario, effective policies of prevention and/or care for patients with hypertension need to be promoted in order to ensure a higher quality of life for these employees.

Lobo et al. (2017) found in their study higher prevalence of hypertension in people with lower schooling, regardless of the years studied and gender. In the present study, 80.7% of the participants had completed and/or graduate education, which could be seen as an important positive impact factor in sah indices, as this educational profile would contribute to the promotion of lower percentages of the disease, consequently, due to the greater capacity to access information about the disease and preventive measures of risk factors. However, the results of the research do not confirm this scenario, because the percentages of sah risk factors were high.

For the variable marital status, married or stable union predominates. Barreto and Marcon (2014) state that the family has an important role in the treatment adhering, since it serves as a support for its members who are in a situation of illness, understanding the necessary transformations related to the chronic condition and being subject to indispensable adjustments.

The BMI analysis showed that most participants were overweight and obese. Excess body fat is a risk factor for the development of SAH, as it is related to different mechanisms of elevation of blood pressure levels, of which it can be highlighted, according to Padilha et al. (2017, p. 2) “altered hemodynamics, impairment of sodium homeotase, renal dysfunction, autonomic nervous system imbalance, endocrine changes, oxidative stress and inflammation and vascular injury”.

Regarding the results of fasting capillary glycemia, an average of 10% presented values ≥ 99 mg/dL. In the research of Radovanovic et al. (2014), it was observed that individuals with diabetes have an increased chance of developing SAH by almost three times than non-diabeticindividuals.

As for blood pressure, in the study by Malachias et al. (2016) with 15,103 public servants from six Brazilian capitals, the prevalence of SAH was observed in 35.8%, with a predominance among men (40.1% vs. 32.2%). However, the present study showed an inversion in this predominance, where 16.2% of men and 13% of women had AP ≥ 121 to 139 and/or 81 to 89 mmHg and 33.3% of men and 21.7% of women had AP ≥ 140 and/or 90 mmHg, values compatible with prehypertension and hypertension, according to the 7th Brazilian Guidelines on Arterial Hypertension (2016).

Regarding the practice of physical activity, 78.4% said they had practiced in the last three months. This percentage was higher than the national average, because data from the Ministry of Health obtained through a population study by Vigitel indicated that:

The frequency of adults who practice physical activity in free time equivalent to at least 150 minutes of moderate physical activity per week ranged from 31.0% in São Paulo to 47.0% in Palmas. Among men, the highest frequencies were found in Florianópolis (54.8%), Macapá (54.2%) and Aracaju (52.7%) and the smallest in São Paulo (36.3%), Porto Alegre (43.6%) and Rio de Janeiro (43.7%). Among women, the highest frequencies were observed in Palmas (44.2%), Vitória (40.3%) and Teresina (40.1%) and the smallest in São Paulo (26.4%), Rio de Janeiro (27.4%) and Porto Alegre (29.0%). (BRAZIL, 2019, p. 56)

There is consensus among researchers that regular physical activity programs are currently recognized as a necessary factor in the therapy of hypertensive patients, and the recommendation is based on several studies, which indicate that physical exercise contributes to the decrease in resting blood pressure of hypertensive individuals (BOTTCHER; KOKUBUN, 2017). The practice of physical activity tends to minimize cardiovascular risks by up to 60%, in addition to reducing the use of antihypertensive drugs and treatment expenses, although studies describe the low adhering to the practice of physical activity by people with SAH (BARBOSA et al., 2019).

It is noteworthy that only 5.5% of the study participants usually take the way to and from work on foot or by bike. Exercise and/or aerobic training reduces the casual AP of prehypertensives and hypertensive patients and also reduces the AP of wakefulness of hypertensive patients, in addition to reducing AP in situations of physical, mental and psychological stress, and should be recommended as a preferred form of exercise for the prevention and treatment of SAH (MALACHIAS et al., 2016).

It is surprising that the study shows such positive percentages of servers practicing physical activity and at the same time have high BMI and CA, leaving an incompatibility between the results. Ideally, these variables would present divergent rather than convergent results, as occurred in the present study, which refers to the need for a deeper study that analyzes the quality, frequency and intensity of physical activities practiced by the servers.

