ijcs International Journal of Cardiovascular Sciences Int. J. Cardiovasc. Sci. 2359-4802 2359-5647 Sociedade Brasileira de Cardiologia Fsm98QGHfbDr6mjTmJpNJpM S2359-56472023000100236 00236 10.36660/ijcs.202220144 Original Article Non-Targeted Self-Measured Blood Pressure and Hypertension Control in Public and Private Health Systems in Brazil 0000-0002-4791-8359 Salazar Gabriela de Oliveira 1 Conception and design of the research analysis and interpretation of the data statistical analysis writing of the manuscript 0000-0002-1366-459X Almeida Glessiane de Oliveira 1 Conception and design of the research acquisition of data 0000-0003-3552-6160 Barreto-Filho José Augusto Soares 1 2 Conception and design of the research critical revision of the manuscript for intellectual content 0000-0003-0622-6257 Almeida-Santos Marcos Antônio 2 3 analysis and interpretation of the data critical revision of the manuscript for intellectual content 0000-0002-9314-4331 Melo Enaldo Vieira de 1 analysis and interpretation of the data 0000-0001-7378-4529 Aidar Felipe J. 1 critical revision of the manuscript for intellectual content 0000-0002-7204-6011 Cruz José Ícaro Nunes 1 analysis and interpretation of the data 0000-0002-4325-0590 Oliveira Joselina Luzia Menezes 1 2 critical revision of the manuscript for intellectual content 0000-0003-1544-7940 Baumworcel Leonardo 1 2 critical revision of the manuscript for intellectual content 0000-0003-0439-9808 Sousa Antônio Carlos Sobral 1 2 Conception and design of the research acquisition of data writing of the manuscript critical revision of the manuscript for intellectual content Universidade Federal de Sergipe Aracaju SE Brazil Universidade Federal de Sergipe, Aracaju, SE – Brazil Clínica e Hospital São Lucas Rede D’Or São Luiz Aracaju SE Brazil Clínica e Hospital São Lucas, Rede D’Or São Luiz, Aracaju, SE – Brazil Universidade Tiradentes Aracaju SE Brazil Universidade Tiradentes, Aracaju, SE – Brazil Mailing Address: Gabriela de Oliveira Salazar, Universidade Federal de Sergipe, Departamento de Medicina. Rua Cláudio Batista, 505. Postal code: 49060-025. Palestina, Aracaju, SE – Brazil. E-mail: Gabrielasalazar103@gmail.com

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

 28 08 2023 2023 36 e20220144 19 09 2022 16 05 2023 14 06 2023 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background:

It is estimated that more than 30% of the Brazilian population has systemic arterial hypertension (SAH), and mostly as an uncontrolled disease. The most recent Brazilian Guideline of Hypertension recommends the practice of self-measurement of blood pressure (BP) as one of the strategies for a better control of SAH, but there is no consensus about the efficiency of this tool.

 Objective:

To assess the control of SAH and the practice of non-targeted self-measured BP (SMBP) among hypertensive users of the Unified Health System (SUS) and the Supplementary Network (SN).

 Methods:

This is a cross-sectional, observational, analytical study, with a stratified probability sample. One thousand volunteers were investigated, being 500 from SUS and 500 from the SN. Uni and multivariate analyses were performed considering a 5% significance level.

 Results:

Patients from SUS presented inferior sociodemographic data (schooling, social status) in relation to those of the SN (p < 0.001), and showed lower control of SAH (p = 0.014), as well as more visits to the emergency room in the past year due to hypertension (p = 0.002), and fewer regular appointments with the cardiologist (p = 0.004). SMBP was equally present in both assessed groups (p = 0.567), even though users of the SN have been more advised to not conduct such a practice (p = 0.002). SMBP (p < 0.001) was an independent factor for uncontrolled SAH both in SUS (OR = 3.424) and in the SN (OR = 3.474).

 Conclusion:

Patients in SUS presented lower SAH control. The practice of SMBP, mostly practiced with an uncalibrated digital device, was equally present in both groups and became an independent factor of uncontrolled SAH.

