A hierarchical model for the study of factors associated with arterial hypertension

in elderly people living in the capitals of the Northeast region of Brazil, 2017.

Introduction

color, overweight people, drinkers,

smokers and people with physical
Systemic arterial hypertension
activity and inadequate fruit
(SAH) is one of the most widespread
consumption4.
pathologies in the world and the main
risk factor for cardiovascular diseases. Thus, it is clear that the

In Brazil, this condition is endemic in prevalence of SAH is more significant

all states and its occurrence is related to in populations less favored

the age group, socioeconomic level, socioeconomically4, bringing social

conditions and lifestyle habits¹. In this inequality as an important factor when

context, SAH is established as a disease thinking about prevention through

of important social and economic changes in lifestyle and eating habits. In

relevance, since it has a high occurrence addition, stress and lifestyle are related

and, consequently,great social impact, to the prevalence of the disease, as these

public health, economy and quality of can be related to food choices5.

life². Therefore, it is also necessary to

consider that SAH does not need to be
Hypertension also stands out for
standardized according to the advancing
affecting a large number of people and
age group, given its vast possibility of
for being one of the most disabling
prevention. In this circumstance,
diseases today, in addition to being
hypertension should be seen as a major
responsible for a significant part of
challenge today for the health care
deaths in Brazil³. The profile of people
network to monitor and control cases6.
affected by SAH found in the literature
is consistent with the profile of the It is known that aging is
general population¹, the results highlight characterized as a dynamic, progressive
women, in which the diagnosis is and irreversible process, closely linked
related to the greater demand in basic to biological, psychological and social
health units (UBS), people aged equal factors3. This process increases the
to or older than 60 years old, brown in incidence of NCDs that are associated
with functional deficiencies and have limited comparability, due to the
disabilities, which can influence the local scope and differences in questions
well-being and quality of life of the and methods, making it difficult to use
elderly6. In this sense, knowing the as a decision tool for public health. For
factors associated with arterial the population aged ≥ 60 years, studies
hypertension in the elderly is extremely in specific locations have revealed
important to develop strategies that will prevalence of hypertension above
intervene in the affected population, 45%6,8. Given the above, the present
promoting preventive actions7. study aims to identify the factors
associated with self-reported arterial
In Brazil, some studies have
hypertension in elderly people living in
investigated this theme in the elderly.
the capitals of the Northeast region of
However, studies,most of the time, they
Brazil.

Materials and methods

This is a cross-sectional weights calculated by the “rake”

