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Knowledge and Understanding of Hypertension Among Tibetan People in Lhasa, Tibet
ORIGINAL ARTICLE
Heart, Lung and Circulation (2016) 25, 600–606 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.11.007
Knowledge and Understanding of Hypertension Among Tibetan People in Lhasa, Tibet Dao-Kuo Yao, MD, PhD a, Wen Su, MD a, Xi Zheng, MD b, Le-Xin Wang, MD, PhD, FCSANZ c* a
Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China Beijing Geriatric Hospital, Beijing University of Chinese Medicine, Beijing, PR China School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
b c
Received 3 January 2015; received in revised form 20 August 2015; accepted 21 November 2015; online published-ahead-of-print 2 December 2015
Background
The aim of this study was to investigate the knowledge and understanding about hypertension among residents in Lhasa, Tibet.
Methods
A total of 1, 370 native Tibetan people aged 18 years old were enrolled in this survey. Individuals were selected using stratified proportional sampling and Lhasa was divided into Urban, Suburban, Agricultural and Pastoral areas. Data pertaining to blood pressure, socio-demographic details, knowledge and perceptions about hypertension were obtained.
Results
The prevalence of hypertension was highest among Urban participants (56.1%) and lowest among Pastoral participants (34.2%). The awareness of hypertension (43.1%) was lowest among Agricultural participants. Less than one third of the respondents knew the normal range of blood pressure. A considerable proportion (49.2%) had no idea of risk factors and consequences of hypertension. With regard to prevention and control, about 30% of the respondents did not know the lifestyle changes for hypertension prevention. Regarding treatment, 30% of participants did not provide an answer. Most of the respondents acquired knowledge of hypertension from healthcare providers. Participants from the Agricultural areas had the lowest knowledge of hypertension. Approximately 75.5% of hypertensive patients ceased antihypertensive medications on their own after improvement of blood pressure.
Conclusions
The understanding of hypertension was poor among the native Tibetan people in Lhasa. There is a need to improve education and primary health care services to this large hypertensive population.
Keywords
Hypertension Knowledge Prevalence Agricultural areas Tibet
Introduction Hypertension is an important contributor to cardiovascular diseases and cerebral-vascular diseases in western countries and in Asia [1–4]. A recent meta-analysis has shown that the overall prevalence of hypertension in China has increased to 21.5% [5]. However, the rates of treatment and control of
hypertension are still low in most parts of the world [5–7]. Further, the knowledge and understanding of hypertension was still poor in many parts of the world. In China, there is a large variation in the prevalence of hypertension among different geographic areas [8]. Lhasa is the capital of Tibet. The native residents are Tibetan people who live at a high altitude of average 3,650
*Corresponding author at: School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2678, Australia. Tel.: +61 2 69332905; fax: +61 2 69332587, Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
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metres above the sea level. Though some studies showed that blood pressure decreased with increase in altitude among permanent inhabitants of high altitude [9,10], our study has shown that hypertension was highly prevalent among native Tibetan people in Lhasa [11]. In our study on 1,370 native Tibetan people aged 18 years old, the prevalence of hypertension was 51.2% [11]. The hypertension prevalence increased with age (77.8% in 60-74 years and 82.5% in 75years group) [11]. The self-awareness, treatment and control rate of hypertension was 63.5%, 24.3% and 7.7%, respectively [11]. Poor knowledge of hypertension may be responsible for the low rates of awareness and control of hypertension. Healthy lifestyle changes, such as dietary modification, exercise and stress reduction, are important for control of hypertension. However, it is not clear whether the native Tibetan people are equipped with this knowledge.
Methods Study Participants This investigation is a cross-sectional survey of self-reported understanding about hypertension, which was part of our survey of hypertension prevalence in Lhasa [11]. Data were collected from April to June, 2010. The selection of the participants was based on a stratified proportional sampling method. The region of Lhasa was divided into Urban, Suburban, Agricultural and Pastoral areas in terms of their financial and agro-stockbreeding status: Urban: central districts in the Lhasa city; Suburban: counties in 20-50kms distance to Lhasa city; Agricultural area: counties mainly on agricultural land about 50-150kms from Lhasa; Pastoral area: counties mainly on stockbreeding land 50-180kms from central Lhasa. The study participants were permanent residents with a record in the household registration of native Tibetan population and were aged 18 years or older. The Ethics Committee of Lhasa Centre for Disease Control approved the study protocol. Informed written consent was obtained from all the participants prior to data collection.
Survey Methods Standardised mercury sphygmomanometers were used for the measurement of blood pressure in the present study. Investigators were trained in the measurement of blood pressure and in administering the survey questionnaire before the study. Blood pressure was measured according to 1999 World Health Organization/ International Society of Hypertension guidelines on hypertension [12]. Hypertension was defined according to the 2007 European Society of Cardiology (ESC) guidelines for the management of arterial hypertension [13]. Self-awareness of hypertension was defined as self-report of any prior diagnosis of hypertension by a healthcare professional. Treatment of hypertension was defined as a prescription medication used for management of hypertension during the previous two weeks. Control of
hypertension was defined as systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg after treatment. All identified participants were seen at a clinic. The sociodemographic details were collected. Height and weight were also measured. All the participants were queried on knowledge and understanding using a pre-tested interview questionnaire. The questionnaire comprised three categories. The first was about knowledge on the optimal level of blood pressure, on risk factors of hypertension and on consequences of uncontrolled hypertension. The second was in relation to measures to prevent and treat hypertension. Participants were asked to select two or more of the anti-hypertension methods. They were also asked whether they had acquired hypertension-related education from healthcare providers. The third part of the questionnaire was aimed at hypertensive patients. A couple of questions were asked to evaluate medication adherence and compliance, as well as perceptions on hypertension control. All responses were validated by the first author randomly by interviewing the participants who had completed the survey. The interview protocol consisted of both closed-ended and open-ended questions. The responses to open-ended questions were narrative and were categorised during analysis.
Statistical Analysis Participants’ characteristics were summarised using means and standard differences (SDs) or counts and percentages as appropriate. Data about the prevalence, self-awareness of hypertension, socio-demographic details, and understanding of hypertension were obtained for the whole sample. Comparison of categorical data between groups split by areas of residence was performed with Chi-square test. P <0.05 was considered statistically significant. SPSS 19.0 software was used for analysis (SPSS, Inc, Chicago).