 Keywords: Hypertension Health Systems Unified Health System Introduction

The control of systemic arterial hypertension (SAH) is a global public health challenge,1,2 once it is considered as the main modifiable risk factor for cardiovascular diseases, chronic kidney disease and premature death.3–6 Besides, there is a significant impact on the direct and indirect costs for the system due to its fatal and non-fatal complications.7–9 Only in 2018, the direct costs for the Brazilian public health related to SAH were R$ 2.03 billion.8,9

The estimation is that more than 30% of the Brazilian adult population has SAH,10 and the control rate is below expected. A systematic review showed that the control rate of SAH in Brazil has ranged between 43.7% and 67%.11 There are many reasons for this number, and one of the most influential elements is the lack of adherence to therapy.6,12

SAH: systemic arterial hypertension; SN: Supplementary Network./ SMBP: self-measured blood pressure.

As one of the strategies to promote higher adherence to treatment, the most recent Brazilian Guideline of Hypertension recommends the practice of blood pressure (BP) self-measurement, called BPSM.6 However, even though this methodology is attractive because it is easy to acquire and use the devices, especially digital ones, it presents practical limitations, such as: lack of calibration and unsatisfactory quality of some instruments; non-standardized BP measurement technique; interference of stressful situations, among others. There is no consensus in the literature as to the real benefit of this method in incrementing the adherence to antihypertensive treatment for disease control; besides, there are few studies approaching the impact of this strategy. Therefore, this investigation was conducted aiming at assessing the control of SAH, as well as the influence of non-targeted self-measured blood pressure (SMBP) in chronic hypertension users of the Unified Health System (SUS) and the Health Supplementary Network (SN).

 Methods Type of study and data collection

This is an observational, cross-sectional and analytical study that included 1,000 patients assisted at the outpatient cardiology clinics of private and public hospitals between June, 2017, and October, 2019 in Aracaju-Sergipe. The sample was defined by convenience and selected in a non-probability consecutive manner, and evaluated 500 individuals in each group.

We included individuals diagnosed with SAH, defined according to the Brazilian Guidelines of Hypertension,6 and aged above 18 years. We excluded the ones who presented with psychiatric conditions. The information was obtained through a standardized questionnaire that included sociodemographic and clinical data of the patient, information about SMBP and self-medication, besides information in the medical record.

SAH control was assessed with the ambulatory blood pressure monitoring (ABPM) or the mean of the two last measurements taken in the ambulatory environment. BP was considered controlled when <130mmHg x 80mmHg or <140 mmHg x 90 in high and low-risk patients, respectively, according to the Brazilian Guidelines of Hypertension.6

 Ethical aspects

All volunteers signed the Informed Consent Form according to resolution 466/2012, allowing the use of their information, as long as the identification data were confidential. This study was approved by the Human Research Ethics Committee, CAAE number:

 Statistical Analysis

The collected data were stored and analyzed using SPSS Statistics 22.0. The quantitative variables were described as mean and standard deviation, according to the normal distribution of the sample, and qualitative variables were absolute number and frequency. The Shapiro-Wilk test was used to verify the normality of the sample distribution.

Pearson’s chi-square or Fisher Exact tests were used, when adequate, to analyze associations, besides the Student’s t-test for independent samples, to verify the difference between groups regarding age. Finally, the univariate and multivariate analyses were conducted, which included logistic regression. We considered admission of a model as p = 0.25, and permanence, p = 0.05. The method of choice was the backward stepwise, which enabled reaching adjusted odds ratio and 95% confidence intervals. For statistical significance, we considered a two-tailed p of 0.05 for all tests.

The variables included in the regression model were: sex, color, age, schooling, social status, marital status, depression, peripheral obstructive arterial disease, diabetes mellitus, dyslipidemia, chronic kidney disease, coronary disease, cerebrovascular disease, chronic heart failure, practice of SMBP and self-medication.

 Results Descriptive analysis

One Thousand volunteers were assessed, being 500 from SUS and 500 from the SN, with mean age of 60.9 ±11.9 years and 61.14 ±13 years, respectively, without differences between both groups (p = 0.618). The total sample was formed by 57.1% of women and 42.9% of men, with no difference between the types of health services (p = 0.085).

There were more black people in SUS and more white people in the SN (p < 0.001), and no differences regarding yellow and brown users. The prevalent social classes in SUS were D and E, whereas in the SN it was A, B and C (p < 0.001). Besides, there was prevalence of higher education in the SN, whereas illiteracy and lower schooling levels were prevalent in SUS (p < 0.001), as demonstrated in Table 1.

