Hypertension and sickness absence: the role of perceived symptoms

Morbidities among older workers and work exit: the HEAF cohort

BACKGROUND

Governments need people to work to older ages, but the prevalence of chronic disease and comorbidity increases with age and impacts work ability.

AIMS

To investigate the effects of objective health diagnoses on exit from paid work amongst older workers.

METHODS

Health and Employment After Fifty (HEAF) is a population cohort of adults aged 50-64 years recruited from English GP practices which contribute to the Clinical Practice Research Datalink (CPRD). Participants have completed questionnaires about health and work at baseline and annually for 2 years: their responses were linked with their objective health diagnoses from the CPRD and data analysed using Cox regression.

RESULTS

Of 4888 HEAF participants ever in paid work, 580 (25%) men and 642 (25%) women exited employment, 277 of them mainly or partly for a health reason (health-related job loss (HRJL)). Amongst HEAF participants who remained in work (n = 3666) or who exited work but not for health reasons (n = 945), there was a similar prevalence of background health conditions. In men and women, HRJL was associated with inflammatory arthritis, sleep disorders, common mental health conditions and musculoskeletal pain. There were however gender differences: widespread pain and lower limb osteoarthritis were associated with HRJL in women but hypertension and cardiovascular disease in men.

CONCLUSIONS

Improved diagnosis and management of common conditions might be expected to increase working lives. Workplace well-being interventions targeting obesity and increasing mobility might contribute to extended working lives. Employers of predominantly female, as compared with male workforces may need different strategies to retain older workers.

Are there consequences of labeling patients with prehypertension? An experimental study of effects on blood pressure and quality of life

OBJECTIVE

The prehypertension classification was introduced to facilitate prevention efforts among patients at increased risk for hypertension. Although patients who have been told that they have hypertension report worse outcomes than unaware hypertensives, little is known about whether or not prehypertension labeling has negative effects. We evaluated the effects of labeling individuals with prehypertension on blood pressure and health-related quality of life three months later.

METHODS

One hundred adults (aged 19 to 82 [mean=40.0] years; 54% women; 64% racial/ethnic minorities) with screening blood pressure in the prehypertensive range (120-139/80-89 mmHg) and no history of diagnosis or treatment of elevated blood pressure were randomly assigned to either a "Labeled" group in which they were informed of their prehypertension, or an "Unlabeled" group in which they were not informed. Subjects underwent office blood pressure measurement, 24-hour ambulatory blood pressure monitoring and completed self-report questionnaires at baseline and at three months.

RESULTS

Multilevel mixed effects regression analyses indicated that changes in the white coat effect, office blood pressure, mean daytime ambulatory blood pressure, and physical and mental health did not differ significantly between the two groups. Adjusting for age, sex, race/ethnicity and body mass index did not affect the results.

CONCLUSION

These findings suggest that labeling patients with prehypertension does not have negative effects on blood pressure or quality of life. Additional research is needed to develop approaches to communicating with patients about their blood pressure that will maximize the clinical and public health impact of the prehypertension classification.

Race differences in the physical and psychological impact of hypertension labeling

BACKGROUND

Blood pressure screening is an important component of cardiovascular disease prevention, but a hypertension diagnosis (i.e., label) can have unintended negative effects on patients' well-being. Despite persistent disparities in hypertension prevalence and outcomes, whether the impact of labeling differs by race is unknown. The purpose of this study was to evaluate possible race differences in the relationship between hypertension labeling and health-related quality of life and depression.

METHODS

The sample included 308 normotensive and unmedicated hypertensive subjects from the Neighborhood Study of Blood Pressure and Sleep, a cross-sectional study conducted between 1999 and 2003. Labeled hypertension was defined (by self-report) as having been diagnosed with high blood pressure or prescribed antihypertensive medications. Effects of labeling and race on self-reported physical and mental health and depressive symptoms were tested using multivariate analysis of covariance, controlling for age, sex, body mass index (BMI), previous medication use, and "true" hypertension status, defined by average daytime ambulatory blood pressure (ABP).

RESULTS

Both black and white subjects who had been labeled as hypertensive reported similarly poorer physical health than unlabeled subjects (P = 0.001). However, labeling was associated with poorer mental health and greater depressive symptoms only among blacks (Ps < 0.05 for the interactions). These findings were not explained by differences in socioeconomic status.

CONCLUSIONS

These results are consistent with previous studies showing negative effects of hypertension labeling, and demonstrate important race differences in these effects. Clinical approaches to communicating diagnostic information that avoid negative effects on well-being are needed, and may require tailoring to patient characteristics such as race.

Health-related quality of life and hypertension status, awareness, treatment, and control: National Health and Nutrition Examination Survey, 2001--2004

OBJECTIVE

We examined health-related quality of life measures by hypertension status, awareness, treatment, and control.

METHODS

Five unfavorable health-related quality of life measures were analyzed among 8303 adults aged 20 years or older who participated in the 2001--2004 National Health and Nutrition Examination Survey. Multivariable logistic regression analyses examined differences in health-related quality of life with adjustment for age, race, sex, healthcare coverage, and other medical conditions.

