Health-related quality of life among adults with and without hypertension: A population-based survey using EQ-5D in Shandong, China
SCIentIfIC REPORts |
Health-related quality of life among adults with and without hypertension: A population-based survey using EQ-5D in Shandong, China
Li Zhang 0
Xiaolei Guo 1
Jiyu Zhang 1
Xi Chen 1
Chengchao Zhou 0 2
Dandan Ge 0
Yangyang Qian 0
0 Department of Social Medicine and Health Service Management, School of Public Health, Shandong University , Jinan , China
1 Shandong Center for Disease Control and Prevention , Jinan , China
2 Collaborative Innovation Center of Social Risks Governance in Health; School of Public Health, Shandong University , Jinan , China. Li Zhang and Xiaolei
OPEN Published: xx xx xxxx Previous studies have focused on health-related quality of life (HRQoL) in hypertensive individuals, but few studies have attempted to compare HRQoL between hypertensive and normotensive individuals using the EQ-5D in China. Based on a survey of 3509 adults aged 18 + years, we compared HRQoL between hypertensive and normotensive individuals using a chi-square test, t-test and multi-linear regression model. The results indicated that HRQoL in hypertensive individuals was poorer than that of normotensive individuals in all domains of the EQ-5D and its utility index. In addition, education, complications, household income, and family history of HBP were associated with HRQoL among the hypertensive patients. Factors including age, education, household income, health expenditure, place of residence, and family history of high blood pressure (HBP) were found to be associated with HRQoL in normotensive individuals. Interventions targeting at-risk subgroups, such as modifying existing health insurance schemes to improve them for poor individuals, might be helpful to improve HRQoL.
As a result of the accelerated process of population ageing, rapid urbanization and worldwide lifestyle changes, an
epidemic of hypertension is emerging globally1. Hypertension is most commonly a non-infectious, chronic
disease, and it is recognized as a major risk factor for cardiovascular diseases, other chronic diseases (e.g., diabetes,
renal disease) and overall mortality, which affects all segments of the population2,3. The burden of hypertension
continues to increase. In the first 25 years of the 21st century, the burden of hypertension is expected to increase
by 60% globally4,5. Hypertension also causes a high burden in China. The disability-adjusted life years (DALY)
due to hypertension account for 12% of the total DALY, and approximately 2 million premature deaths result from
elevated blood pressure every year in China2.
Health-related quality of life (HRQoL) is the health status (including physical, emotional and social aspects)
reported by individuals themselves6. HRQoL assesses how an individual?s well-being may be affected by a disease,
disability, or disorder over time6,7. It is usually measured using questionnaires. In the past few decades, hundreds
of HRQoL questionnaires have been developed to assess the quality of life of patients with various illnesses8?10.
Such questionnaires can be generalized into two categories: specific instruments (e.g., LC-13, HADS) and generic
instruments (e.g., SF-36). Many of the currently existing condition-specific instruments are not adequate, and
generic measures lack simplicity. The EQ-5D, a generic measure of HRQoL developed by the EuroQol Group in
1990, can address these issues and effectively evaluate HRQoL11.
Numerous studies have addressed the impact of hypertension on HRQoL12,13. Carvalho MV et al. used SF-36
to evaluate the HRQoL of hypertensive versus non-hypertensive individuals in Brazil and found that hypertension
impaired the HRQoL of patients who suffered from it14. Bardage C et al. found that persons with hypertension
had lower HRQoL than normotensive individuals in Sweden15. A population-based study in China found that
persons with hypertension experienced lower HRQoL compared with those without hypertension16. However,
most previous studies measured HRQoL using rather long generic instruments, such as SF-36, WHOQOL-100,
or WHOQOL-BREF. Further, in many studies, only hypertensive patients were included, and it was not clear
who served as the reference group. To date, very few studies concerning the HRQoL of hypertensive patients in
China have evaluated HRQoL using the EQ-5D17,18. There is also a lack of research to compare HRQoL between
hypertensive and normotensive individuals in China.
