The Relation Between Knowledge About Hypertension and

Education in Hospitalized Patients With Stroke in Vienna

Doris Samal, MD; Stefan Greisenegger, MD; Eduard Auff, MD;
Wilfried Lang, MD; Wolfgang Lalouschek, MD

Downloaded from http://stroke.ahajournals.org/ by guest on September 25, 2016

Background and PurposeKnowledge about hypertension and its control influences blood pressure control in patients
with hypertension. We assessed these parameters in a large cohort of patients with ischemic stroke or transient ischemic
attack and analyzed their association with educational attainment.
MethodsFive hundred ninety-one consecutive patients with stroke with a medical history of hypertension were
interviewed about knowledge concerning hypertension within a multicenter hospital-based stroke registry. We analyzed
answers in relation to educational level with multivariate logistic regression adjusted for age and sex.
ResultsSeventy-seven percent of the patients stated to have known about hypertension being a risk factor for stroke, but
only 30% felt at increased risk of stroke. Less than half (47%) could identify 140 mm Hg or less as the maximum
tolerated systolic blood pressure, and 53% had their blood pressure only controlled monthly or less often. Knowledge
of possible consequences of myocardial infarction, nephropathy, peripheral vascular disease, and retinopathy was 64%,
20%, 11%, and 16%, respectively. Approximately half of patients were acquainted with the nonpharmacologic treatment
options of physical activity (49%), reduction of salt intake (54%), and reduction of caloric intake (48%), whereas
relaxation techniques were only known to 17%. Adherence to those treatment options ranged from 42% to 67%.
Educational level was significantly associated with knowledge of increased risk, possible consequences of hypertension,
and knowledge about nonmedication treatment options.
ConclusionKnowledge in our population was insufficient and partly associated with educational level, leaving much
room for improvement by educational campaigns. Furthermore, we found a gap between knowledge of the increased risk
for stroke in patients with hypertension and awareness of their own risk. (Stroke. 2007;38:1304-1308.)
Key Words: education hypertension ischemic socioeconomic status stroke

ypertension is the leading modifiable risk factor for

stroke, being causally involved in nearly 70% of all
stroke cases.1 Sixty percent of all patients with stroke report
a history of arterial hypertension2,3 and up to three fourths of
those with known and treated hypertension are not adequately
controlled.4,5 It has been estimated that nearly half (45%) of
all strokes among subjects with treatment for hypertension
might be attributed to poorly controlled hypertension.6,7
Moreover, a meta-analysis of 17 randomized, controlled trials
demonstrated a 38% reduction of stroke by blood pressure
lowering.8 This leaves plenty of room for population-based
strategies of blood pressure control to produce a substantial
relief in the global burden of stroke.
In hypertensive subjects, awareness about their increased
risk for stroke is connected to higher compliance in stroke
prevention practices.9 However, patients at risk for cerebrovascular disease tend to underestimate their risk, especially if
they are currently without symptoms and lack direct experience with the questioned event. Previous studies showed that

only a minority of individuals at an increased risk for stroke

or already under investigation for possible stroke were aware
of their increased risk.9,10 In these reports, socioeconomic
status was an independent predictor of awareness, a higher
education being linked with increased awareness. We sought
to assess awareness for hypertension and individual knowledge about it in a patient population with transient ischemic
attack (TIA) or ischemic stroke and a history of arterial
hypertension. We also investigated whether socioeconomic
status is associated with knowledge about hypertension.

Methods
Patients
This study was nested in the Vienna Stroke Registry, a prospective
population-based registry of patients admitted to one of the eight
participating neurologic departments in Vienna, Austria, serving a
community of 1.9 million people. Details of the Vienna Stroke
Registry have been published elsewhere.11 In short, all patients with
TIA or ischemic stroke, who were admitted within 72 hours of
symptom onset, were prospectively documented on the basis of

Received June 22, 2006; final revision received October 20, 2006; accepted October 30, 2006.
From the Department of Neurology (D.S., S.G., E.A., W.L.), Medical University of Vienna, Austria; and the Department of Neurology (W.L.), Hospital
Barmherzige Brueder, Vienna, Austria.
Correspondence to Wolfgang Lalouschek, MD, Medical University of Vienna, Department of Neurology, Waehringer Guertel 18-20, 1090 Vienna,
Austria. E-mail wolfgang.lalouschek@meduniwien.ac.at
2007 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org

DOI: 10.1161/01.STR.0000259733.43470.27

1304

Samal et al

Knowledge About Hypertension in Patients With Stroke

TABLE 1. Questions for Assessment of Knowledge and

Awareness of Hypertension

TABLE 2.