Results Basic Characteristics of the Participants A total of 1,370 adults aged 18 years agreed to participate. Table 1 shows the basic characteristics of these participants by the area of residence. A total of 54 items were missing though all participants responded to the questions. Compared to other groups, most of the Pastoral participants were in a younger age group and Agricultural Area had more old people (75 years) (p <0.001). Women were significantly more than men in Pastoral Area and Suburban Area (p <0.001). A total of 46.4% of Agricultural participants did not have any formal education. In addition, they smoked and drank more than participants from other areas (both p <0.001). The majority of Urban participants received formal education, some of whom completed higher education. Their smoking rate was the lowest in these four groups. However, a higher proportion of Urban participants were overweight or obese. As to income level, the ratio of high
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Table 1 Basic characteristics of the participants Groups
Urban
Suburban
Agricultural
Pastoral
(n=508)
(n=367)
(n=235)
(n=260)
P value
<0.001
Age 18-44years
110(21.7)
99(27.0)
65(27.7)
159(61.2)
<0.001
45-59years
219(43.1)
125(34.1)
78(33.2)
34(13.1)
<0.001
60-75years
161(31.7)
130(35.4)
73(31.1)
54(20.8)
0.010
75 years
18(3.5)
13(3.5)
19(8.1)
13(5.0)
0.038 <0.001
Sex Male
208(40.9)
143(39.0)
118(50.2)
76(29.2)
0.003
Female Ethnics
300(59.1)
224(61.0)
117(49.8)
184(70.8)
0.027 >0.05
Zang
505(99.4)
367(100)
234(99.6)
260(100)
1.000
Han
3(0.6)
0(0)
1(0.4)
0(0)
Education (missing 2)
0.317 <0.001
No education
157(30.9)
158(43.1)
109(46.4)
89(34.2)
0.002
1-6years
143(28.1)
140(38.1)
67(28.5)
126(48.5)
<0.001
7-12years
162(31.9)
58(15.8)
51(21.7)
36(13.8)
<0.001
46(9.1)
11(3.0)
8(3.4)
7(2.7)
<0.001 <0.001
Low
107(21.1)
205(55.9)
90(38.3)
58(22.3)
<0.001
Medium
269(53.0)
113(30.8)
89(37.9)
85(32.7)
<0.001
High
132(26.0)
48(13.1)
56(23.8)
116(44.6)
<0.001
Single
134(26.4)
103(28.1)
65(27.7)
94(36.2)
Married
374(73.6)
264(71.9)
170(72.3)
166(63.8)
0.482 <0.001 0.001
13-15years Income level (missing 2)*
Marital status
Smoking (missing24) Yes No
0.036
116(22.8)
114(31.1)
84(35.7)
55(21.2)
383(75.4)
246(67.0)
139(59.1)
199(76.5)
Alcohol drinking (missing 2)
0.109
0.046 <0.001
Yes
172(33.9)
103(28.1)
86(36.6)
47(18.1)
No
335(65.9)
264(71.9)
148(63.0)
213(81.9)
BMI (kg/m2,missing 24)
<0.001 0.040 <0.001
4(0.8)
32(8.7)
15(6.4)
6(2.3)
<0.001
338(66.5) 157(30.9)
273(74.4) 53(14.4)
195(83.0) 21(8.9)
213(81.9) 39(15.0)
0.036 <0.001
Prevalence of hypertension
285(56.1)
197(53.7)
130(55.3)
89(34.2)
<0.001
Awareness of hypertension
200(70.2)
134(68.0)
56(43.1)
55(61.8)
<0.001
Treatment of hypertension
86(30.2)
39(19.8)
28(21.5)
17(19.1)
0.025
Control of hypertension
12(13.9)
20(51.3)
11(39.3)
11(64.7)
<0.001
<18.5 18.5-24.9 25
Data are present as n (%). BMI = body mass index.*Income level: Low indicates the income per year of <2000RMB, Medium indicates the income per year of 2000-5000 RMB, High indicates the income per year of 5000RMB.
income level was comparatively higher in Pastoral Area. The prevalence of hypertension was highest among Urban participants (56.1%) and lowest among Pastoral participants (34.2%). The awareness of hypertension was highest among Urban participants (70.2%) and lowest among Agricultural participants (43.1%). Although the awareness and treatment of hypertension was comparatively higher, the final control rate of hypertension was comparatively lower in Urban participants (13.9%).
Knowledge of Hypertension and its Consequences Among all participants as Table 2 shows, most people could not tell the normal blood pressure level, regardless where they lived. Only 16.4% participants could answer the upper limit of normal blood pressure correctly. The education level was comparatively high among Urban participants, but only 23.4% of them stated the upper limit of normal
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Knowledge of hypertension in Tibet
Table 2 Knowledge of hypertension and its consequences by different strata P value
Urban
Suburban
Agricultural
Pastoral
(n=508)
(n=367)
(n=235)
(n=260)
170/110mmHg
12(2.4)
13(3.5)
8(3.4)
6(2.3)
0.667
110/70mmHg
78(15.4)
11(3.0)
29(12.3)
97(37.3)
<0.001
140/90mmHg
119(23.4)
27(7.4)
40(17.0)
39(15.0)
<0.001
80/55mmHg
3(0.6)
3(0.8)
2(0.9)
4(1.5)
0.617
296(58.3)
313(85.3)
156(66.4)
114(43.8)
<0.001
Think the upper limit of normal BP as
Cannot say
<0.001
<0.001
Whether should someone above 35years take their BP every year (missing 3) Yes
156(30.7)
121(33.0)
62(26.4)
94(36.2)
Only when symptoms appear
281(55.3)
180(49.0)
100(42.6)
121(46.5)
0.103
71(14.0)
66(18.0)
71(30.2)
43(16.5)
<0.001
94(18.5)
59(16.1)
36(15.3)
61(23.5)
1-6 months
151(29.7)
73(19.9)
51(21.7)
55(21.2)
0.012
7-12 months
50(9.8)
2(0.5)
15(6.4)
10(3.8)
<0.001
12 months Never
21(4.1) 63(12.4)
27(7.4) 57(15.5)
9(3.8) 45(19.1)
13(5.0) 21(8.1)
0.149 0.005
No How long is your latest time measuring BP Within 30 days
0.253
<0.001 0.114
People susceptible to hypertension Who eat more fat
253(49.8)
192(52.3)
86(36.6)
148(56.9)
<0.001
Who consume more salt
330(65.0)
266(72.5)
124(52.8)
174(66.9)
<0.001
Smokers
323(63.6)
248(67.6)
112(47.7)
147(56.5)
<0.001
Drinkers
364(71.7)
275(74.9)
129(54.9)
172(66.2)
<0.001
Overweight people
246(48.4)
197(53.7)
87(37.0)
113(43.5)
<0.001
Excited people Passive smokers
300(59.1) 216(42.5)
285(77.7) 135(36.8)
95(40.4) 85(36.2)
129(49.6) 82(31.5)
<0.001 <0.001
Consequences of uncontrolled hypertension Stroke
146(28.7)
100(27.2)
23(9.8)
52(20.0)
<0.001
Coronary heart disease
152(29.9)
108(29.4)
73(31.1)
42(16.2)
<0.001
Cancer
115(22.6)
60(16.3)
22(9.4)
25(9.6)
<0.001
11(2.2)
27(7.4)
8(3.4)
11(4.2)
0.002
241(47.4)
192(52.3)
127(54.0)
170(65.4)
<0.001
No consequences Cannot say
Multiple responses were given. Data are present as n (%). BP, blood pressure.