Sociodemographic analysis and comorbidities in the population of the SUS and SN
SUS SN P value
Color <0.001
White 10.80% 27.40%
Black 29% 11.80%
Yellow 1% 0.60%
Brown 58.80% 60.80%
Social Class <0.001
A 0% 15.60%
B 0.40% 25.80%
C 1% 35%
D 31.40% 17.20%
E 67.20% 6.40%
Schooling <0.001
Elementary School 46.60% 11.60%
High school 33.40% 29.60%
Higher Education 3% 51.20%
Post-graduation 0.80% 7.40%
Illiteracy rates 16.20% 0.20%
Comorbidities
Diabetes 24,60% 18,60% 0,021
Dyslipidemia 42,60% 25,40% <0,001
CAD 9,6% 13,6% 0,06
CKD 1% 1% 1
CVA 5,2% 4% 0,45
Depression 2,2% 2,2% 1
CHF 4,8% 4,2% 0,64
COPD 1,6% 1,6% 1
PAD 2,4% 2,6% 0,83

CAD: coronary artery disease; CKD: chronic kidney disease; CVA: cerebrovascular accident; CHF: chronic heart failure; COPD: peripheral obstructive pulmonary disease; PAD: peripheral obstructive arterial disease; SUS: Unified Health System; SN: Supplementary Network.

As to the comorbidities, the patients in SUS presented with diabetes (p = 0.021) and dyslipidemia more often (p < 0,001) than users in the SN. However, it was not possible to observe discrimination between groups regarding the occurrence of coronary disease, heart failure, peripheral obstructive arterial disease, cerebrovascular disease, chronic kidney disease, chronic obstructive pulmonary disease and depression (Table 1).

 Control of SAH and SMBP in the SN and SUS

As to the behavior of SAH, the patients cared for in SUS had less control of the disease, more visits to the emergency room in the past year due to hypertension, and attended fewer regular appointments with the cardiologist (p < 0.05). Besides, patients in the SN self-medicated more often (p < 0.001) (Table 2).

Control of hypertension, self-measured BP and self-medication in the SUS and the SN
Variables Public Private OR for the public group 95% CI P Value
Uncontrolled SAH 203 165 1.172 1.035-1.326 0.014
Regular appointments with the cardiologist 446 471 0.748 0.630 -0.887 0.004
Visits to the emergency room in the past year 216 168 1.220 1.079-1.379 0.002
SMBP 219 228 _ _ 0.567
Self-medication 178 235 0.786 0.688 -0.897 <0.001
Discussion about SMBP with the physician 27 60 0.599 0.435-0.824 <0.001
Medical indication for SMBP: _ _ 0.002
Did not talk about it 26 18 _ _
Recommended 440 416 _ _
Not recommended 34 66 _ _

SAH: systemic arterial hypertension; SMBP: self-measured blood pressure.

Of the total population, 44.7% did SMBP, mostly using a digital device (93.8%). Besides, 21.1% were aware of the need for the annual calibration of the device, which was performed in only 10.7% of the devices.

There were no differences regarding the practice of SMBP between groups (p = 0.567), which was performed by 43.8% of SUS users and 45.6% of SN users. However, in the SN there were more discussions about the positive and negative aspects of self-measurement with an assistant physician, as well as more advice against that practice (p < 0.05). In general, most patients were advised to do SMBP, both in SUS (88%) and in the SN (83.2%).

The practice of SMBP was associated with more symptoms of hypertension and self-medication, both in SUS and in the SN. Among users of the SN, those belonging to higher social classes performed less SMBP. Among volunteers of SUS, the discussion with the physician about SMBP was more common among those who practiced it (Tables 3 and 4).

Variables associated with self-measured BP in patients of the Health SN
Variables BP Self-measurement P value
Social class Practices self-measurement Does not practice self-measurement 0.006
A 29 49
B 45 84
C 89 86
D 48 38
E 17 15
Symptoms of hypertension 180 127 <0.001
Self-medication 161 74 <0.001

BP: Blood pressure.