Baseline Characteristics of the Study Population

n591

Did you know about hypertension being a risk factor for stroke?

Sex, %, female/male

Did you feel at increased risk for stroke/myocardial infarction?

Age, median (interquartile range)

Which values should not be exceeded by systolic/diastolic blood pressure?

Education, %

44/56
70 (6078)

How often was your blood pressure controlled?

No basic school education

Do you own a blood pressure meter?

Secondary school graduation

26

Did you know about the following consequences of hypertension:

Apprenticeship

50

Myocardial infarction

Upper secondary graduation

10

Damage of kidney

College

Disturbed blood circulation of the legs

Disturbance of vision
Did you know about the following nonpharmacologic treatment options:

1305

Stroke type, %
TIA/minor stroke

37

Major stroke

63

Physical activity
Reduction of salt intake
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Results

Reduction of caloric intake

Relaxation techniques
Did you adhere to the following nonpharmacologic treatment options:
Physical activity
Reduction of salt intake
Reduction of caloric intake
Relaxation techniques

informed consent. We recorded clinical and neurologic parameters

(National Institutes of Health Stroke Scale, Scandinavian Stroke
Scale, modified Rankin Scale, Barthel Index), results of technical
and laboratory investigations, and performed a structured interview
for demographic factors, medical history, socioeconomic circumstances, and knowledge about risk factors. The diagnosis of stroke
was confirmed by cerebral computed tomography or magnetic
resonance imaging scan. Followup was done at 3, 12, and 24 months
after the qualifying event. Recruitment was done between December
1999 and December 2001. The protocol was approved by the local
ethics committee.

Educational Level
We chose education as a marker of socioeconomic status, because it
is reliably recalled, can be easily quantified in terms of numbers of
years, and reverse causation does not confuse interpretation.12 We
divided patients into five categories: no basic school education,
secondary school graduation, apprenticeship, upper secondary
school graduation, and university or college graduation.

Assessment of Awareness and Knowledge

About Hypertension
The questions for assessment of awareness and knowledge about
hypertension are given in Table 1.

Statistical Analysis
Statistical analysis was conducted with SPSS 11.0. Continuous data
are given as means. Categorical data are given as counts and
percentages. Binary and categorical data were analyzed using contingency tables and a 2 statistic. To assess the influence of socioeconomic status on knowledge, we applied multivariate logistic
regression and adjusted for age and sex. Probability values of 0.05
were considered statistically significant. Apprenticeship was used as
the reference category in the logistic regression model. The HosmerLemeshow test was used to assess the model fit; probability values
0.1 indicate an agreeable model fit.

Study Population
Of 1250 patients admitted with ischemic stroke or TIA
between December 1999 and December 2001, 868 (70%)
reported a history of arterial hypertension. One hundred
twenty-one patients were excluded, because their level of
education was unknown. Of the remaining 747 patients, 591
(68% of the population with hypertension) completed the
questionnaire concerning knowledge about hypertension and
were available for further analysis. Compared with the whole
hypertensive population, they did not differ in gender distribution (44% female in either group), but they were significantly younger (median 70 versus 73 years, P0.001).
Characteristics of the study population are summarized in
Table 2. Three hundred thirty-one (44%) were female and
260 (56%) were male. Female sex was associated with a
lower level of education (P0.001). Mean age was 69 years
(SD, 12; median, 70; interquartile range, 60 to 78). There
were no differences in age or severity of the event (TIA or
minor stroke versus major stroke) defined by educational
level. Distribution of cardiovascular risk factors according to
education is given in Table 3. There was no difference in
prevalence of diabetes, current smoking, hypercholesterinemia,
prior stroke, or coronary artery disease between the groups.