blood pressure and the rates were lower in other strata (p <0.001). Most people thought they should take their blood pressure only when symptoms appear, and there were no differences in the rates of taking blood pressure when symptoms appear between the four groups. Only 42.3% of people had blood pressure checks in the six months prior to this study. In order to have an insight into participants’ knowledge of hypertension, we asked which kinds of people were susceptible to hypertension. Over 50% of people stated that people who have high salt intake in their diet were at risk of having hypertension. When asked about consequences of hypertension, 49.2% respondents had no idea of consequences due to hypertension such as stroke or coronary heart disease. The people in Agricultural and Pastoral areas were less aware of the consequences of hypertension (p <0.001).
Understanding of the Prevention and Treatment of Hypertension Table 3 presents the understanding of how to prevent and treat hypertension. About 30% of the respondents did not know the exact measures for hypertension prevention. 67.2% of participants mentioned one of the lifestyle changes such as healthy diet, proper exercise, weight control, reducing tension and no smoking or drinking as preventive measures. There were significant differences in the understanding of parts of lifestyles including less fat, more vegetable and fruit intake, exercise and no drinking among the four groups (all p <0.001). Above 35% of participants from every stratum stated low salt diet may prevent hypertension. However, more than 70% did not know how many grams of salt a normal adult should have every day. As to treatment, around 30% of
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Table 3 Perceptions on how to prevent and treat hypertension Urban
Suburban
Agricultural
Pastoral
(n=508)
(n=367)
(n=235)
(n=260)
P value
Measures to prevent hypertension Less fat
79(15.6)
92(25.1)
24(10.2)
56(21.5)
<0.001
Exercise
118(23.2)
78(21.3)
36(15.3)
33(12.7)
0.001
Weight control
91(17.9)
57(15.5)
34(14.5)
31(11.9)
0.174
Reducing tension
74(14.6)
57(15.5)
50(21.3)
25(9.6)
More vegetable and fruit
75(14.8)
101(27.5)
34(14.5)
39(15.0)
<0.001
Low salt
186(36.6)
130(35.4)
94(40.0)
100(38.5)
0.674
No smoking No drinking
74(14.6) 130(25.6)
65(17.7) 125(34.1)
33(14.0) 43(18.3)
32(12.3) 102(39.2)
0.379 <0.001
Do not know
165(32.5)
127(34.6)
74(31.5)
83(31.9)
0.84
0.004
0.001
How many grams of salt should one normal adult eat daily 6g
35(6.9)
20(5.4)
20(8.5)
22(8.5)
0.426
3g
99(19.5)
52(14.2)
31(13.2)
55(21.2)
0.046
5(1.0)
11(3.0)
5(2.2)
3(1.2)
0.128
369(72.6)
274(74.7)
179(76.2)
190(71.9)
0.955
9g Do not know Measures to treat hypertension
33(6.5)
15(4.1)
16(6.8)
11(4.2)
Dietary changes
No need
210(41.3)
191(52.0)
86(36.6)
143(55.0)
<0.001
Pleasant emotion
130(25.6)
174(47.4)
71(30.2)
41(15.8)
<0.001
63(12.4)
39(10.6)
38(16.2)
31(11.9)
0.228
362(71.3)
302(82.3)
138(58.7)
179(68.8)
Proper exercise
0.264
Where do you acquire the related knowledge of hypertension Healthcare providers
<0.001
Multiple responses were given. Data are present as n (%).
participants did not provide an answer, regardless of whether they were hypertensive or not. Methods such as ‘‘dietary changes’’, ‘‘stress control’’, ‘‘proper exercise’’, ‘‘weight control’’ and ‘‘medicine’’ were also offered. When asked where they acquired the knowledge of hypertension, 71.6% of the respondents stated they acquired the knowledge from healthcare providers, rather than television, radio, newspaper or brochures.
missed the anti-hypertensive medication at least once. Rates of taking medications were higher in Agricultural (71.2%) and Pastoral Areas (59.4%) than in Urban (50.7%) or Suburban (47.1%) Area. 75.5% of the patients stopped antihypertensive medication by themselves when blood pressure improved.
Knowledge of Blood Pressure among Hypertensive Patients
Discussion
A further survey was conducted of the people who had already been diagnosed with hypertension, as shown in Table 4. Approximately 90% of them had taken measures to treat hypertension, except for people in the Pastoral area where the rate was 66.1%. Medicines, dietary changes, stress reduction or quitting smoking and drinking were considered by these respondents. About half of these hypertensive patients stated that they could stop taking medicine when blood pressure was normal. Above 30% stated that there is no need for medicine unless hypertension becomes symptomatic. Of the participants with hypertension, many had
The main findings of this study are: First, there was considerable variation in the awareness of hypertension among the residents of Lhasa. Less than one third of the respondents knew the normal levels of blood pressure. A considerable proportion of the respondents had no idea of the risk factors and consequences of hypertension. Second, about one third of the respondents did not know the preventative measures for hypertension, or the treatments for hypertension. Finally, the majority of hypertensive patients discontinued their antihypertensive medications by themselves when blood pressure improved. Poor adherence to anti-hypertension medications was common among hypertension patients.
