Original articles
Hypertension and health-related quality of life: an epidemiological study in Sweden

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Abstract

The aim of this study was to describe the relationship between hypertension and health-related quality of life (HRQL) in a Swedish general population using the 36-item short form questionnaire (SF-36). The study is based on a postal questionnaire that was sent to a random sample of 8000 inhabitants aged 20–84 years (response rate 68%) in Uppsala County, Sweden, in 1995. The results showed that those with hypertension scored lower in the linear regression analyses in most of the eight domains of the SF-36 than those without hypertension after controlling for age, sex, sociodemographic factors, and comorbidity. Diabetes and angina pectoris were related to lower scores in most of the domains of the SF-36. Previous myocardial infarction was associated with lower general health and vitality. Those with a previous stroke had lower scores in physical functioning, general health, vitality, and social functioning. The findings suggest that hypertensives represent a vulnerable population that merits special attention from health care providers and systems. This is especially important given that low HRQL can be a risk factor for subsequent cardiovascular events or complications.

Introduction

Hypertension, especially in mild to moderate stages, is usually considered as an asymptomatic condition. However, whether hypertension is a condition associated with alterations in well-being and health-related quality of life (HRQL) 1, 2 is still a controversial issue. A hypertension diagnosis may increase an individual's awareness of bodily symptoms and make an otherwise “healthy” person ill 3, 4. The Medical Outcome Study in America found lower general health perception in hypertensive patients compared with those patients without chronic conditions [5]. In a recent population-based study, hypertensive individuals were found to have lower health status compared with individuals free from hypertension [6]. In some studies, hypertension has been associated with headache, dizziness, and tiredness 7, 8, 9. Hypertensives also have been described as more depressed and more anxious than “normotensives” 10, 11. In other studies, however, no relationship between hypertension and symptoms have been found 12, 13. Inconsistency between studies might result from use of different study populations, different scales, and selection of methods. Some of the instruments that have been used are also unsatisfactorily documented in terms of reliability and validity. Further epidemiological studies on HRQL in hypertension using well-validated instruments are required.

Numerous studies have addressed the impact of hypertension and its treatment on HRQL. Few of the studies, however, evaluated health-related quality of life among hypertensives in a general population using a comprehensive well-validated instrument, such as the 36-item short form questionnaire (SF-36) 6, 14. In the study by Fryback et al., the impact of different chronic diseases on HRQL was analysed. The study, however, did not focus on hypertension in particular. Moreover, in these previous studies only results from the general health perception scale were presented and discussed. In the Medical Outcomes Study, Stewart et al. examined HRQL in hypertension using a shorter, earlier version of the SF-36, the SF-20 [5]. The study was based on patients visiting physicians and may have been subject to selection bias. Further, because prior population studies in nonpatient samples have shown an impact of demographic and socioeconomic status on health-related quality of life in the SF-36 15, 16, an effect among hypertensives is also to be expected. However, in prior studies on hypertension using the SF-36, sociodemographic factors other than age and sex were not taken into account.

The effects of hypertension and antihypertensive medication on HRQL have also been assessed in randomised clinical trials in order to compare how well different drugs are tolerated 17, 18, 19, 20, 21, 22, 23, 24, 25. Most of the studies, however, have been fairly small, among very select subgroups, and may not well reflect clinical practice due to the necessities of the study design [26]. Patients selected and studied in clinical trials have often not been representative of the general hypertensive population as a whole [27].

Comorbidity with other diseases associated with hypertension may influence how persons with hypertension rate their HRQL. Hypertension is a well-known major risk factor for all forms of cardiovascular and renal disease 28, 29, 30. In the present study diabetes was included in the analyses as a risk factor for hypertension. Angina pectoris, myocardial infarction, and stroke were included as late complications of hypertension.

The aim of this study was to describe the relationship between hypertension and health-related quality of life in a general population using the SF-36 instrument and to estimate this relationship while controlling for age, sex, sociodemographic factors, diabetes, angina pectoris, myocardial infarction, and stroke.

Section snippets

Study population and design

This study is based on sample from the population register in the county of Uppsala, Sweden. A postal questionnaire, after local piloting, was sent to 8000 inhabitants, aged 20–84 years, independently and randomly selected from the population register in 1995. Uppsala County consists of a university city, smaller towns, and agricultural areas. The county had 288,475 inhabitants in 1995. The questionnaire was designed to elicit information about health, health care utilisation, medication use,

Results

Characteristics of the study population are shown in Table 1. The mean age was 46 years, and 54% were women. In the sample, 9% reported hypertension; 10% of the women and 8% of the men reported hypertension. The mean age among persons with hypertension was 61 years, ranging form 21 to 84 years. A greater proportion of hypertensives were divorced or widowed. There was more hypertension among persons with less than a high school education and low income than among those with higher education and

Discussion

The SF-36 instrument used in this study is a well-documented and validated generic instrument. Few studies have analysed health-related quality of life among persons with hypertension in a general population using a comprehensive, generic instrument 6, 38, and with a multivariate approach to identify associations that are independent of sociodemographic factors [23]. In this study, we examined the impact of hypertension on the dimensions in the SF-36, while adjusting for sociodemographic

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