Awareness of and Knowledge About

Arterial Hypertension
Results of assessing awareness and knowledge about arterial
hypertension are summarized in Table 4. Seventy-seven
percent of patients claimed to be aware of hypertension as a
risk factor for stroke, but knowledge was highly significantly
correlated with educational level (P0.001). Only 30% had
considered themselves at increased risk for stroke and 34%
felt themselves at increased risk for myocardial infarction.
There was no difference between educational groups. Less
than half of the patients with hypertension (47%) stated a
systolic blood pressure of or below 140 mm Hg as the upper
limit but only 20% of patients stated this without a basic
school education (P0.05 compared with the reference
category). Knowledge of the maximum tolerated diastolic
blood pressure was the same throughout the groups and
comparably high with 81% of patients stating a value of

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Stroke

April 2007

TABLE 3.

Vascular Risk Factors According to Level of Education

No Basic
(n31)

Secondary
(n151)

Apprenticeship
(n294)

Upper Secondary
(n60)

University
(n55)

Diabetes, %

39

28

31

18

20

0.11

Current smoking, %

26

20

22

20

0.13

Hypercholesterinemia, %

58

57

54

47

60

0.61

Prior stroke, %

13

21

17

10

15

0.4

Coronary artery disease, %

23

34

25

20

22

0.14

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90 mm Hg or below. Fifty-three percent had their blood

pressure controlled at least weekly, whereas the remaining
47% controlled it monthly or less often. Patients without a
basic school education had a significantly lower frequency of
blood pressure measurements than the others (P0.05 compared with the reference category). Three fourths (76%) of
the patients stated they owned a blood pressure meter, but
only 63% used it.
Knowledge of other possible consequences of hypertension, namely myocardial infarction, nephropathy, peripheral
TABLE 4.

vascular disease, and retinopathy, were significantly associated with educational attainment. Knowledge about these
consequences ranged from 64% for myocardial infarction to
11% for peripheral vascular disease. Concerning nonpharmacologic options for lowering blood pressure, there were
significant differences defined by educational level as well;
the higher the educational level, the more patients were likely
to know about physical activity, reduction of salt intake,
reduction of caloric intake, and relaxation techniques. Knowledge about these options ranged from 17% (relaxation tech-

Awareness and Knowledge About Hypertension as a Risk Factor for Stroke According to Level of Education

Level of Education

n*

No
Basic

Secondary

Vocational

Upper
Secondary

University

Average

591

55

70

80

85

89

77

0.001

Knowledge about hypertension

Knowledge of hypertension as a risk
factor for stroke
Awareness of increased risk
Myocardial infarction

538

22

42

33

33

31

34

0.14

Stroke

539

26

33

29

22

32

30

0.62

Maximum systolic blood pressure,

140 mm Hg

468

20

48

48

43

52

47

0.17

Maximum diastolic blood pressure,

90 mm Hg

450

67

84

81

77

86

81

0.39

Blood pressure control daily/weekly

580

35

55

56

47

57

53

0.21

Own blood pressure meter

580

62

71

75

85

89

76

0.02

Possible consequences
Myocardial infarction

570

54

49

67

81

83

64

0.001

Nephropathy

563

14

17

32

46

20

0.001

Peripheral vascular disease

562

11

23

23

11

0.003

Retinopathy

564

14

14

25

31

16

0.002

Nonpharmacologic treatment
Physical activity

569

19

33

52

66

69

49

0.001

Reduction of salt intake

569

44

45

56

58

71

54

0.01

Reduction of caloric intake

568

48

38

49

54

67

48

0.007

Relaxation techniques

564

15

14

34

29

17

0.001

Adherence to
Physical activity

270

60

42

41

39

37

41

0.81

Reduction of salt intake

303

58

61

71

59

64

66

0.39

Reduction of caloric intake

269

50

45

53

38

50

49

0.57

94

100

55

41

17

21

37

0.52

Relaxation techniques

*Not all questions were answered by all patients.

Only patients who claimed being aware of the nonpharmacologic treatment option were included in the analysis.
Numbers represent percentages; total number of patients who responded to each of the questions are given on the left.
n1.

Samal et al

Knowledge About Hypertension in Patients With Stroke

niques) to 54% (reduction of salt intake). When asking about

adherence to these lifestyle modifications, 37% to 66%
affirmed to do so.