population-based study that used data method9.
referring to the population aged 60 or These weights seek to match the
over, living in the capitals of the sociodemographic distributions of the
Northeast region of Brazil, collected in sample in each city to the estimated
2017 by VIGITEL (Surveillance of risk distribution for the city's total adult
and protection factors for chronic population. The post-stratification
diseases by telephone survey). The weight of each individual in the
VIGITEL system is performed VIGITEL sample is used to generate all
annuallyby the Ministry of Health since estimates provided by the system for
2006, in the 26 Brazilian capitals and in each of the 27 cities.
the Federal District. This systemuses The VIGITEL data collection
probabilistic samples from the adult instrument addresses demographic and
population (≥ 18 years old) living in socioeconomic characteristics of
households served by at least one individuals, characteristics of the
landline. To compensate for the bias of pattern of eating and physical activity
not universal coverage for fixed associated with the occurrence of
telephony, we use post-stratification NCDs, reported weight and height,
frequency of consumption of cigarettes (22 to 27 Kg / m2) and overweight (>
and alcoholic beverages, self- 27 Kg / m2) 10.
assessment of health status. health, Since the outcome under study is
reference to previous medical diagnosis not a rare event, it is possible to observe
of hypertension and diabetes, among an overestimation of the odds ratio
other subjects9. when compared to the prevalence ratio.
For this investigation, the For this reason, instead of using logistic
prevalence of self-reported arterial regression, multivariate Poisson
hypertension was considered as an regression models with robust variance
outcome variable according to the were defined11,12. In all analyzes, the
positive answer to the question "Has effect of the sample design was
any doctor ever told you that you have considered for the analysis of surveys
high blood pressure?" based on complex designs of the Stata
The explanatory variables were: 15.0 program.
sex (male, female), age group (60 to 64, The statistical analysis was
65 to 69, 70 to 74 and ≥ 75 years), performed according to a predefined
marital status (single, married / united, conceptual model (Figure 1). The model
widowed and separated / divorced), race defined two hierarchical levels: the first
/ skin color (white, brown, black or level (distal) included only one block
yellow / indigenous), education (0 to 4, with all variables of the demographic /
5 to 8 and 9 or more years of study), socioeconomic factors and the second
possession of health insurance (yes or level (proximal) included two blocks,
no), smoking (non-smoker, ex -smoker one for the behavioral variables
and current smoker), physical (lifestyle) and another for variables of
inactivityin the domains “leisure”, health conditions.
“work”, “commuting” and “domestic Univariate and multivariate
activities” (yes, no), consumption of analyzes were performed using Poisson
alcoholic beverages (yes, no), regression with robust variance. The
recommended consumption of fruits and variables that in the univariate analyzes
vegetables - five or more servings per showed ap-values ≤0.05 were included
day (yes, no), referred diabetes (yes, no) in the next step, which was an intra-
and poor health status assessment (yes, block multivariate analysis.
no). The body mass index was classified Finally, the set of significant
as low weight (<22 kg / m2), eutrophic variables (p-value≤0.05) from the
multivariate analysis in each block was were interested in the effect of the distal
inserted in the hierarchical analysis, level variables (even if they are
following the order defined in the mediated by the proximal variables),
conceptual structure. Level 1 variables our final estimate for the effect of the
were first introduced in the hierarchical distal variables is that before the
model and level 2 variables were introduction of the proximal variables,
followed, since the effect of variables at The variables in the multivariate
the distal level can be mediated by model within each level and the
variables at the proximal level. All the variables at the proximal level were
variables in the level 2 blocks were maintained in the final model when they
introduced together, as we postulate that presented a p-value ≤ 0.05.
they operate at the same level. As we

Level 1

Demographic / socioeconomic factors

Sex Race / Skin color

Age groups Education
Marital Situation Possession of health insurance

Level 2
Lifestyle Health conditions
Recommended consumption of fruits and
vegetables Medical diagnosis of diabetes
Alcohol consumption Poor health status assessment
Smoking
Physical inactivity at leisure

Arterial hypertension

Figure 1 - Hierarchical model proposed for factors associated with arterial

hypertension in the elderly.
Results hypertension among the Northeastern

In 2017, for the set of 9 cities in elderly was 57.92% (95% CI: 57.84 -

the Northeast region, Vigitel conducted 58.01), being lower among the elderly

18,382 interviews with adults (≥18 residents in Fortaleza (50.78%; 95% CI:

years old), which indicates a 50.60 - 60.96). Prevalence of self-

participation rate of 71.75%, varying reported systemic arterial hypertension

between 71.16% in Recife and 72.60% above 60% was observed for the elderly

in Salvador. residents in Maceió (63.89%; 95% CI:

63.60-64.18), Natal (62.94%; 95% CI:
Among the 18,382 individuals 62.65- 63.23), Salvador (61.08%; 95%
surveyed, 6,793 were elderly. The CI: 60.91-61.25) and Teresina (61.09%;
prevalence of self-reported arterial 95% CI: 60.77-61.41) (Table 1).

Table 1 - Prevalence of arterial hypertension in the elderly in capitals in the

Northeast region. Vigitel, Brazil, 2017.

