Public Awareness of Health-Related Risks From Uncontrolled Hypertension

Uncontrolled hypertension, a common disorder, is associated with increased long-term risk of several serious conditions. Awareness of the health risks of uncontrolled hypertension is not well understood. We used data from a nationwide panel survey to assess the awareness of risk associated with uncontrolled hypertension, stratified by cardiovascular disease risk factors. Awareness of increased risk from uncontrolled hypertension was high for some outcomes (heart attack, heart failure, stroke), and low for others (kidney disease, dementia). Several disparities in awareness were found. Complementary clinical and public health interventions could be instituted to increase awareness and target people who are high risk.


Objective
Uncontrolled hypertension increases the risk of heart attack, heart failure, kidney disease, stroke, and cognitive decline (1-3). Low control rates are partly explained by lack of awareness of hypertension; improving awareness could lead to improved control rates (4,5). However, few reports exist on what proportion of adults are aware of health risks from uncontrolled hypertension. We analyzed data from a national, web-based panel survey to assess awareness of risk of cardiovascular disease (CVD) and dementia associated with uncontrolled hypertension stratified by comorbidities, sociodemographic variables, and CVD risk factors.

Methods
HealthStyles is a web-based panel survey developed and licensed by Porter Novelli Public Services and conducted by GfK's Know-ledgePanel (www.gfk.com/products-a-z/us/knowledgepanelunited-states/) as a probability-based online panel representative of the US adult population aged 18 or older. The survey was sent to 6,166 respondents in June and July of 2016; 4,203 completed the survey (68% response rate). The survey collected data on demographics, health conditions, health beliefs and awareness of health risks, and behaviors. Data were weighted for sex, age, household income, race/ethnicity, household size, education, census region, metropolitan status, and prior Internet access on the basis of the 2015 US Current Population Survey. All data were self-reported. Licensed data were provided; data did not include individual identifiers, was provided in aggregate form, and was granted an exemption by the Centers for Disease Control and Prevention institutional review board.
We excluded 37 pregnant hypertensive respondents, and the final sample was 4,166. We used Wald χ 2 tests to assess differences in awareness among hypertensive adults by selected characteristics. Two-tailed P values of ≤ .05 were considered significant. All analyses were conducted using SAS version 9.3 (SAS Institute Inc).

Results
The prevalence of self-reported hypertension was 30.0% (Table  1), with significant differences by age, race/ethnicity, annual household income, education, BMI, and selected comorbidities. Hypertensive adults had significantly higher estimates of awareness for increased risk for stroke associated with uncontrolled hypertension compared with their normotensive counterparts (90.9% vs 77.2%, P < .001). Similar patterns were seen among hypertensive adults versus normotensive adults for awareness of risk of heart attack (88.4% vs 78.7%, P < .001), heart failure (71.6% vs 65.8%, P = .002), and kidney disease (38.5% vs 24.8%, P < .001). Though not significant, awareness for risk of dementia was markedly low in both groups: 8.7% for hypertensive adults and 7.9% for normotensive adults (P = .47).
Among hypertensive adults, respondents with depression were more likely to be aware of the risk of heart failure from uncontrolled hypertension than those without depression (79.2% vs 69.8%, P = .01). Respondents with diabetes had no differences in awareness for all CVD outcomes compared with those without diabetes. Respondents with high cholesterol were more aware of the risks from uncontrolled hypertension for stroke than those without (94.1% vs 88.6%, P = .004). Respondents with 2 or more comorbidities had significantly higher risk awareness of heart attack and heart failure associated with uncontrolled hypertension than those with none or one of the conditions (Table 2).

Discussion
While awareness was high among most respondents for traditionally well-known CVD outcomes (heart attack, heart failure, stroke), it was remarkably lower for others (kidney disease, de-mentia), suggesting areas for focusing education. As previously reported (6,7), we found notable socioeconomic and racial/ethnic differences in awareness of the risks of hypertension. For example, we found greater awareness of the association between uncontrolled hypertension and kidney disease, stroke, and dementia in high-income households than in low-income households. Non-Hispanic whites had greater risk awareness than non-Hispanic blacks, who have higher prevalence of hypertension and uncontrolled hypertension (8).
Education levels are associated with greater health literacy (7), which influences a patient's ability to understand hypertension education, complications from uncontrolled hypertension, and disparities in access to hypertension care (9). Increasing access to appropriate clinical care, supported by broad public health initiatives such as promoting use of community health workers to educate patients may help address the lack of awareness of risks from uncontrolled hypertension (7). Moreover, encouraging health care providers to more effectively communicate the dangers of uncontrolled hypertension can improve adherence to medications and prognosis (10). Additionally, risk awareness initiatives should tailor interventions to people with both diabetes and hypertension given the concurrent and heightened CVD and chronic kidney disease risks uncontrolled hypertension poses for them.
Our study's limitation was that the survey was subject to recall bias, which is inherent in self-reported data and convenience sampling. The strength of our study is that the panel was drawn from a quota sampling to obtain a study group that matched the US population on 7 census demographics.
This study highlights the areas of need for educating populations who are unaware of the risks from uncontrolled hypertension. With nearly 35 million people with uncontrolled hypertension (4), effective interventions are needed to raise awareness of its risks. Public health initiatives should be replicated and expanded for more diverse populations to provide education on the risks of uncontrolled hypertension.