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Knowledge of hypertension in Tibet
Table 4 Knowledge of control aspects of hypertension among hypertensive patients Urban
Suburban
Agricultural
Pastoral
(n=207)
(n=140)
(n=66)
(n=64)
P value
<0.001
Have you taken measures to treat hypertension (missing 3) Yes
183(89.3)
125(89.9)
49(87.5)
39(66.1)
0.124
No
22(10.7)
14(10.1)
7(12.5)
20(33.9)
<0.001
If yes, how? 86(16.9)
39(10.6)
28(11.9)
17(6.5)
<0.001
Dietary changes
123(24.2)
89(24.3)
24(10.2)
27(10.4)
<0.001
Pleasant emotion Proper exercise
75(14.8) 1(0.2)
81(22.1) 2(0.9)
12(5.1) 2(0.8)
13(5.0) 0(0)
<0.001 0.218 0.152
Medicines
Weight control Quit smoking and drinking Take your BP at least weekly Have the idea that one can stop
0(0)
0(0)
2(0.8)
1(0.3)
22(4.3)
19(5.2)
2(0.9)
8(3.1)
0.038
56(27.1)
19(17.9)
17(26.6)
27(42.2)
<0.001
105(50.7)
90(64.3)
29(42.6)
39(60.0)
<0.001
86(41.5)
67(47.9)
21(31.8)
25(39.1)
<0.001
medicine when BP is normal Have the idea that no need for medicine unless symptoms appear Medication compliance Forget to take medicine once
105(50.7)
66(47.1)
47(71.2)
38(59.4)
<0.001
Stop taking medicine when
153(73.9)
112(80.0)
49(74.2)
46(71.9)
<0.001
symptoms improve Multiple responses were given. Data are present as n (%). BP, blood pressure.
Blood pressure control appears to be a great challenge among native Tibetan people. General lack of related knowledge of hypertension and unique local life styles may be the major causes. Levels of health care are relatively lower in ethnic minority areas of China [14]. In our study, the awareness of hypertension was lowest among Agricultural participants and people there lacked knowledge of hypertension [11]. Most participants in our survey thought they should take their blood pressure only when symptoms appear. The unawareness rate in the present study was consistent with a previous study of a rural Australian population which showed that above 50% of the patients with elevated blood pressure were unaware of the presence of hypertension [15]. Patients unaware of hypertension received no therapy. The most important reason for the lack of knowledge of hypertension may be inadequate education. Our results are consistent with the findings that education is associated with risk of complex diseases [16,17]. In our study, few Tibetans have completed higher education and a very high proportion (46.6%) of agricultural residents could not get any formal education. Even amongst the city participants, only 9.1% of them have completed 13-15 years of education. Studies have shown that education was associated with blood pressure among African Americans in the United States [18]. A study from the United States reported awareness of hypertension was above 80% in a well-educated population [19], suggesting that ongoing studies and interventions to increase
hypertension awareness and treatment could be successful. The primary healthcare system in China has put more emphasis on cities. It is generally considered that inadequate efforts have been made to reduce hypertension risk factors in ethnic minority areas. Improved access to education, in particular health education, in Tibetans may help to reduce the prevalence of hypertension and improve its management or control. Socio-economic status may be another reason for the lower awareness and knowledge of hypertension in the present study population in Lhasa. Many studies have identified the relationship of socio-economic status with hypertension [20,21]. Better working conditions and higher incomes, which interrelated with education, improve health benefits and increase the knowledge of hypertension [20,21]. In accordance with prior studies [22,23], Agricultural and Pastoral participants in our study had less knowledge about hypertension and its treatment. Consequences of hypertension were underestimated by residents in Lhasa, particularly residents of Agricultural and Pastoral Areas. Understanding of risk factors such as obesity, lack of physical exercise and smoking were poor in Lhasa, as well as knowledge of how to prevent and treat hypertension. Although a majority knew a high salt diet was a risk factor, they had no idea about the optimal amount of salt to consume daily. Accesses to available healthcare services are still insufficient for Lhasa residents. Many of the hypertensive patients
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residing in Lhasa did not know when to start or stop antihypertensive medicines. Most of the patients in our study stopped taking medicine by themselves when symptoms improved. The poor anti-hypertension medication adherence was considered as one of the main reasons for uncontrolled hypertension [24,25]. Poor knowledge might be due to the silent nature of hypertension as well as a lack of high-quality health care. These results indicate that there is significant room for improvement in the primary healthcare system in Lhasa. In conclusion, although hypertension was considerably prevalent in the native Tibetan residents in Lhasa, the rates of self-awareness and understanding of the prevention or treatment were low. There is a need to enhance the health education of hypertension among the native Tibetan residents in Lhasa.