Regarding cigarette use, almost all participants do not smoke and also declare not to live with people who usually smoke indoors. This result was positively impacting the research, since of 255 people only 6 smoke. Cavalcanti et al. (2019) state that the prevalence of smoking in Brazil fell from 15.6% in 2006 to 10.8% in 2014. The study data show a small percentage of smokers and/or smokers within their homes, corroborating the data on smoking drop in Brazil.

Alcohol consumption was admitted by 50.2% of the participants, and 40.6% ingested 1 to 2 days a week and 20.4% of 3 or more days per week. Munhoz et al. (2017) analyzed Vigitel data between 2006 and 2013, observing an increase in alcohol abuse between the ages of 30 and 39 years and a stationary trend for the other age groups, highlighting that alcohol abuse was higher as it increases the education of individuals in all periods under study. Malachias et al. (2016) report that habitual alcohol consumption increases AP linearly and excessive consumption is associated with an increase in the incidence of SAH, estimating that an increase of 10 g/day in alcohol intake increases AP by 1 mmHg, and the decrease in AP consumption reduces AP, recommending moderation in alcohol consumption.

Regarding participation in some preventive or educational activity in health in the CJSA, more than two thirds of the participants said yes. Machado et al. (2016) report that international agencies, such as the World Health Organization (WHO) and the American Heart Association (AHA), have released documents with strategies aimed at reducing the main risk factors for cardiovascular diseases, among which educational interventions can be highlighted. Guerra et al. (2016) state that health education is an essential component in the spheres of health promotion and disease prevention, especially when dealing with chronic diseases such as SAH, morbidity whose progress in the population is increasing, and leads to the risk of health problems, associated with increased life expectancy of the population. Janini, Bessler and Vargas (2015) corroborate ensuring that education plays an important role in health promotion, as it functions as a driver of transformation in the behavior, personal practices, autonomy and quality of life of each individual.

Health education is undoubtedly one of the main means of health promotion, helping to develop the responsibility of individuals with their quality of life, through the adoption of behaviors that promote disease prevention.

When asked if they read the health report, disclosed via e-mail, 36.5% stated that they did not. The health report is one of the main tools to promote health risk factors promoted by the CJSA, which together with the health profile and periodic examination become the main actions of health education and research and monitoring of risk factors for hypertension in the institution.

Considering that the person needs to obtain knowledge about the risk factors of SAH, which may have a negative impact on their health, health education emerges as a mediator in prevention, as it constitutes a political option, which seeks participation as a way to guarantee subjects the possibility of deciding on their own destinies (individual/collective), through a reflection/action/reflection, in which the subject and community build their own historical trajectory in search of a better life (SANTOS; LIMA, 2008).

When asked about the evaluation of health actions promoted by the CJSA, 60.4% considered satisfactory and 34.5% as unsatisfactory. In addition, 49% of the employees reported the health actions did not influence any change in their lifestyle.

The change in lifestyle is a difficult task, as it is almost always accompanied by a resistance movement and requires an investment of physical, mental and emotional energy, in proportions that often seem to exceed the possibilities, where most people cannot make modifications and especially maintain them for a long time. However, health education is one of the alternative solutions to lead people to these changes for the purpose of prevention and/or control of sah risk factors, through healthy habits and attitudes (SANTOS; LIMA, 2008).

Primary Health Care is part of a strategic area of control of SAH, where educational actions are an important tool to instigate changes in the lifestyle of individuals and thus reduce cardiovascular risk factors. Machado et al. (2016) studies have analyzed the importance, effectiveness and limitations of these strategies, and the results observed demonstrate the occurrence of decreased AP, body weight and waist circumference, as well as improvement of lipid profile and glucose, changes in food intake and better knowledge about the health-disease-care process.

The good quality therapeutic relationship is considered a fundamental factor for change, so interpersonal factors that comprise the professional-patient relationship are also decisive, as they encompass trust, satisfaction, communication, participation in options and decisions, emotional support, accreditation, cooperation, among other decision-makers, which, when well worked and developed, condition therapeutic adherence (SILVA; BOUSFIELD, 2016).

