Prevalence, Awareness, Treatment and Influence of Socioeconomic Variables on Control of High Blood Pressure: Results of the ELSA-Brasil Study
Prevalence, Awareness, Treatment and Influence of Socioeconomic Variables on Control of High Blood Pressure: Results of the ELSA-Brasil Study
Dóra Chor 0 1
Antonio Luiz Pinho Ribeiro 0 1
Marilia Sá Carvalho 0 1
Bruce Bartholow Duncan 0 1
Paulo Andrade Lotufo 0 1
Aline Araújo Nobre 0 1
Estela Mota Lima Leão de Aquino 0 1
Maria Inês Schmidt 0 1
Rosane Härter Griep 0 1
Maria Del Carmen Bisi Molina 0 1
Sandhi Maria Barreto 0 1
Valéria Maria de Azeredo Passos 0 1
Isabela Judith Martins Benseñor 0 1
Sheila Maria Alvim Matos 0 1
José Geraldo Mill 0 1
0 1 Department of Epidemiology, National School of Public Health , Oswaldo Cruz Foundation, Rio de Janeiro, RJ , Brazil , 2 Department of Internal Medicine, Federal University of Minas Gerais , Belo Horizonte, MG, Brazil, 3 Scientific Computing Program, Oswaldo Cruz Foundation, Rio de Janeiro, RJ , Brazil , 4 Postgraduate Studies Program in Epidemiology, School of Medicine, Federal University of Rio Grande do Sul , Porto Alegre, RS , Brazil , 5 School of Medicine, University of Sao Paulo , São Paulo, SP , Brazil , 6 Institute of Collective Health, Federal University of Bahia , Salvador, BA , Brazil , 7 Laboratory of Health and Environment Education , Oswaldo Cruz Foundation, Rio de Janeiro, RJ , Brazil , 8 Post Graduate Program of Collective Health, Federal University of Espírito Santo , Vitória, ES , Brazil , 9 Faculty of Medicine, Federal University of Minas Gerais , Belo Horizonte, MG , Brazil , 10 Department of Physiological Sciences, Federal University of Espirito Santo , Vitória, ES , Brazil
1 Academic Editor: Spencer Moore, University of South Carolina, UNITED STATES
High blood pressure (HBP) is the leading risk factor for years of life lost in Brazil. Factors associated with HBP awareness, treatment and control need to be understood better. Our aim is to estimate prevalence, awareness, and types of anti-hypertensive treatment and to investigate the association of HBP control with social position. Data of 15,103 (54% female) civil servants in six Brazilian state capitals collected at the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline (2008-2010) were used to estimate prevalence and cross-sectional association of HBP control with education, per capita family income and self-reported race, using multiple logistic regression. Blood pressure was measured by the oscillometric method. 35.8% were classified as presenting HBP; 76.8% of these used anti-hypertensive medication. Women were more aware than men (84.8% v. 75.8%) and more often using medication (83.1% v. 70.7%). Adjusted HBP prevalence was, in ascending order, Whites (30.3%), Browns (38.2%) and Blacks (49.3%). The therapeutic schemes most used were angiotensin-converting enzyme inhibitors, in isolation (12.4%) or combined with diuretics (13.3%). Among those in drug treatment, controlled blood pressure was more likely in the (postgraduate) higher education group than among participants with less than secondary school education (PR = 1.21; 95% CI: 1.14-1.28), and among Asian (PR = 1.21; 95% CI: 1.12-1.32) and 'Whites (PR = 1.19; 95% CI: 1.12-1.26) compared to Blacks. Socioeconomic and racial inequality-as measured by different indicators-are
Data Availability Statement: The authors confirm
that all data underlying the findings are fully available
without restriction. The data used in this study is
available for research proposal on request to the
ELSA's Datacenter and to the ELSA's Publications
Committee (publiELSA). Additional information can
be obtained from the ELSA's Datacenter (
) and from the ELSA
Coordinator from the Research Center of Rio de
Janeiro ( ).