The present study?s overall goal is to empirically compare HRQoL between hypertensive and normotensive
individuals in China using the EQ-5D. This study has two specific objectives. First, we compare HRQoL, its
domains and utility index between hypertensive patients and normotensive individuals. Second, we identify risk
factors for HRQoL in hypertensive and normotensive individuals.
Study population and data collection. The present study uses the interim survey data of the Salt
Reduction for Preventing Hypertension Project (SRPHP) in Shandong province. The SRPHP was organized by
the Government of Shandong Province and the National Health and Family Planning Commission of the People?s
Republic of China and was conducted by Shandong Center for Disease Control and Prevention. This interim
survey was conducted in Shandong province, China, in 2014.
The baseline survey of this project was conducted in 2011. Eight urban districts and twelve rural counties were
randomly selected as the study sites based on the GDP per capita and location. Two sub-districts or townships
were selected in each sampling site. Likewise, three communities (or villages) were selected in each sub-district
(or township). Finally, 100 residents (over 18 years) were randomly selected from each community or village. In
the interim survey, two of the eight urban districts (Fushan District, Laicheng District) and four of the twelve
rural counties (Gaomi, Gaotang, Junan, and Zoucheng) were selected as study sites based on the GDP per capita,
location of the sites (eastern, central and western), and proportion of urban and rural population in Shandong
(1:2). Two hundred residents (over 18 years old) were randomly selected from each community or village. In total,
3509 eligible participants were included in this study.
Data collection. A standardized questionnaire was designed to collect data, including socio-demographic
information on the individuals and households, health-related behaviours, health conditions (hypertension and
its complications, family history, and the economic burden of hypertension), quality of life, and utilization of
health services. All participants were interviewed face to face in an isolated room in their houses by trained
postgraduate students from the Shandong University School of Public Health and staff from the Shandong Centre for
Disease Prevention and Control. The interviewers were trained in the background of the project and investigation
skills. To ensure quality, completed questionnaires were carefully checked by quality supervisors after the
interviews each day.
Dependent Variables. HRQoL was measured by the EQ-5D. The EQ-5D enables participants to classify
their health condition in five dimensions, and its reliability and validity have been demonstrated as acceptable
in China19. These domains define health status in terms of mobility, self-care, usual activities, pain/discomfort,
and anxiety/depression11. Each domain is divided into three levels (no problems, some problems and extreme
problems)8,10. The EQ-5D index score is generated by applying societal preference weights to each of the five
dimensions according to the Chinese population-based time trade-off (TTO) model19. Higher scores indicate
Independent variables. All hypertensive patients were identified by the question, ?Have you been
diagnosed with hypertension by a doctor?? If yes, respondents were also asked if they had been diagnosed with any
of the following complications: angina pectoris, myocardial infarction, stroke, or hypertensive nephropathy.
Complication was defined as having any of the diseases listed above.
Socio-demographic factors included age (<40, 40+, 50+), sex (male, female), education (primary or below,
junior, and senior or above), occupation (farmers and others), residence (rural, urban), household income
(<20000, 20000+, and 40000 + RMB Yuan), health insurance (yes, no), and health expenditure (<900, 900+,
and 1800 + RMB Yuan).
Health behaviour-related factors included sleeping time and drinking (yes, no). Sleeping time was recorded
as <7, 7+ and 8+ hours per day.
Hypertension-related information included family history of high blood pressure (HBP) (yes, no),
complications (yes, no), anti-hypertension medication in the past two weeks (yes, no), willingness to acquire health-related
knowledge, and HBP knowledge level. Willingness to acquire health-related knowledge was coded as ?yes? or
?no? by asking the question, ?Do you take the initiative to acquire health-related knowledge?? Hypertension
knowledge level was measured by three questions: ?Do you know the association between diet and obesity with
hypertension??, ?Do you know the association between overweight and hypertension??, and ?Do you know the
association between smoking and hypertension?? Each question was coded as yes (
) or no (0). Higher scores
indicate better hypertension knowledge level.