Discussion

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Awareness and knowledge about hypertension in patients

with stroke with a history of hypertension were suboptimal in
our population. Although three fourths (77%) stated they had
known about the increased risk for stroke associated with
hypertension, actually less than one third (30%) felt themselves at increased risk. This implies that more than half of
patients who affirmed the question Do you have a medical
history of hypertension? and had received the information
High blood pressure is a risk factor for stroke neglected
possible consequences for their own risk. The level of
awareness thus was lower than reported previously. Carroll et
al, who interviewed patients with stroke/TIA, found 43% of
the hypertensives were aware of their own risk.13 Samsa et al,
who interviewed 1261 patients with increased stroke risk,
found 41% of them were aware of it.9
Educational level markedly influenced knowledge of hypertension as a risk factor of stroke. It steadily increased from
54% in patients without a basic school education to 89% of
patients with a college degree. Interestingly, missing awareness of being at an increased risk for stroke and myocardial
infarction was the same throughout the groups. Because
patients with higher education were more likely to know
about the connection between stroke and hypertension, this
implies that they also more often denied this fact for themselves. To our knowledge, we are the first to investigate
knowledge and awareness separately, but our results
indicate that these are not necessarily linked to each other.
Notably, only half of the patients were able to state the
maximum tolerated systolic blood pressure (or a value below), which seems surprisingly low but is consistent with a
survey in the United States in 2005, where 49% could name
the target values of blood pressure.14
Questioning about consequences of hypertension revealed
another deficit: myocardial infarction was known by 64% of
the patients followed by nephropathy known by one of
fivewhereas peripheral vascular disease and retinopathy
reached only 11% and 16%, respectively. Compared with
knowledge in older Americans in a recent report, in which
86% could identify heart disease and 49% kidney failure as a
consequence of hypertension, this is clearly lower.15 Again,
there were highly significant differences between the different educational groups.
Nonpharmacologic treatment options by adoption of
healthy lifestyles have been recommended as an indispensable part of management in patients with hypertension.16
Weight reduction was shown to lower blood pressure with a
5 to 20-mm Hg systolic blood pressure reduction per 10-kg
weight loss,17,18 as does reduction of sodium intake (2 to
8 mm Hg)19 21 and regular physical activity (4 to 9 mm Hg).22,23
All named treatment options were known by approximately
half of our population with exception a fourth option we
askedpracticing relaxing techniqueswhich was only familiar to 17% of patients. Again, there were clear differences
between the educational groups. Consecutively asking about

1307

adherence to these lifestyle modifications showed that better

knowledge is not necessarily related to a better practice; the
only statistical significance according to educational level
concerned reduction of salt intake, whereas the other three
options were adopted by a maximum of nearly 40% of
patients in all educational levels.
In summary, there is much room for improvement in
hypertensive patients awareness of and knowledge about
hypertension, its consequences, and nonpharmacologic ways
to control it. Moreover, it seems to be important to help
patients transfer their knowledge adequately into practice.
Perceived risk is one of the key factors for promoting
behavioral changes; a person perceiving risk for some adverse event as high is more likely to take preventive action to
reduce the risk.10 For our patients, this could, for example,
mean providing individualized risk feedback, which was
shown to be effective in increasing perceived stroke risk
among patients who had underestimated their stroke risk.10
For better adherence to lifestyle modifications, Burke et al
found a structured modification program to be effective.24
Our results do not only point out a strong need for improvement of knowledge in people at increased risk for cerebrovascular disease, but also the need of increasing awareness of
their individual risk. Because the drugs for effective lowering
of blood pressure exist, education of affected patients is an
important target to convert the possible 40% risk reduction
into reality for all patients with hypertension.

Disclosures
None.

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The Relation Between Knowledge About Hypertension and Education in Hospitalized

Patients With Stroke in Vienna
Doris Samal, Stefan Greisenegger, Eduard Auff, Wilfried Lang and Wolfgang Lalouschek
Downloaded from http://stroke.ahajournals.org/ by guest on September 25, 2016

Stroke. 2007;38:1304-1308; originally published online February 22, 2007;

doi: 10.1161/01.STR.0000259733.43470.27
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2007 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628

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