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[9] Negi PC, Bhardwaj R, Kandoria A, Asotra S, Ganju N, Marwaha R, et al. Epidemiological study of hypertension in natives of spiti valley in Himalayas and impact of hypobaric hypoxemia; a cross-sectional study. J Assoc Physicians India 2012;60:21–5. [10] Shrestha S, Shrestha A, Bhattarai D. Blood pressure in inhabitants of high altitude of western nepal. JNMA J Nepal Med Assoc 2012;52:154–8. [11] Zheng X, Yao DK, Zhuo-Ma CR, Tang J, Wang TR, Zhang HH, et al. Prevalence, self-awareness, treatment, and control of hypertension in Lhasa, Tibet. Clin Exp Hypertens 2012;34:328–33. [12] 1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension. Guidelines subcommittee. J Hypertens. 1999;17:151–183. [13] Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et al., The task force for the management of arterial hypertension of the European Society of Hypertension. 2007 guidelines for the management of arterial hypertension: The task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2007;28:1462–1536. [14] So WK, Chan CW, Choi KC, Chan DN. Perspectives on the use of and service needs of cancer preventive services for ethnic minorities in Hong Kong: A study protocol. J Adv Nurs 2013;69(9):2116–22. [15] White F, Wang L, Jelinek H. Awareness and pharmacotherapy of hypertension in a rural community. Med Princ Pract 2009;18:261–5. [16] Kim C, Eby E, Piette JD. Is education associated with mortality for breast cancer and cardiovascular disease among Black and White women? Gend Med 2005;2(1):13–8. [17] Farmer MM, Ferraro KF. Are racial disparities in health conditional on socioeconomic status? Soc Sci Med 2005;60(1):191–204. [18] Non AL, Gravlee CC, Mulligan CJ. Education, genetic ancestry, and blood pressure in African Americans and Whites. Am J Public Health 2012;102(8):1559–65. [19] Olives C, Myerson R, Mokdad AH, Murray CJ, Lim SS. Prevalence, awareness, treatment, and control of hypertension in united states counties, 2001-2009. PLoS One 2013;8:e60308. [20] Mujahid MS, Diez Roux AV, Cooper RC, Shea S, Williams DR. Neighborhood stressors and race/ethnic differences in hypertension prevalence (The Multi-Ethnic Study of Atherosclerosis). Am J Hypertens 2011;24(2):187–93. [21] Grotto I, Huerta M, Sharabi Y. Hypertension and socioeconomic status. Curr Opin Cardiol 2008;23:335–9. [22] Lerner AG, Bernabe-Ortiz A, Gilman RH, Smeeth L, Miranda JJ. The ‘‘rule of halves’’ does not apply in Peru: Awareness, treatment, and control of hypertension and diabetes in rural, urban, and rural-to-urban migrants. Crit Pathw Cardiol 2013;12:53–8. [23] Tomei G, Sancini A, Tomei F, Vitarelli A, Andreozzi G, Rinaldi G, et al. Prevalence of systemic arterial hypertension, electrocardiogram abnormalities, and noise-induced hearing loss in agricultural workers. Arch Environ Occup Health 2013;68:196–203. [24] Whitworth JA. World Health Organization (WHO)/International Society of Hypertension (ISH) Statement on Management of Hypertension. J Hypertens 2003;21:1983–92. [25] Yu Y, Sun X, Zhuang Y, Dong X, Liu H, Jiang P, et al. What should the government do regarding health policy-making to develop community health care in Shanghai? Int J Health Plann Manage 2011;26:379–435.
Heart, Lung and Circulation (2016) 25, 600–606 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.11.007
Knowledge and Understanding of Hypertension Among Tibetan People in Lhasa, Tibet Dao-Kuo Yao, MD, PhD a, Wen Su, MD a, Xi Zheng, MD b, Le-Xin Wang, MD, PhD, FCSANZ c* a
Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China Beijing Geriatric Hospital, Beijing University of Chinese Medicine, Beijing, PR China School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
b c
Received 3 January 2015; received in revised form 20 August 2015; accepted 21 November 2015; online published-ahead-of-print 2 December 2015
Background
The aim of this study was to investigate the knowledge and understanding about hypertension among residents in Lhasa, Tibet.
Methods
A total of 1, 370 native Tibetan people aged 18 years old were enrolled in this survey. Individuals were selected using stratified proportional sampling and Lhasa was divided into Urban, Suburban, Agricultural and Pastoral areas. Data pertaining to blood pressure, socio-demographic details, knowledge and perceptions about hypertension were obtained.
Results
The prevalence of hypertension was highest among Urban participants (56.1%) and lowest among Pastoral participants (34.2%). The awareness of hypertension (43.1%) was lowest among Agricultural participants. Less than one third of the respondents knew the normal range of blood pressure. A considerable proportion (49.2%) had no idea of risk factors and consequences of hypertension. With regard to prevention and control, about 30% of the respondents did not know the lifestyle changes for hypertension prevention. Regarding treatment, 30% of participants did not provide an answer. Most of the respondents acquired knowledge of hypertension from healthcare providers. Participants from the Agricultural areas had the lowest knowledge of hypertension. Approximately 75.5% of hypertensive patients ceased antihypertensive medications on their own after improvement of blood pressure.
Conclusions
The understanding of hypertension was poor among the native Tibetan people in Lhasa. There is a need to improve education and primary health care services to this large hypertensive population.
Keywords
Hypertension Knowledge Prevalence Agricultural areas Tibet
Introduction Hypertension is an important contributor to cardiovascular diseases and cerebral-vascular diseases in western countries and in Asia [1–4]. A recent meta-analysis has shown that the overall prevalence of hypertension in China has increased to 21.5% [5]. However, the rates of treatment and control of
hypertension are still low in most parts of the world [5–7]. Further, the knowledge and understanding of hypertension was still poor in many parts of the world. In China, there is a large variation in the prevalence of hypertension among different geographic areas [8]. Lhasa is the capital of Tibet. The native residents are Tibetan people who live at a high altitude of average 3,650
*Corresponding author at: School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2678, Australia. Tel.: +61 2 69332905; fax: +61 2 69332587, Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
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metres above the sea level. Though some studies showed that blood pressure decreased with increase in altitude among permanent inhabitants of high altitude [9,10], our study has shown that hypertension was highly prevalent among native Tibetan people in Lhasa [11]. In our study on 1,370 native Tibetan people aged 18 years old, the prevalence of hypertension was 51.2% [11]. The hypertension prevalence increased with age (77.8% in 60-74 years and 82.5% in 75years group) [11]. The self-awareness, treatment and control rate of hypertension was 63.5%, 24.3% and 7.7%, respectively [11]. Poor knowledge of hypertension may be responsible for the low rates of awareness and control of hypertension. Healthy lifestyle changes, such as dietary modification, exercise and stress reduction, are important for control of hypertension. However, it is not clear whether the native Tibetan people are equipped with this knowledge.
Methods Study Participants This investigation is a cross-sectional survey of self-reported understanding about hypertension, which was part of our survey of hypertension prevalence in Lhasa [11]. Data were collected from April to June, 2010. The selection of the participants was based on a stratified proportional sampling method. The region of Lhasa was divided into Urban, Suburban, Agricultural and Pastoral areas in terms of their financial and agro-stockbreeding status: Urban: central districts in the Lhasa city; Suburban: counties in 20-50kms distance to Lhasa city; Agricultural area: counties mainly on agricultural land about 50-150kms from Lhasa; Pastoral area: counties mainly on stockbreeding land 50-180kms from central Lhasa. The study participants were permanent residents with a record in the household registration of native Tibetan population and were aged 18 years or older. The Ethics Committee of Lhasa Centre for Disease Control approved the study protocol. Informed written consent was obtained from all the participants prior to data collection.