Funding: The ELSA-Brasil study was supported by
the Brazilian Ministry of Health (Science and
Technology Department) and the Brazilian Ministry of
Science and Technology (Financiadora de Estudos e
Projetos and CNPq National Research Council)
(grants 01 06 0071.00 RJ, 01 06 0212.00 BA, 01 06
0300.00 ES, 01 06 0278.00 MG, 01 06 0115.00 SP,
01 060010.00 RS). DC received a fellowship from the
Conselho Nacional de Desenvolvimento Científico e
Tecnológico (National Council for Scientific and
Technological Development) under Award Number
300694/2010-5. MSC received a fellowship from the
CNPq under Award Number 309692/2013-0 and
FAPERJ E-23557/2014. The funders had no role in
study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing Interests: The authors have declared
that no competing interests exist.
strongly associated with HBP control, beyond the expected influence of health services
High blood pressure (HBP) accounted for 9.4 million deaths and 7% of global
disabilityadjusted life years in 2010, making it the leading single risk factor in the global burden of
disease. According to recent World Health Organization (WHO) estimates, the prevalence of
HBP in adults ( 25 years) is 29.2% of males and 24.8% of females, leading to worldwide
prevalence of hypertension estimated at more than 1 billion individuals. About 54% of strokes
and 47% of coronary heart disease worldwide are attributable to HBP, which is also a risk
factor for heart failure, diabetes, chronic kidney disease, cognitive decline and other diseases.
Overall, about 80% of the HBP-related burden of disease occurs in low-income and
middleincome countries, where the prevalence of hypertension has been rising and rates of
awareness, treatment and control are lower than in developed countries.
Brazil is a South American country of continental dimensions with the fifth-largest
population in the world, where rates of morbidity and mortality are strongly affected by geographical,
racial and social inequalities. Cardiovascular diseases, particularly stroke and coronary heart
disease, have been–and, despite their decline, continue to be–the main cause of death in Brazil
: in 2010, about 29% of all deaths were attributable to cardiovascular diseases. HBP is the
leading risk factor for death and years of life lost in Brazil. Nonetheless, information about
prevalence, awareness, treatment and control of HBP in Brazil is limited[8–10]. National
prevalence estimates are derived from interviews and telephone surveys[11,12] and data about HBP
awareness, treatment and control are available only from local surveys conducted in specific
Brazilian cities or states[13–16]. Moreover, no studies of antihypertensive drug prescribing
patterns in Brazil were found. Accurate data on prevalence, awareness, management and control
from a larger, more diverse Brazilian sample can guide future evidence-driven health policies
and may allow comparisons with other countries.
In Brazil, it is largely unknown how socioeconomic, racial and demographic factors
influence control of HBP. Higher prevalence of hypertension and poorer therapeutic control have
been noted among those of lower socioeconomic position[18,19]. Social class, race and gender
are the basic axes of the social hierarchy which shape "the causes of causes" of diseases,
since they cause an uneven distribution of risk factors, including HBP. Examining
differences in the prevalence and control of HBP by education, income, race and gender helps
avoiding the oversimplification of the multifaceted nature of social disadvantage and its effects on
ELSA-Brasil (Estudo Longitudinal de Saúde do Adulto—Longitudinal Study of Adult
Health) is a large (15,105-subject), multiracial, multicentre cohort study focused on the risk of
cardiovascular diseases, diabetes, and obesity in Brazilian adults aged 35–74 years. From
the ELSA cohort’s baseline data, this present study examined prevalence, awareness,
management and control of HBP, as well as patterns of antihypertensive drug use. It further evaluated,
in participants using antihypertensive drugs, how controlled high blood pressure associated
with age, gender, education levels, per capita family income and race.
Detailed information on ELSA-Brasil can be found in another publication. Briefly, it is a
multicentre cohort study involving public servants at six teaching and research institutions in
six towns in Brazil. Its main aims were to examine the incidence of cardiovascular disease and
diabetes, as well as their main social, contextual, occupational and biological determinants.
Baseline assessment consisted of an approximately 7-hour evaluation, which included a
comprehensive set of measurements, clinical, laboratory and imaging exams and a detailed
inperson interview by trained personnel.
For the baseline study (2008–2010), 15,105 retired and active civil servants from 35 to 74
years old were recruited, out of which 2 individuals were excluded because of there was no
information on anti-hypertensive drug use.
Measurement of blood pressure and anti-hypertensive drugs. Arterial pressure was
measured after five minutes’ rest, with the participant sitting in a quiet room at controlled
temperature (20–24°C), using a validated oscillometric device (Omron HEM 705CPINT)
[24,25], following recommendations of the Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2004). Three
measurements were taken at one-minute intervals.