Capitals Prevalence (%) CI (95%)

Aracaju 58.18 57.81 - 58.55
Fortaleza 50.78 50.60 - 60.96
João Pessoa 53.81 53.49 - 54.12
Maceió 63.89 63.60 - 64.18
Natal 62.94 62.65 - 63.23
Recife 59.32 59.11 - 59.52
Salvador 61.08 60.91 - 61.25
São Luís 54.58 54.23 - 54.92
Teresina 61.09 60.77 - 61.41
Total 57.92 57.84 - 58.01
CI: Confidence interval.

Table 2 shows the distribution of (63.73%), in those who declare

the elderly population and the themselves black (70.43%), in those
prevalence of hypertensive patients with schooling from 0 to 4 years of
according to sociodemographic factors study (62.28%) and those who do not
(level 1 variables). There is a higher have health insurance (50.70%). The
prevalence of arterial hypertension prevalence of SAH among the elderly
among females (61.73%), in widowers tends to increase with advancing age,
with a prevalence of 63.88% for the age hypertension when compared to white
group of 75 years or more. people (PR = 1.27; 95% CI: 1.16 -
1.40), even after adjusting for intra-
All sociodemographic factors
block factors. In the intra-block
were significantly associated with
multivariate analysis, with the exception
arterial hypertension in the univariate
of health insurance, all variables
analysis, (p-value <0.05). Elderly
remained significantly associated with
people who declared themselves black
arterial hypertension with a p-value
had a higher prevalence of arterial
<0.05 (Table 2).

Table 2 - Crude and adjusted associations between arterial hypertension in the

elderly in the Northeast region and the level 1 variables (block demographic /
socioeconomic factors). Vigitel, Brazil, 2017.

Level 1 Frequen Prevalenc RPa CI RPb CI

cy e (95%) (95%)
(%) (%)
Sex
Male 39.12 52.00 1.00 1.00
Female 60.88 61.73 1.19 1.11- 1.23 1.14-1.33
1.27
Age range
60 to 64 years 38.06 51.66 1.00 1.00
65 to 69 years 20.87 60.17 1.16 1.07- 1.16 1.06-1.27
1.27
70 to 74 years 18.03 60.94 1.18 1.08- 1.19 1.08-1.31
1.29
> = 75 years 23.04 63.88 1.24 1.14- 1.22 1.11-1.34
1.34
Marital Situation
Not married 13.21 52.70 1.00 1.00
Married / stable relationship 58.52 57.02 1.08 0.98- 1.14 1.03-1.27
1.19
Widower 19.70 63.73 1.21 1.09- 1.09 0.97-1.22
1.34
Separated / divorced 8.57 58.85 1.11 0.98- 1.13 0.98-1.30
1.27
Race / Skin color
White 43.55 54.39 1.00 1.00
Black 13.30 70.43 1.29 1.18- 1.27 1.16-1.40
1.42
Brown 40.59 57.73 1.06 0.99- 1.08 1.00-1.16
1.14
Yellow / indigenous 2.56 60.32 1.11 0.91- 1.05 0.86-1.28
 1.35
Schooling (years of study)
> = 9 years 34.07 52.53 1.00 1.00
From 5 to 8 years 24.93 58.13 1.11 1.02- 1.06 0.96-1.16
1.20
From 0 to 4 years 41.00 62.28 1.19 1.11- 1.12 1.04-1.22
1.27
Possession of health
insurance
Yes 43.01 55.74 1.00 1.00
Not 56.99 59.70 1.07
1.01- 1.05
0.98-1.13
1.14
The
Gross prevalence ratio; b Prevalence ratio adjusted for all variables of the
demographic and socioeconomic bloc.