Survey Methods Standardised mercury sphygmomanometers were used for the measurement of blood pressure in the present study. Investigators were trained in the measurement of blood pressure and in administering the survey questionnaire before the study. Blood pressure was measured according to 1999 World Health Organization/ International Society of Hypertension guidelines on hypertension [12]. Hypertension was defined according to the 2007 European Society of Cardiology (ESC) guidelines for the management of arterial hypertension [13]. Self-awareness of hypertension was defined as self-report of any prior diagnosis of hypertension by a healthcare professional. Treatment of hypertension was defined as a prescription medication used for management of hypertension during the previous two weeks. Control of
hypertension was defined as systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg after treatment. All identified participants were seen at a clinic. The sociodemographic details were collected. Height and weight were also measured. All the participants were queried on knowledge and understanding using a pre-tested interview questionnaire. The questionnaire comprised three categories. The first was about knowledge on the optimal level of blood pressure, on risk factors of hypertension and on consequences of uncontrolled hypertension. The second was in relation to measures to prevent and treat hypertension. Participants were asked to select two or more of the anti-hypertension methods. They were also asked whether they had acquired hypertension-related education from healthcare providers. The third part of the questionnaire was aimed at hypertensive patients. A couple of questions were asked to evaluate medication adherence and compliance, as well as perceptions on hypertension control. All responses were validated by the first author randomly by interviewing the participants who had completed the survey. The interview protocol consisted of both closed-ended and open-ended questions. The responses to open-ended questions were narrative and were categorised during analysis.
Statistical Analysis Participants’ characteristics were summarised using means and standard differences (SDs) or counts and percentages as appropriate. Data about the prevalence, self-awareness of hypertension, socio-demographic details, and understanding of hypertension were obtained for the whole sample. Comparison of categorical data between groups split by areas of residence was performed with Chi-square test. P <0.05 was considered statistically significant. SPSS 19.0 software was used for analysis (SPSS, Inc, Chicago).
Results Basic Characteristics of the Participants A total of 1,370 adults aged 18 years agreed to participate. Table 1 shows the basic characteristics of these participants by the area of residence. A total of 54 items were missing though all participants responded to the questions. Compared to other groups, most of the Pastoral participants were in a younger age group and Agricultural Area had more old people (75 years) (p <0.001). Women were significantly more than men in Pastoral Area and Suburban Area (p <0.001). A total of 46.4% of Agricultural participants did not have any formal education. In addition, they smoked and drank more than participants from other areas (both p <0.001). The majority of Urban participants received formal education, some of whom completed higher education. Their smoking rate was the lowest in these four groups. However, a higher proportion of Urban participants were overweight or obese. As to income level, the ratio of high
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Table 1 Basic characteristics of the participants Groups
Urban
Suburban
Agricultural
Pastoral
(n=508)
(n=367)
(n=235)
(n=260)
P value
<0.001
Age 18-44years
110(21.7)
99(27.0)
65(27.7)
159(61.2)
<0.001
45-59years
219(43.1)
125(34.1)
78(33.2)
34(13.1)
<0.001
60-75years
161(31.7)
130(35.4)
73(31.1)
54(20.8)
0.010
75 years
18(3.5)
13(3.5)
19(8.1)
13(5.0)
0.038 <0.001
Sex Male
208(40.9)
143(39.0)
118(50.2)
76(29.2)
0.003
Female Ethnics
300(59.1)
224(61.0)
117(49.8)
184(70.8)
0.027 >0.05
Zang
505(99.4)
367(100)
234(99.6)
260(100)
1.000
Han
3(0.6)
0(0)
1(0.4)
0(0)
Education (missing 2)
0.317 <0.001
No education
157(30.9)
158(43.1)
109(46.4)
89(34.2)
0.002
1-6years
143(28.1)
140(38.1)
67(28.5)
126(48.5)
<0.001
7-12years
162(31.9)
58(15.8)
51(21.7)
36(13.8)
<0.001
46(9.1)
11(3.0)
8(3.4)
7(2.7)
<0.001 <0.001
Low
107(21.1)
205(55.9)
90(38.3)
58(22.3)
<0.001
Medium
269(53.0)
113(30.8)
89(37.9)
85(32.7)
<0.001
High
132(26.0)
48(13.1)
56(23.8)
116(44.6)
<0.001
Single
134(26.4)
103(28.1)
65(27.7)
94(36.2)
Married
374(73.6)
264(71.9)
170(72.3)
166(63.8)
0.482 <0.001 0.001
13-15years Income level (missing 2)*
Marital status
Smoking (missing24) Yes No
0.036
116(22.8)
114(31.1)
84(35.7)
55(21.2)
383(75.4)
246(67.0)
139(59.1)
199(76.5)
Alcohol drinking (missing 2)
0.109
0.046 <0.001
Yes
172(33.9)
103(28.1)
86(36.6)
47(18.1)
No
335(65.9)
264(71.9)
148(63.0)
213(81.9)
BMI (kg/m2,missing 24)
<0.001 0.040 <0.001
4(0.8)
32(8.7)
15(6.4)
6(2.3)
<0.001
338(66.5) 157(30.9)
273(74.4) 53(14.4)
195(83.0) 21(8.9)
213(81.9) 39(15.0)
0.036 <0.001
Prevalence of hypertension
285(56.1)
197(53.7)
130(55.3)
89(34.2)
<0.001
Awareness of hypertension
200(70.2)
134(68.0)
56(43.1)
55(61.8)
<0.001
Treatment of hypertension
86(30.2)
39(19.8)
28(21.5)
17(19.1)
0.025
Control of hypertension
12(13.9)
20(51.3)
11(39.3)
11(64.7)
<0.001
<18.5 18.5-24.9 25
Data are present as n (%). BMI = body mass index.*Income level: Low indicates the income per year of <2000RMB, Medium indicates the income per year of 2000-5000 RMB, High indicates the income per year of 5000RMB.
income level was comparatively higher in Pastoral Area. The prevalence of hypertension was highest among Urban participants (56.1%) and lowest among Pastoral participants (34.2%). The awareness of hypertension was highest among Urban participants (70.2%) and lowest among Agricultural participants (43.1%). Although the awareness and treatment of hypertension was comparatively higher, the final control rate of hypertension was comparatively lower in Urban participants (13.9%).