Quality assurance and control procedures were implemented across centres to minimise
error. Test-retest measurements were performed under similar conditions shortly after the
original set of measurements. The intra-class correlation coefficients were 0.88 (95% CI
0.82;0.91) for systolic blood pressure and 0.89 (95% CI 0.83;0.82) for diastolic blood pressure
All participants were asked about use of continuous medication in the prior two weeks
and were instructed to bring prescriptions and/or drugs used to the study clinic. This
information was recorded during the interview on a specifically-prepared form. The antihypertensive
drugs reported by participants were classified into seven categories by main pharmacological
action: diuretics (thiazides, loop diuretics, aldosterone antagonists and potassium-sparing
drugs); beta-blockers; calcium-channel blockers; angiotensin-converting enzyme (ACE)
inhibitors; angiotensin-II antagonists; vasodilators (direct action); and central and peripheral
Definitions. Casual blood pressure (BP) was considered to be the mean of the last two of
the three BP measurements taken. Hypertension was defined in terms of three criteria: systolic
BP 140 mmHg or diastolic BP 90 mmHg or use of medication to treat HBP.
To be considered an anti-hypertensive drug user a participant had to report a specific
medication in at least one of the categories listed above and to respond ‘Yes’ to the question "Are
any of the drugs you have taken in the past two weeks for hypertension (high blood
pressure)?".Controlled blood pressure was defined as SBP <140 mm Hg and DBP <90 mm Hg.
Those who responded ‘Yes’ to the question "Has a doctor ever told you that you have
hypertension (high blood pressure)?" were considered to be aware of the condition of HBP, except
women who reported the diagnosis only during pregnancy. Controlled HBP was defined as
systolic BP < 140 mmHg and diastolic BP < 90mmHg. This study did not evaluate
nondrug treatment of HBPhypertension.
Covariates. The following covariates were considered: age (35–44,45–54,55–64,65–74),
gender, education (<secondary, secondary, undergraduate, postgraduate), self-declared race
(Black, Brown, White, Asian and Indigenous) and per capita family income in US dollars
(USD) (<500.00, 501.00 to 1000.00, >1000.00)—local currency, Brazilian reais (BRL) was
converted to USD at a rate of BRL 2.00 = US$1.00.
Cohort characteristics were summarized using prevalence of high blood pressure by age,
gender, education, per capita family income and race. Prevalence adjusted for age and gender were
estimated using a logistic regression model. It consists in direct adjustment to estimate
prevalence ratio from logistic regression using the conditional and marginal methods.
Asymptotic confidence intervals for the conditional and marginal prevalence ratios were proposed by
Flanders and Rhodes. Details can be found in Bastos et. al 2015. In this paper we
estimated the prevalence ratio using marginal methods. The adjusted prevalences were estimated
using the same approach. Prevalence of HBP, awareness, anti-hypertensive drug use and
controlled HBP were also calculated by age and gender.
The association between covariates and controlled HBP was investigated through multiple
logistic regression. We fitted four models including each socio-demographic variable step by
step, in order to be able to discuss the contribution and changes of estimates in each one.The
Marginal prevalence ratios were estimated as proposed by Wilcosky&Chambless. All
analyses were performed using R Core.
Approvals were granted by all institutional review boards: Sao Paulo University, Oswaldo Cruz
Foundation, Federal University of Bahia, Federal University of Minas Gerais, Federal
University of Espírito Santo, and Federal University of Rio Grande do Sul. All participants signed
declarations of informed consent.
Prevalence of HBP was greater among the men than among the women (40.1% vs. 32.2%) and
increased with age (Table 1). In addition, it varied strongly and inversely with level of
education (prevalences adjusted for sex and age), from 44% among participants who had not
completed secondary school to 28.4% among those with postgraduate studies; and also with per
capita family income. Participants who classified themselves as Black showed greater adjusted
prevalence (49.3%) than those who classified themselves in the other colour/race categories.
Overall, 35.8% were classified as having HBP (Table 2 and S1 File). Of these, 80.2% were
aware they had HBP, that awareness being more frequent among women than among men
(84.8% vs. 75.8%) in all age groups, although especially salient in the youngest age group (35–
44 years old).
Table 2 presents the prevalence of high blood pressure, its awareness and the use of
antihypertensive drugs among all participants. In addition the proportion of blood pressure control
is presented both among all participants classified with high blood pressure and among those
using anti-hypertensive drugs.Use of at least one anti-hypertensive drug was reported by 76.8%
(n = 4147) of participants classified as having HBP and was also more frequent among women
in all age groups (Table 2). Among users of anti-hypertensives, 69.4% showed controlled blood
pressure levels (65.5% of the men and 72.9% of the women). Considering all the participants
classified as having HBP, about 53% showed appropriate blood pressure levels.