Table 3 shows the distribution of (with a p-value <0.05), with the

the elderly population and the exception of the variable related to
prevalence of hypertensive patients regular consumption of fruits and
according to lifestyle factors and health vegetables. Overweight older adults had
conditions (level 2 variables). There is a a higherprevalence of arterial
higher prevalence of hypertension hypertension (PR = 1.37; 95% CI: 1.24
among the elderly who answered “no” - 1.52), even after adjustment for intra-
to regular consumption of fruits and block factors. Likewise, a 39% higher
vegetables (58.63%); for those who prevalence of arterial hypertension was
consume alcoholic beverages (59.23%), found in the elderly who reported a
for non-smokers (59.06%), for those medical diagnosis of diabetes (PR =
with physical inactivity (62.45%), for 1.39; 95% CI: 1.31 - 1.47). In the intra-
those who are overweight (66.57%), for block multivariate analysis, the
those who reported having diabetes following variables remained with p-
(76.34%) and for those who evaluated value <0.05: smoking (PR = 0.74; 95%
their health status as poor (70.98%). CI: 0.62-0.88), physical inactivity (PR =
1.08; CI95 %: 1.01-1.14), body mass
Most lifestyle factors and health
index (PR = 1.37; 95% CI: 1.24-1.52),
conditions were associated with high
and poor health status assessment (PR =
blood pressure in univariate analyzes
1.15; 95% CI : 1.05-1.27).
 Table 3 - Crude and adjusted associations between arterial hypertension in
elderly people in the northeast region and level 2 variables (block of lifestyle
factors and health conditions). Vigitel, Brazil, 2017.

Level 2 Frequency Prevalence RPa CI RPb CI

(%) (%) (95%) (95%)
Regular consumption
of fruits and
vegetables
Yes 35.05 56.61 1.00 1.00
Not 64.95 58.63 1.04 0.97-1.10 1.03 0.97-1.10
Alcohol consumption
Not 77.48 59.23 1.00 1.00
Yes 22.52 53.43 1.11 1.03-1.20 1.04 0.96-1.12
Smoking
Non-smoking 57.69 59.06 1.00 1.00
Current smoker 5.36 42.17 0.71 0.59-0.86 0.74 0.62-0.88
Ex smoker 36.95 58.44 0.99 0.93-1.05 0.98 0.92-1.04
Physical inactivity
Not 67.16 55.71 1.00 1.00
Yes 32.84 62.45 1.12 1.06-1.19 1.08 1.01-1.14
Body mass index
Low weight 16.26 46.19 1.00 1.00
Strophic 41.64 53.77 1.16 1.05-1.30 1.16 1.04-1.29
Overweight 42.09 66.57 1.44 1.30-1.60 1.37 1.24-1.52
Diabetes
Not 77.33 52.52 1.00 1.00
Yes 22.67 76.34 1.45 1.37-1.53 1.39 1.31-1.47
Poor health status
assessment
Not 92.78 56.91 1.00 1.00
Yes 7.22 70.98 1.25 1.13-1.37 1.15 1.05-1.27
The
Gross prevalence ratio; b Prevalence ratio adjusted for all variables in the lifestyle and
health conditions block.

The results of the final group aged 75 or older (PR = 1.21; 95%
multivariate hierarchical analysis are CI: 1.10 - 1.32) , overweight (PR =
shown in Table 4. The variables that 1.40; 95% CI: 1.25 - 1.56) and medical
increased the prevalence of arterial diagnosis of diabetes (PR = 1.33; 95%
hypertension by more than 20% in the CI: 1.25 - 1.42). There is also a higher
elderly were: female gender (PR = 1.22; prevalence of arterial hypertension
95% CI: 1.13 - 1.33 ), black skin color among married elderly (PR = 1.14; 95%
(PR = 1.27; 95% CI: 1.16 - 1.40), age CI: 1.02-1.27), in those with schooling
≤ 4 years of study (PR = 1.16; 95% CI: elderly smokers had a significantly
1.07-1.25) and in those who assessed lower prevalence (PR = 0.76; 95% CI:
their health status as poor (PR = 1.14; 0.63 - 0.92), that is,
95% CI: 1.02-1.26). In contrast, the

Table 4 - Variables associated with arterial hypertension in elderly people in the

northeast region obtained from multiple hierarchical regression. Vigitel, Brazil,
2017.