Knowledge of Hypertension and its Consequences Among all participants as Table 2 shows, most people could not tell the normal blood pressure level, regardless where they lived. Only 16.4% participants could answer the upper limit of normal blood pressure correctly. The education level was comparatively high among Urban participants, but only 23.4% of them stated the upper limit of normal
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Knowledge of hypertension in Tibet
Table 2 Knowledge of hypertension and its consequences by different strata P value
Urban
Suburban
Agricultural
Pastoral
(n=508)
(n=367)
(n=235)
(n=260)
170/110mmHg
12(2.4)
13(3.5)
8(3.4)
6(2.3)
0.667
110/70mmHg
78(15.4)
11(3.0)
29(12.3)
97(37.3)
<0.001
140/90mmHg
119(23.4)
27(7.4)
40(17.0)
39(15.0)
<0.001
80/55mmHg
3(0.6)
3(0.8)
2(0.9)
4(1.5)
0.617
296(58.3)
313(85.3)
156(66.4)
114(43.8)
<0.001
Think the upper limit of normal BP as
Cannot say
<0.001
<0.001
Whether should someone above 35years take their BP every year (missing 3) Yes
156(30.7)
121(33.0)
62(26.4)
94(36.2)
Only when symptoms appear
281(55.3)
180(49.0)
100(42.6)
121(46.5)
0.103
71(14.0)
66(18.0)
71(30.2)
43(16.5)
<0.001
94(18.5)
59(16.1)
36(15.3)
61(23.5)
1-6 months
151(29.7)
73(19.9)
51(21.7)
55(21.2)
0.012
7-12 months
50(9.8)
2(0.5)
15(6.4)
10(3.8)
<0.001
12 months Never
21(4.1) 63(12.4)
27(7.4) 57(15.5)
9(3.8) 45(19.1)
13(5.0) 21(8.1)
0.149 0.005
No How long is your latest time measuring BP Within 30 days
0.253
<0.001 0.114
People susceptible to hypertension Who eat more fat
253(49.8)
192(52.3)
86(36.6)
148(56.9)
<0.001
Who consume more salt
330(65.0)
266(72.5)
124(52.8)
174(66.9)
<0.001
Smokers
323(63.6)
248(67.6)
112(47.7)
147(56.5)
<0.001
Drinkers
364(71.7)
275(74.9)
129(54.9)
172(66.2)
<0.001
Overweight people
246(48.4)
197(53.7)
87(37.0)
113(43.5)
<0.001
Excited people Passive smokers
300(59.1) 216(42.5)
285(77.7) 135(36.8)
95(40.4) 85(36.2)
129(49.6) 82(31.5)
<0.001 <0.001
Consequences of uncontrolled hypertension Stroke
146(28.7)
100(27.2)
23(9.8)
52(20.0)
<0.001
Coronary heart disease
152(29.9)
108(29.4)
73(31.1)
42(16.2)
<0.001
Cancer
115(22.6)
60(16.3)
22(9.4)
25(9.6)
<0.001
11(2.2)
27(7.4)
8(3.4)
11(4.2)
0.002
241(47.4)
192(52.3)
127(54.0)
170(65.4)
<0.001
No consequences Cannot say
Multiple responses were given. Data are present as n (%). BP, blood pressure.
blood pressure and the rates were lower in other strata (p <0.001). Most people thought they should take their blood pressure only when symptoms appear, and there were no differences in the rates of taking blood pressure when symptoms appear between the four groups. Only 42.3% of people had blood pressure checks in the six months prior to this study. In order to have an insight into participants’ knowledge of hypertension, we asked which kinds of people were susceptible to hypertension. Over 50% of people stated that people who have high salt intake in their diet were at risk of having hypertension. When asked about consequences of hypertension, 49.2% respondents had no idea of consequences due to hypertension such as stroke or coronary heart disease. The people in Agricultural and Pastoral areas were less aware of the consequences of hypertension (p <0.001).
Understanding of the Prevention and Treatment of Hypertension Table 3 presents the understanding of how to prevent and treat hypertension. About 30% of the respondents did not know the exact measures for hypertension prevention. 67.2% of participants mentioned one of the lifestyle changes such as healthy diet, proper exercise, weight control, reducing tension and no smoking or drinking as preventive measures. There were significant differences in the understanding of parts of lifestyles including less fat, more vegetable and fruit intake, exercise and no drinking among the four groups (all p <0.001). Above 35% of participants from every stratum stated low salt diet may prevent hypertension. However, more than 70% did not know how many grams of salt a normal adult should have every day. As to treatment, around 30% of
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Table 3 Perceptions on how to prevent and treat hypertension Urban
Suburban
Agricultural
Pastoral
(n=508)
(n=367)
(n=235)
(n=260)
P value
Measures to prevent hypertension Less fat
79(15.6)
92(25.1)
24(10.2)
56(21.5)
<0.001
Exercise
118(23.2)
78(21.3)
36(15.3)
33(12.7)
0.001
Weight control
91(17.9)
57(15.5)
34(14.5)
31(11.9)
0.174
Reducing tension
74(14.6)
57(15.5)
50(21.3)
25(9.6)
More vegetable and fruit
75(14.8)
101(27.5)
34(14.5)
39(15.0)
<0.001
Low salt
186(36.6)
130(35.4)
94(40.0)
100(38.5)
0.674
No smoking No drinking
74(14.6) 130(25.6)
65(17.7) 125(34.1)
33(14.0) 43(18.3)
32(12.3) 102(39.2)
0.379 <0.001
Do not know
165(32.5)
127(34.6)
74(31.5)
83(31.9)
0.84
0.004
0.001
How many grams of salt should one normal adult eat daily 6g
35(6.9)
20(5.4)
20(8.5)
22(8.5)
0.426
3g
99(19.5)
52(14.2)
31(13.2)
55(21.2)
0.046
5(1.0)
11(3.0)
5(2.2)
3(1.2)
0.128
369(72.6)
274(74.7)
179(76.2)
190(71.9)
0.955
9g Do not know Measures to treat hypertension
33(6.5)
15(4.1)
16(6.8)
11(4.2)
Dietary changes
No need
210(41.3)
191(52.0)
86(36.6)
143(55.0)
<0.001
Pleasant emotion
130(25.6)
174(47.4)
71(30.2)
41(15.8)
<0.001
63(12.4)
39(10.6)
38(16.2)
31(11.9)
0.228
362(71.3)
302(82.3)
138(58.7)
179(68.8)
Proper exercise
0.264
Where do you acquire the related knowledge of hypertension Healthcare providers
<0.001
Multiple responses were given. Data are present as n (%).
participants did not provide an answer, regardless of whether they were hypertensive or not. Methods such as ‘‘dietary changes’’, ‘‘stress control’’, ‘‘proper exercise’’, ‘‘weight control’’ and ‘‘medicine’’ were also offered. When asked where they acquired the knowledge of hypertension, 71.6% of the respondents stated they acquired the knowledge from healthcare providers, rather than television, radio, newspaper or brochures.
missed the anti-hypertensive medication at least once. Rates of taking medications were higher in Agricultural (71.2%) and Pastoral Areas (59.4%) than in Urban (50.7%) or Suburban (47.1%) Area. 75.5% of the patients stopped antihypertensive medication by themselves when blood pressure improved.