RESULTS

The 30% of respondents with hypertension were more likely to report fair or poor health status (adjusted odds ratio 1.72, 95% confidence interval 1.44-2.05), 14 or more unhealthy days in the past 30 days (1.23, 1.06-1.43), 14 or more physically unhealthy days (1.39, 1.15-1.67), and 14 or more activity-limited days (1.55, 1.17-2.04) than those without hypertension. Among adults with hypertension, the 73.2% who were aware of their condition were more likely to report fair or poor health status (2.19, 1.54-3.12), 14 or more unhealthy days (1.53, 1.12-2.09), 14 or more physically unhealthy days (1.49, 1.10-2.03), 14 or more mentally unhealthy days (1.70, 1.05-2.75), and 14 or more activity-limited days (2.38, 1.39-4.05) than those who were unaware. Among those aware they had hypertension, 14 or more physically unhealthy days (0.50, 0.28-0.90) was associated with current treatment. Health-related quality of life measures did not differ by blood pressure control status.

CONCLUSIONS

Having hypertension and being aware of it was related to lower health-related quality of life. Antihypertensive medication was associated with more physically unhealthy days, while there were no differences in health-related quality of life by control status. Further study is needed to examine these differences including: disease severity, sex and racial/ethnic differences, comorbidities not examined, and impact of health-related quality of life and its changes on outcomes.

The impact of perceived hypertension status on anxiety and the white coat effect

BACKGROUND

The white coat effect can lead to overdiagnosis of hypertension and unnecessary pharmacologic treatment. Mechanisms underlying the white coat effect remain poorly understood but are critical to improving the accuracy of clinic blood pressure measurement.

PURPOSE

This study investigated whether perceived hypertension status was associated with state anxiety levels during a clinic visit and the magnitude of the white coat effect, independent of true blood pressure status.

METHODS

This observational study included 214 normotensive and mildly hypertensive participants who were 18 to 80 years old, had no cardiac history, and were willing to discontinue antihypertensive medications for 8 weeks. Participants underwent 36 hr ambulatory blood pressure monitoring and physician blood pressure measurement. Outcome measures were state anxiety reported during the clinic visit and the white coat effect.

RESULTS

An analysis of covariance indicated that participants who perceived themselves as hypertensive reported greater state anxiety (p<.001) and showed larger white coat effects (ps<.01) compared with those who perceived themselves as normotensive. True hypertension status based on ambulatory blood pressure was not related to either outcome. Anxiety accounted for approximately 19% of the association between perceived hypertension status and the white coat effect.

CONCLUSIONS

These findings suggest that the perception of being hypertensive is associated with greater anxiety during clinic blood pressure measurement and a larger white coat effect, independent of the true blood pressure level. Anxiety appears to be a mechanism by which perceived hypertension status contributes to the white coat effect.

Hypertension labelling was associated with poorer self-rated health in the Third US National Health and Nutrition Examination Survey

Individuals labelled as having hypertension tend to report poor self-rated health (SRH), but it is unclear whether this association is independent of actual hypertension, socioeconomic status and adiposity, and extends across racial and ethnic groups. In a cross-sectional study we compared hypertensive and normotensive individuals (N = 19,057) who varied in whether they had ever been labelled hypertensive. Blood pressure was measured in participants' homes and mobile examination centres in the United States as part of the Third National Health and Nutrition Examination Survey, 1988-1994. The main outcome measure was global SRH. Hypertensive labelling was associated with poorer SRH and was independent of established SRH predictors, antihypertensive medication use, body mass index, and hypertension status (adjusted odds ratio (OR) = 1.79, 95% confidence interval (CI), 1.61-1.99). Hypertension was also associated with poorer SRH (OR = 1.26; 95% CI 1.09-1.46) but this association was eliminated by adjustment for hypertensive labelling (OR 1.06; 95% CI 0.92-1.22). These effects were consistent across non-Hispanic white, non-Hispanic black, and Hispanic subgroups. Individuals labelled hypertensive are more likely to have lower SRH and this labelling effect predominates over that of actual hypertension. Public health efforts to increase the number of individuals screened for high blood pressure may successfully detect the presence of hypertension but may also reduce health-related quality of life as measured by global SRH.

Articulating silences: experiential and biomedical constructions of hypertension symptomatology

In this article, we explore the flexible configuration of a local knowledge system about hypertension symptoms, foregrounding it against prevailing biomedical assertions regarding the asymptomatic or "silent" nature of hypertension. The complex and coherent knowledge system held by older African Americans living in a southern, rural community stands in contrast to the current scientific discourse and local biomedical perspectives on hypertension symptomatology. The older African American participants in this study apply local knowledge of hypertension symptomatology to make health decisions nearly every day. Despite this, most biomedical practitioners maintain a distance from these lay sources of knowledge, often remaining stalwart in their refusal to recognize the existence or influence of symptoms. We conclude that authoritative knowledge ultimately lies in the minds and bodies of the elders, who have encountered symptoms as guideposts that direct action, rather than with a biomedical "reality" that is yet unresolved.