Levels RP CI (95%)
Level 1*
Sex
Male 1.00
Female 1.22 1.13-1.33
Age range
60 to 64 years
65 to 69 years 1.16 1.06-1.27
70 to 74 years 1.18 1.08-1.30
> = 75 years 1.21 1.10-1.32
Marital Situation
Not married 1.00
Married / stable relationship 1.14 1.02-1.27
Widower 1.08 0.97-1.21
Separated / divorced 1.13 0.98-1.30
Race / Skin color
White 1.00
Black 1.27 1.16-1.40
Brown 1.09 1.01-1.17
Yellow / indigenous 1.09 0.90-1.32
Schooling (years of study)
> = 9 years 1.00
From 5 to 8 years 1.08 0.98-1.18
From 0 to 4 years 1.16 1.07-1.25
Level 2**
Smoking
Non-smoking 1.00
Current smoker 0.76 0.63-0.92
Ex smoker 0.98 0.91-1.05
Body mass index
Low weight 1.00
Strophic 1.16 1.03-1.31
Overweight 1.40 1.25-1.56
Diabetes
Not 1.00
Yes 1.33 1.25-1.42
Poor health status assessment
Not 1.00
 Yes 1.14 1.02-1.26
PR: Prevalence ratio; CI: Confidence interval;
* Adjustment by demographic / socioeconomic variables;
** Adjustment by variables of the demographic / socioeconomic blocks and lifestyle /
health conditions.