Among those using anti-hypertensives, the prevalence of controlled blood pressure,
adjusted for age, level of education, per capita family income and colour/race (Table 3, Model
4), was 15% greater among women than among men (PR = 1.14; 95% CI: 1.10–1.19). Besides,
thisprevalence varied inversely with education: among participants with postgraduate studies,
it was 21% greater (PR = 1.21; 95% CI: 1.14–1.28) than among those who had not completed
secondary school. Interestingly, as compared with those who had not completed secondary
school, there was a difference between participants who had postgraduate studies and those
Table 1. Study population (n and %) and prevalence of high blood pressure by gender, age, socioeconomic position and race. Longitudinal Study
of Adult Health (ELSA-Brasil), 2008–2010.
High blood pressure
Adjusted by age and gender
Blood Pressure Controlled
Table 3. Association between socioeconomic position, race and control of blood pressure among
hypertensives who used anti-hypertensive drugs. Longitudinal Study of Adult Health (ELSA-Brasil),
Controlled blood pressure
N = 4082.
Note: The reference category for each covariate was specified only when first included.
with undergraduate studies only: among the latter, the prevalence of controlled blood pressure
was smaller (PR = 1.13; 95% CI: 1.06–1.20. Per capita family income showed no statistically
significant association in the model adjusted for all the other variables. Prevalence of controlled
blood pressure levels was 21% greater among self-reported Asian participants (mainly of
Japanese descent) than self-reported Blacks (PR = 1.21; 95% CI: 1.12–1.32), and 19% greater
among Whites than among Blacks (PR = 1.19; 95% CI: 1.12–1.26). No difference was observed
between Browns and Blacks.
Among the 4147 participants in treatment with drugs, the classes of anti-hypertensives
most used, in isolation or combination, were: diuretics (53%); angiotensin-converting enzyme
inhibitors (ACE inhibitors) (38.7%); beta blockers (31.7%); angiotensin II receptor antagonists
(29.3%); calcium-channel blockers (18.9%); central action sympatholytics (1.71%); alfa-1
blockers (0.51%); vasodilators (0.4%). Among the diuretics (n = 2471), most used were
thiazides (85.7%), followed by aldosterone antagonists and potassium-sparing drugs (11.6%) and
loop diuretics (2.8%) (data not shown).
Most used in treatment with one or more drug classes (Table 4) were ACE inhibitors
combined with diuretics (13.3%) or alone (12.4%), angiotensin II antagonists (11%), diuretics
(9.2%) and beta blockers (8.9%).
The drugs most used alone (Table 5) were hydrochlorothiazide (39.6%), followed by
enalapryl (23.4%), atenolol (21.9%), losartan (19.2%), amlodipine (14.2%), captopril (10.7%),
chlortalidone (8.5%), and amiloride(5.4%) in association with other diuretics, and propranolol
(4.9%). Among diuretics, the most used was hydrochlorothiazide (78%), followed by the loop
diuretic furosemide +bumetamide (3%), or spironolactone (2.5%). Chlorthalidone was used by
17% of participants.
In this cohort, from 35 to 74 years old, 35.8% of participants were classified as hypertensive,
with greater prevalence among the men. The women showed more frequent prior awareness of
their condition of HBP, use of anti-hypertensive drugs and control of blood pressure (BP).
Control of BP among users of anti-hypertensive drugs varied inversely with socioeconomic
position and was lower among self-reported Black participants. The drug classes most used for
treatment were, in decreasing order, diuretics, ACE inhibitors, beta blockers and angiotensin II
antagonists. The great majority of participants classified as having HBP used more than
one anti-hypertensive drug, particularly ACE inhibitors in combination with diuretics.
Drug classes and combinations
No information: n = 6.
Total users of anti-hypertensives: 4147.
Others(<1%):Aliskiren, Bisoprolol, Bumetanide, Clopamide, Benazepril, Delapril, Hydralazine, Nebivolol,
Sotalol, Verapamil, Manidipine, Diltiazem, Felodipine, Fosinopril, Ibesartan, Isradipine, Lacidipine,
Lercanidipine, Doxazosin, Methyldopa, Moxonidine, Nadolol, Nitrendipine, Perindopril, Pindolol, Piretanide,
Reserpine, Rilmenidine, Triamterene.