5. CONCLUSION

Multifactorial systemic arterial hypertension has a high prevalence in the world and Brazilian population, being associated with the main complications of cardiovascular diseases. Both its prevalence and its risk factors were present in the study, attracting special attention because it is a chronic disease of silent evolution, with great possibility of causing debilitating complications if it does not have interference in its course, either by drug or not.

The study showed that 27.5% of the civil servants of the Court of Justice of the State of Amapá presented blood pressure values compatible with hypertension. The analysis of their risk factors and sociodemographic aspects showed that some results differed from the results of other studies and from the literature references of the theme.

The data also allow an alert in relation to the human-health binomial, with the development of a health policy to encourage them to have a greater and more responsible surveillance on their health with the search for healthy lifestyle habits, as the results showed that their blood pressure indexes are above the average of other studies.

Schooling is seen as an important tool in the health education process, as it is believed that individuals with a higher level of education have greater access to information about the disease and preventive measures of risk factors. To confirm this statement, studies associate higher prevalence of SAH in people with lower schooling, but this assertion should be evaluated in moderation if analyzed based on the data of the present study, since the majority of the study population had completed higher education and post-graduation, however, there was no impact on the indexes when compared to other studies that had populations with fewer years of study.

The analysis of clinical variables allowed a better visualization of the indices of the main risk factors of SAH, where the results showed high percentages of overweight and/or obesity, expressive rate of servers fasting glucose values above normal, as well as arterial pressure data with values compatible with arterial hypertension.

Body mass index, abdominal circumference, diabetes mellitus and SAH are, in themselves, considered risk factors for cardiovascular diseases and when associated, take alarming proportions. The high rate of these factors in the study raises great concern, mainly due to the large percentage of servers with an aging perspective over the course of a decade, and cardiovascular diseases are currently the main cause of death in this age group. This scenario alerts to the need to effective a policy of monitoring, control and prevention of these risk factors, with the adoption of healthier lifestyle habits.

The variables involving life habits, physical activity and cigarette use showed encouraging results, while the feeding and consumption of alcoholic beverages had a worrying behavior. In relation to this, educational actions can function as a tool for changing habits, favored by the high level of education of participants, which may at first have greater access and ease of apprehension of health information, since knowledge about the disease and its causes is of great importance for people to prevent their risk factors.

The result of the variable physical activity deserves to be analyzed with reservations, as a high percentage of participants declare to practice, but its reflex is not observed when the percentages of BMI and abdominal circumference are observed. Thus, it is necessary a study that better evaluates the frequency and quality of these activities. However, it is a practice that needs to be always stimulated, given the benefits in health promotion.

Alcohol consumption is considered one of the risk factors for SAH and more than 50% of participants reported consuming. Actions of discouraged or reduced alcohol consumption should be stimulated, because in addition to a risk factor for SAH, it may also be associated with several social and family problems.

The high prevalence of risk factors for SAH and a significant percentage of employees who evaluate health actions promoted by the CJSA as unsatisfactory, demonstrates the need for better planning of health education actions performed, to increase the efficacy and control of risk factors for SAH, especially modifiable ones. Health policies that achieve this goal will certainly have great impact on the reduction of morbidity and mortality from cardiovascular diseases.

Health education actions, undoubtedly, are a tool with a fundamental role to modify scenarios such as that found in research, contributing to change lifestyles that act against health promotion. The prevention of diseases, whose progress in the population is increasing, such as SAH, is very important, given the high risk of health problems.

The analysis of a possible failure in the interaction between professionals and the servers is a measure to be sought, in order to have a diagnosis for a significant percentage of participants who consider the health actions promoted by the CJSA to be unsatisfactory.

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APPENDIX – TABLES IN ENGLISH

Table 1.

Table 2.

Table 3.

Table 4.

^[1] Nurse, Master in Health Sciences by the Graduate Program in Health Sciences of the Federal University of Amapá (UNIFAP), Macapá/Brazil.

^[2] Nurse, PhD in Education, Professor at the Federal University of Amapá (UNIFAP), Nursing Department, Macapá/Brazil.

Sent: June, 2020.

Approved: August, 2020.