Data analysis. We used SPSS 18.0 to analyse the data. When analysing the data, we weighted the sample by
stratification and clustering to adjust for the sampling design. The socio-demographic characteristics of
individuals with and without hypertension were compared by chi-square for categorical variables. A t-test was employed
to compare the five domains of the EQ-5D and the EQ-5D index between hypertensive and normotensive
Primary or below
Senior or above
Household income (RMB Yuan)
2000040000Sleeping time (hours per day)
78Health expenditure (RMB Yuan)
Family history of HBPa
Willingness to acquire health-related knowledge
HBP knowledge level
Domains of EQ-5D
individuals. Multiple stepwise linear regression analyses were used to identify associated factors of EQ-5D among
hypertensive and normotensive individuals, respectively. The statistical significance in this paper was set at the
No additional data available.
Ethical consideration. This study was approved by the Ethical Committee of the Shandong Center for Disease
Control and Prevention. The investigation was conducted in accordance with the principles of Declaration
of Helsinki and approved guidelines, and it was carried out after the informed consent of all participants was
Table?1 shows the basic information about the participants. Of the 3509 respondents, 419 participants were
hypertensive patients. Generally, the majority of the participants had the following characteristics: female (52.4%), aged
50 and above (39.8%), a junior or below education level (82.6%), farmers (63.3%), non-drinkers (73.3%), rural
residents (87.7%), no history of high blood pressure (79.1%), covered by health insurance (77.4%), and willing to
acquire health-related knowledge (62.2%). Among the hypertensive patients, 52.7% had no complications, and
72.3% had used antihypertensive medication in the last two weeks.
The individuals with hypertension experienced lower scores in all domains of the EQ-5D and the EQ-5D
index compared with those without hypertension (Table?2), and the differences were statistically significant in all
domains of the EQ-5D and the EQ-5D index (P < 0.001) (Table?2).
The results of multivariate linear regression for the EQ-5D index are shown in Table?3. Hypertensive patients
with lower education attainment (P = 0.045), complications (P < 0.001), lower family income (P = 0.004), and a
family history of HBP (P = 0.005) reported lower HRQoL than did those without complications. Among the
normotensive individuals, those who were older (P = 0.001), spent higher annual health expenditure (P < 0.001), had
lower education attainment (P < 0.001), had lower household income (P < 0.001), lived in rural areas (P = 0.008),
and had a family history of HBP (P = 0.012) tended to report lower HRQoL.
Our research showed that hypertensive patients reported significantly lower scores in each of the EQ-5D domains
and a lower health utility index than did normotensive individuals, suggesting that hypertension is associated
with HRQoL15,16. Similar to a previous study, we found that the score in the domain of pain/discomfort among
the hypertensive individuals was significantly lower than that among the normotensive individuals. Some clinical
studies have shown a relationship between disease severity and body pain/discomfort15. Hypertensive individuals
with body pain/discomfort might have a poorer HRQoL than the general population. This study indicated that
hypertensive individuals had poorer scores in anxiety/depression than normotensive individuals did. Saboya P et
al. found that anxiety and, especially, depressive symptoms were significantly associated with hypertension and
had an adverse effect on hypertensive patients? quality of life20, which was consistent with our study. Some studies
found lower physical capacity among hypertensive individuals compared with normotensive individuals15, which
might explain the findings in the current study that hypertension was related to lower scores in mobility, self-care
and usual activity.
The current study showed that family history of HBP was an important risk factor in HRQoL for both
hypertensive and normotensive individuals21. A previous study indicated that family history of HBP might exert stress
on family members, which could result in anxiety, depression, and other mental disorders. Such psychological
disorders would adversely impact the HRQoL of the family members with a history of HBP22. In addition, lower
household income was found to be associated with poorer HRQoL for both hypertensive and normotensive
individuals. People with low household income tended to have higher healthcare needs but lacked the financial
capacity to pay for health services. The discomfort caused by the lack of healthcare utilization exaggerates the
dissatisfaction of self-rated health, which inevitably has a negative effect on people?s HRQoL23.