The prevalence of HBP found among participants in ELSA-Brasil is greater than the 28.7%
reported in a meta-analysis based on 10 Brazilian cross-sectional studies, because, on
average, the populations evaluated in this meta-analysis are younger. Just as in ELSA-Brasil, in the
investigations in this meta-analysis, blood pressure was measured rather than using the
The estimate given here is also comparable with those found in the United States in 2011–
12 (29.1%), England in 2006 (29%) and China in 2011–12 (40%)[34–36]. Self-reported
diagnosis of high blood pressure estimated for the population of Brazil’s state capitals (22.7%) is
smaller than the 35.8% found in ELSA, possibly because it includes individuals 18 or more
In this study population, 80.2% of participants classified as having high blood pressure were
aware of their condition, which is similar to levels in Canada (82.6%) and the United States
(74%) in comparable populations [37,38], in spite of the existing differences in health systems,
conceptualized in this study as mediators between distal social determinants and blood
pressure awareness and control. Consistent with the available literature, awareness of high blood
pressure, use of drugs and control of BP were greater among women than men. That result is
found in countries as different, socially and culturally, as India, United States, China, South
Africa and Cuba [34,39–43]. More frequent use of medical care and health services by women
seems to be one of the reasons for that result, reflecting different ways that men and women
express disease. Although high levels of awareness are as desirable among men as among
women, this ‘advantage’ of women’s has significant impact on overall cardiovascular health,
because high blood pressure, diabetes and their combinations have greater impact on
cardiovascular risk among women than among men, especially after menopause[45,46].
Importantly, although awareness of a diagnosis of high blood pressure is a key factor in
controlling the condition, it is not enough to assure adherence to treatment nor to change
behaviour, especially because high blood pressure is generally asymptomatic. Confidence in the
health system, routine visits to the same service or doctor and the number of visits
have been cited as factors that can influence control of high blood pressure. In Brazil, although
many of the drugs used are distributed free of charge by the national health system (e.g., all the
diuretics most used by the ELSA population, except amiloride), these drugs are not always
available. When they have to be paid for, their prices are a considerable constraint on treatment
Anti-hypertensive drugs were widely used, at levels similar to those reported for the
populations of the United States (75.7%) and Canada (79.0%). The anti-hypertensive drugs most
used were thiazide diuretics, which agrees with the recommendation to prefer this drug class
by Brazilian and international guidelines current at the time of the study[1,2]. In Brazil, as in
other countries, hydrochlorothiazide forms part of most combination antihypertensive pills
containing a diuretic. However, there is evidence to suggest chlorthalidone is a much more
effective diuretic. Almost all the drugs in use (98%) belong to the five preferred classes
(diuretics, ACI inhibitors, beta blockers, angiotensin II antagonists, calcium-channel blockers)
. Also noteworthy is that almost 60% of participants used two or more drugs, corroborating
evidence that prescribing of multiple drugs is most common for controlling high blood
Controlled blood pressure in about 50% of hypertensives is in line with the literature.
Less frequent, however, is the high proportion (about 70%) of our study participants who were
in treatment with drugs and whose blood pressure was controlled. In a meta-analysis based
on Brazilian cross-sectional studies (10 studies), the percentage of control estimated for
Brazil in the 2000s was 24.1%, which is comparable with other countries[49,51]. The difference
between control in the ELSA population and in other population groups in Brazil can be
explained by the high level of education in our study population. Travassos et al. found that
health service use in Brazil can largely be explained in terms of education, income and
occupation. As the ELSA population comprises individuals in employment and with high levels of
education, socioeconomic position is an important factor conditioning high levels of
awareness, treatment and control. In addition, non-drug measures to reduce body weight,
particularly leisure-time physical activities, can mediate relations between socioeconomic position and
blood pressure control, which would contribute to explaining these good results. Note,
however, that prevalence of obesity is really high in ELSA-Brasil, while prevalence of physical
activity regarded as sufficient for disease prevention purposes is low, suggesting that proper use
of drugs may be the most important factor explaining the blood pressure control rates
Despite the socioeconomic position characteristics of the ELSA population and the
narrower range of socioeconomic variation than for the overall population of Brazil, unequal
prevalence of controlled blood pressure among users of anti-hypertensives are expressed strongly
and clearly. As in other studies[41,53,54], participants with less education and, independently,
Blacks and Browns show lower frequencies of HBP control.
The lower percentage of control among participants with undergraduate, as compared with
postgraduate, university education is particularly striking. Given that these two groups have
both studied at university level, it is improbable that differences in information as to the
importance of control, nor health service use, contributed to that result. However, it is conceivable
that greater autonomy and acquisition of new skills (control over work processes), which are
identified as protective against men’s developing high blood pressure, may partly explain
these results. In addition, it can be speculated that this advantageous situation originating in
the work environment, coupled with greater social prestige, may be reflected in the way the
individual deals with health-related factors overall.