Discussion

Among the elderly interviewees female gender, advancing age, married

living in the capitals of the northeast marital status / stable union, black skin
region of Brazil, the prevalence of color, low education, overweight,
arterial hypertension was 57.92%.The diabetes, being a smoker and assessing
prevalence of SAH in the elderly found their status of health as bad. In the
in this region corroborates with results present analysis, the prevalence of self-
found in other studies conducted in reported arterial hypertension was
Brazil16, 17, 18
in which they relate the influenced by factors of all hierarchical
higher prevalence of chronic non- levels, with overweight and diabetes
communicable diseases (CNCD) with increasing the prevalence of SAH by
advancing age4, 6, 7, 8, leading taking into more than 30%.The results of this study
account that the natural aging process are reinforced with similar findings in
brings with it the accumulation of risk different contexts and with different
factors, increasing the prevalence from methodologies that reported the factors
this age group3, 4, 6
. In some studies it associated with arterial hypertension.
was possible to observe the prevalence
Regarding sociodemographic
of the diagnosis of arterial hypertension
factors, women had a higher prevalence
in at least half of the population from 55
of arterial hypertension, corroborating
years of age showing that the
findings from other studies of chronic
prevalence of hypertension and its
diseases in the elderly in Brazil1 4, 6, 8, 13,
complications and limitations increases 15, 17, 33
, this finding is explained by the
1, 13
with advancing age .
greater zeal on the part of women for
In this study, the results showed health issues and, consequently, greater
that the factors associated with self- demand for health services1, 8, 13. It is also
reported arterial hypertension in observed that elderly people who are
northeastern elderly people were: married or in a stable relationship had a
higher prevalence of arterial skin color are factors of inequity in
hypertension, this finding may be access to care practices for hypertensive
relatedwith a positive influence of patients, demanding more and more
women on their spouses in the search affirmative public policies in addressing
for health services, in addition, it is inequalities17, 26, 27, 29, 33.
found in the literature that among the
Smoking presented an inverse
individuals who never measured the
and significant association with the
pressure, men had a higher proportion 1,
prevalence of arterial hypertension. This
13
strengthening the argument of less
result corroborates with other studies
demand for health services , by male
conducted with the elderly17, 36
. The
individuals.
negative association between smoking
Elderly people with black skin
and arterial hypertension has been
color had a higher prevalence of arterial
attributed to the fact of reverse casualty,
hypertension, as has been observed in
that is, the abandonment of this habit
other studies8, 17, 20. Regarding education,
due to health problems. Considering
it was possible to observe a higher
that in the present study the prevalence
prevalence of hypertension in elderly
of arterial hypertension was lower
people with less years of study,
among elderly smokers, it is believed
corroborating with the findings of other
that this fact may indicate the
research1, 7, 8, 13, 21
. Skin color is an
monitoring of blood pressure levels.
important determinant of social
The increase in demand for health
inequality and linked to low education
services, to control blood pressure
reveals a group in a vulnerable
levels, results in a greater number of
socioeconomic situation8, 20, 27
, which
recommendations and educational
may be related to the presence of
interventions that encourage smoking
chronic diseases17, leading to taking into
cessation36. Although non-smoking is
account access to health services,
not related to lowering blood pressure,
medical care or access to medicines for
it, alone, remains one of the main risk
long-term treatment26, 27
. In addition,
factors for cardiovascular diseases and,
access to information assists in healthier
therefore, cessation should be
choices and habits in daily life, and can
recommended both in primary and
be considered a social determinant of
secondary prevention36.
health and disease conditions.
Ptherefore, low schooling and black
 The findings of this article are factors for chronic non-communicable
reinforced with the results found in diseases33, 37.
other studies in which diabetes
Self-perceived poor health was
alsoshowed an association with SAH
associated with a higher prevalence of
among the elderly, the prevalence of
SAH, this result corroborates with what
arterial hypertension was significantly
was found in another study35. The
higher among the elderly who reported
perceived health condition goes through
having diabetes. Results of clinical
several sociodemographic and
research indicate that about 70% of
economic factors such as income,
diabetics have hypertension, and the
education, lifestyle and the presence of
coexistence of hypertension and
comorbidities42, thus, the result found
diabetes significantly increases the risk
can be explained by the accumulation of
of developing cardiovascular diseases
diseases accentuated with advancing
and other comorbidities40.
age, and the relationship between
With regard to nutritional status,
arterial hypertension with other
a higher prevalence of arterial
diseases3, 32, 35, 36, 38. As a result, the set of
hypertension was observed in
these morbidities and, as a consequence,
overweight elderly people, the
the need for rigid and prolonged drug
relationship between overweight and
control, greater attendance at medical
SAH has already been portrayed in the
appointments, may contribute to a
literature1, 4, 7, 8, 21, 33, 37, 38, 39
. The
worse perception of health status32, 35, 42.
prevalence of obesity may increase with
advancing age since excess weight is
The results of the present study
determined by the decrease in the rate of
must be interpreted with some
basal metabolism, which can occur as a
limitations. This is a cross-sectional
consequence of the loss of muscle mass,
study, which evaluates only the
natural of senility37. Overweight can
association between variables, with no
also result in changes in other
possibility of defining a causal
pathophysiological mechanisms such as
relationship. Another limitation is the
insulin resistance, hyperinsulinemia and
use of self-reported arterial
increased sodium and water
hypertension, although the use of this
reabsorption due to renal changes38,
measure has been shown to be a
adding to the accumulation of risk
recommended indicator in population-
based studies with large samples such as answered the objectives and the
this21,28. Despite these limitations, the associations found were compatible
methodology used in this study with other studies.

Conclusion
The results of the present study among the elderly residents in the
showed that the prevalence of arterial Northeastern capitals in 2017, showing
hypertension in the elderly in the that the problem is even more impactful
Northeast region was over 57%, in certain subgroups of society.
portraying an important public health The high prevalence of arterial
problem in Brazil that needs to be hypertension among the elderly and the
addressed with attention. The associated factors, identified in this
advancement of age, black skin color, study, are important to assist in the
low education, overweight and the development of preventive programs
report of medical diagnosis of diabetes and in the formulation of public policies
were associated with a higher for coping with this less favored region.
prevalence of arterial hypertension

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