Complications with other diseases are relatively common in hypertensive patients, such as angina pectoris,
myocardial infarction, and stroke15. Our research observed that hypertensive patients with such complications
(angina pectoris, myocardial infarction, stroke, and hypertensive nephropathy) tended to have lower HRQoL
compared to those without such complications. There are two explanations for this result. First, the complications
of hypertension might contribute to poor ADL (e.g., stroke) and bodily pain (e.g., angina pectoris), with the
result that lower HRQoL among these patients might be due to subsequent complications, not to the
hypertension itself24?26. Second, the complications might affect hypertensive patients? perception of their general health
condition27, which influences how the patients rate their HRQoL. Moreover, other complications28 (e.g.,
nephropathy, retinopathy) that we did not include in this study may have had an effect on HRQoL in the hypertensive
In addition, we found that HRQoL in the normotensive individuals was associated with factors including age,
educational level, and health expenditure. High health expenditure was considered an economic burden to the
household, and it often placed households at higher risk of catastrophic health expenditure and pushed them into
poverty. People with higher educational levels tended to have higher levels of health literacy, which was
considered helpful for improving HRQoL29. Further, living in rural areas and being older were found to be risk factors
of HRQoL in our study, findings that have been previously verified22,30.
The EQ-5D used in this study is a simple, well-documented, and validated generic instrument31. It has been
widely used in China to measure HRQoL in recent years13,30. Similar to other instruments measuring HRQoL, the
EQ-5D can reflect the health utility index score. However, the utility index score cannot be generated by the direct
measures of the EQ-5D. A population-based time trade-off (TTO) model can help to convert the measurement
results of the EQ-5D into health utility index scores21. In this study, both the direct measurements and the health
utility index scores of the EQ-5D were analysed, which can provide real profiles of HRQoL among hypertensive
and normotensive individuals. This is the first study in China to compare HRQoL between hypertensive and
normotensive individuals using the EQ-5D.
This study has a number of strengths. First, this study is one of the only studies to measure the EQ-5D by
health utility index scores based on a Chinese time TTO model, which provides a real profile of EQ-5D utility
index scores among hypertensive individuals in China. Second, this is the first study in China to compare HRQoL
between hypertensive and normotensive individuals using the EQ-5D.
The present study also has certain limitations. First, information including willingness to acquire
health-related knowledge and the EQ-5D were self-reported, leading to the possibility of subjective bias. Second,
as a cross-sectional design, the correlation between HRQoL and associated factors cannot be interpreted as
causal. Third, there might be other potential factors that affect HRQoL, such as medication adherence, hospital
admission, and other chronic diseases, which might cause a deviation of the results and will be remedied in the
This population-based study found that individuals with hypertension had lower HRQoL compared with those
without hypertension. Complications in the individuals with hypertension were found to be associated with even
lower HRQoL. Educational level, household income and family history of HBP were found to be important risk
factors of HRQoL in both hypertensive and normotensive individuals, which indicates that existing health
insurance schemes may need to be modified to improve their benefit to poor individuals. This study also identified a
number of associated factors for HRQoL among normotensive individuals, including age, residence, and health
expenditure, providing potential evidence for policy design (e.g., to promote health literacy among those with
poor education) to improve HRQoL among normotensive individuals.
We would like to thank the officials of local health agencies and all participants and staff at the study sites for
their cooperation.We are grateful for funding support from the Department of Science and Technology of
Shandong Province (2012GSF11828), Shandong Health and Family Planning Commission (2015 WS0284), and
the Independent Innovation Foundation of Shandong University (2012DX006).
C.Z. and L.Z. conceived the idea. C.Z., X.G., J.Z. and X.C. implemented the study. L.Z. and C.Z. participated in
the statistical analysis and interpretation. L.Z. drafted the manuscript. C.Z., D.G., Y.Q. offered many valuable
comments on the draft and polished it. All authors read and approved the final manuscript.
Competing Interests: The authors declare that they have no competing interests.
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