The association between lower socioeconomic position and greater prevalence of HBP is
reported in other countries[19,39,53], as is the association with lower frequency of
awareness, treatment and control[56,57]. Lack of material resources is the source of a vicious circle
comprising disadvantages that start during intrauterine life and continue later through less
access to healthy foods, less time to engage in, and less access to settings that encourage,
physical activity (a habit that is important to preventing or controlling HBP), and less frequent
use of health services.
In the United States, the excess of high blood pressure shown by Afro-Americans as
compared with Whites has been one of the main characteristics of health inequalities[37,53].
Explanatory mechanisms have been polarised between social and genetic factors and it is only
recently that racial inequality in the occurrence of cardiovascular diseases has been addressed
in epigenetic terms. On that approach, observed biological variations should not be confused
with genetic explanations, which are inappropriate. Kuzawa&Sweet write: "A genetic
interpretation of the residual race effect problematically conflates observed biological variation with
inferred genetic contributions, and ignores evidence that social factors can have durable
lifecourse and transgenerational effects on health. Whereas group membership and continental
race are poor predictors of genetic variation, these same categories are directly related to the
social and structural manifestations of inequality that impact the development of responsive
In addition to showing higher prevalence of HBP, Afro-Americans displayed lower blood
pressure control rates, even comparing only those who use anti-hypertensive drugs[37,54].
Socioeconomic position, drug type and cardiovascular comorbidities have been proposed as
possible explanations. Racial discrimination has also been investigated as a contributing
factor in chronic stress and greater prevalence of HBP, especially among Afro-Americans
In Brazil, empirical studies of racial inequalities in the occurrence and control of HBP are
scarce, but suggest greater prevalence among Blacks [62–64] and among Blacks who report
having suffered discrimination.
In ELSA, Black participants represented 25% of the group with up to secondary education
and only 6% of those with postgraduate education. In addition, they reported discrimination
more often than participants self-reported as in other racial categories (results not presented).
It can be imagined that racism and socioeconomic disadvantage act simultaneously to increase
the risk of high blood pressure and decrease the opportunities to control it.
This study presents results based on standardised blood pressure measurements and
detailed data on anti-hypertensive drug use among 15103 participants of the ELSA-Brasil
cohort. As that study was conducted in six of Brazil’s state capitals, these results offer limited
scope for generalisation to Brazil’s overall adult population. Although relating to a specific
population, the ELSA-Brasil results may indicate the situation of the portion of Brazil’s population
comprising residents of large urban centres who are in employment. For example, lower
frequencies of HBP awareness and control among men—a finding encountered universally in the
available literature–constitute one important bottleneck for prevention and control of HBP in
Brazil and other countries. Improved understanding of the different social roles, opportunities
and constraints experienced in different manners by men and women can inform public health
policies more effectively and contribute to improving men’s health and life expectancy.
Besides gender, other fronts on which to extend prevention and control of HBP in Brazil
include reducing social inequalities in access to information, use of quality health services and
access to public spaces and conditions that facilitate healthy lifestyle habits. Reverse causality,
although always possible in cross-sectional analyses, is improbable in interpreting these
associations between indicators of social position and control of HBP, because they involve a
population of 35 to 74 years old with stable employment, admission to which was unrelated to blood
To conclude, higher levels of HBP awareness and control is an essential precondition to
reducing the impact of diseases, complications and deaths from cardiovascular diseases and
diabetes in Brazil, which is going through a period of rather peculiar social and demographic
transitions. The results of this study and future analyses of the ELSA population, which–unlike
other cohorts comprising exclusively individuals with high blood pressure–is made up of
workers, can yield important contributions to improving understanding of the factors that act
to increase the prevalence of high blood pressure and hinder its control. Explanations that
extend beyond the health care system can contribute to the development of strategies better
tailored to the population and its various constituent groups.
sure: according to age groups and sex.
S1 File. Mean and standard deviation of systolic blood pressure and diastolic blood
presConceived and designed the experiments: DC MSC EMA MIS BBD SMB VMAP IMB PAL
JGM. Performed the experiments: DC MSC EMA MIS BBD SMB VMAP IMB PAL JGM RHG
MDCM SMM. Analyzed the data: DC MSC AAN. Wrote the paper: DC ALPR JGM PAL MSC.
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