Knowledge of Blood Pressure among Hypertensive Patients
Discussion
A further survey was conducted of the people who had already been diagnosed with hypertension, as shown in Table 4. Approximately 90% of them had taken measures to treat hypertension, except for people in the Pastoral area where the rate was 66.1%. Medicines, dietary changes, stress reduction or quitting smoking and drinking were considered by these respondents. About half of these hypertensive patients stated that they could stop taking medicine when blood pressure was normal. Above 30% stated that there is no need for medicine unless hypertension becomes symptomatic. Of the participants with hypertension, many had
The main findings of this study are: First, there was considerable variation in the awareness of hypertension among the residents of Lhasa. Less than one third of the respondents knew the normal levels of blood pressure. A considerable proportion of the respondents had no idea of the risk factors and consequences of hypertension. Second, about one third of the respondents did not know the preventative measures for hypertension, or the treatments for hypertension. Finally, the majority of hypertensive patients discontinued their antihypertensive medications by themselves when blood pressure improved. Poor adherence to anti-hypertension medications was common among hypertension patients.
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Knowledge of hypertension in Tibet
Table 4 Knowledge of control aspects of hypertension among hypertensive patients Urban
Suburban
Agricultural
Pastoral
(n=207)
(n=140)
(n=66)
(n=64)
P value
<0.001
Have you taken measures to treat hypertension (missing 3) Yes
183(89.3)
125(89.9)
49(87.5)
39(66.1)
0.124
No
22(10.7)
14(10.1)
7(12.5)
20(33.9)
<0.001
If yes, how? 86(16.9)
39(10.6)
28(11.9)
17(6.5)
<0.001
Dietary changes
123(24.2)
89(24.3)
24(10.2)
27(10.4)
<0.001
Pleasant emotion Proper exercise
75(14.8) 1(0.2)
81(22.1) 2(0.9)
12(5.1) 2(0.8)
13(5.0) 0(0)
<0.001 0.218 0.152
Medicines
Weight control Quit smoking and drinking Take your BP at least weekly Have the idea that one can stop
0(0)
0(0)
2(0.8)
1(0.3)
22(4.3)
19(5.2)
2(0.9)
8(3.1)
0.038
56(27.1)
19(17.9)
17(26.6)
27(42.2)
<0.001
105(50.7)
90(64.3)
29(42.6)
39(60.0)
<0.001
86(41.5)
67(47.9)
21(31.8)
25(39.1)
<0.001
medicine when BP is normal Have the idea that no need for medicine unless symptoms appear Medication compliance Forget to take medicine once
105(50.7)
66(47.1)
47(71.2)
38(59.4)
<0.001
Stop taking medicine when
153(73.9)
112(80.0)
49(74.2)
46(71.9)
<0.001
symptoms improve Multiple responses were given. Data are present as n (%). BP, blood pressure.
Blood pressure control appears to be a great challenge among native Tibetan people. General lack of related knowledge of hypertension and unique local life styles may be the major causes. Levels of health care are relatively lower in ethnic minority areas of China [14]. In our study, the awareness of hypertension was lowest among Agricultural participants and people there lacked knowledge of hypertension [11]. Most participants in our survey thought they should take their blood pressure only when symptoms appear. The unawareness rate in the present study was consistent with a previous study of a rural Australian population which showed that above 50% of the patients with elevated blood pressure were unaware of the presence of hypertension [15]. Patients unaware of hypertension received no therapy. The most important reason for the lack of knowledge of hypertension may be inadequate education. Our results are consistent with the findings that education is associated with risk of complex diseases [16,17]. In our study, few Tibetans have completed higher education and a very high proportion (46.6%) of agricultural residents could not get any formal education. Even amongst the city participants, only 9.1% of them have completed 13-15 years of education. Studies have shown that education was associated with blood pressure among African Americans in the United States [18]. A study from the United States reported awareness of hypertension was above 80% in a well-educated population [19], suggesting that ongoing studies and interventions to increase
hypertension awareness and treatment could be successful. The primary healthcare system in China has put more emphasis on cities. It is generally considered that inadequate efforts have been made to reduce hypertension risk factors in ethnic minority areas. Improved access to education, in particular health education, in Tibetans may help to reduce the prevalence of hypertension and improve its management or control. Socio-economic status may be another reason for the lower awareness and knowledge of hypertension in the present study population in Lhasa. Many studies have identified the relationship of socio-economic status with hypertension [20,21]. Better working conditions and higher incomes, which interrelated with education, improve health benefits and increase the knowledge of hypertension [20,21]. In accordance with prior studies [22,23], Agricultural and Pastoral participants in our study had less knowledge about hypertension and its treatment. Consequences of hypertension were underestimated by residents in Lhasa, particularly residents of Agricultural and Pastoral Areas. Understanding of risk factors such as obesity, lack of physical exercise and smoking were poor in Lhasa, as well as knowledge of how to prevent and treat hypertension. Although a majority knew a high salt diet was a risk factor, they had no idea about the optimal amount of salt to consume daily. Accesses to available healthcare services are still insufficient for Lhasa residents. Many of the hypertensive patients
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residing in Lhasa did not know when to start or stop antihypertensive medicines. Most of the patients in our study stopped taking medicine by themselves when symptoms improved. The poor anti-hypertension medication adherence was considered as one of the main reasons for uncontrolled hypertension [24,25]. Poor knowledge might be due to the silent nature of hypertension as well as a lack of high-quality health care. These results indicate that there is significant room for improvement in the primary healthcare system in Lhasa. In conclusion, although hypertension was considerably prevalent in the native Tibetan residents in Lhasa, the rates of self-awareness and understanding of the prevention or treatment were low. There is a need to enhance the health education of hypertension among the native Tibetan residents in Lhasa.
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