 Variables associated with SMBP in patients of the SUS
Variables Practices self-measurement Does not practice self-measurement P Value
Symptoms of hypertension 161 140 <0.001
Self-medication 98 80 <0.001
Discussion with the physician about SMBP 22 5 <0.001

BP: Blood pressure; SMBP: self-measured blood pressure.

 Variables that are independently associated to the non-control of BP in the groups

In multivariate analyses, SMBP and the female gender were predictors of uncontrolled SAH in patients of SUS and the SN. In SUS, another predictor of uncontrolled SAH was self-medication (Tables 5 and 6).

Predictive factors of uncontrolled hypertension in the Health SN
Factor OR 95%CI P Value
Female gender 1.543 1.030-2.312 0.035
SMBP 3.474 2.322-5.195 <0.001

BP: blood pressure; SMBP: self-measured blood pressure.

 Predictive factors of uncontrolled hypertension in patients of the SUS
Factor OR 95%CI P Value
Female gender 1.666 1.122-2.474 0.011
SMBP 3.424 2.331-5.029 <0.001
Self-medication 2.030 1.366-3.015 <0.001

BP: blood pressure; SMBP: self-measured blood pressure.

 Discussion

The main findings of this investigation were: a) the practice of SMBP was an independent predictor for the non-control of BP, both in individuals assisted by the public and the private health system; b) there was a recommendation for SMBP for most members in both groups, and the encouragement to not practice it was more prevalent in those belonging to the SN; c) most users are unaware of the need for the annual calibration of the device, and finally, d) SMBP was associated with more self-medication in both assessed groups – Central Figure.

The most recently published Brazilian Guidelines of Hypertension (2020) indicates self-measured BP as one of the possible strategies for the control of BP, with level of recommendation I.6 In fact, randomized and standardized studies, with only one type of specific and well-calibrated device, and skilled volunteers regarding the technique of BP checking and frequency of measurements, back up this methodology for better BP control.13,14 However, in the daily practice, self-measurement is not advised and is carried out with different types of devices, many of which are not properly calibrated. In our study population, of those who did SMBP, 93.8% used a digital device, and only 21.1% of them were aware of the need for its annual calibration, which was performed in only 10.7% of the devices.

Similar findings were observed in other investigations which were not able to demonstrate the benefits of SMBP for the control of pressure levels.15,16 We can speculate that these observations would be a result of false BP values generated by an unsatisfactory measurement technique and/or use of uncalibrated devices,16 which encourage improper behaviors, such as self-medication, especially in anxious individuals.15 Therefore, it is important that the patient be aware of the technical details of BP measurement, as well as the frequency with which it should be done, besides aspects regarding tensiometers (type, calibration), before recommending SMBP.

Besides, it was observed that black individuals, those with lower schooling levels, in lower social classes were more prevalent in SUS, which was the group associated with 172% more chances of not controlling SAH. Also, they attended fewer regular appointments with the cardiologist and attended the emergency room more often in the past year due to hypertension. The existence of inequalities regarding both BP control and access to health is a well-established reality.17–20 Certainly, the investment in more intense actions in primary care may help reduce the overload of more complex sector, for example, reducing the visits to the emergency room.21,22

The limitations of the study are intrinsic to a cross-sectional study, such as the inability of pointing out causes to the outcomes, which would be possible in a cohort study. Besides, other factors not considered in the analysis may impact the assessed events. Finally, the results refer only to patients assisted in cardiology services of private and public hospitals of Aracaju-Sergipe, which limits the generalization of data.

 Conclusions

In the assessed sample, patients in SUS, with lower socioeconomic indexes, showed lower SAH control, fewer regular appointments with the cardiologist and more visits to the emergency room due to hypertension. The non-targeted SMBP, mostly performed with an uncalibrated digital device, was equally present among SUS and SN users, and presented itself as an independent predictor of uncontrolled SAH in both groups, besides being associated with the practice of self-medication.

Sources of Funding

There were no external funding sources for this study.

Study Association

This study is not associated with any thesis or dissertation work.

Ethics Approval and Consent to Participate

This study was approved by the Ethics Committee of the CEP da Universidade Federal de Sergipe (UFS) under the protocol number 60473316.9.0000.5546. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study.

 References Whelton PK Epidemiology of Hypertension Lancet 1994 344 8915 101 106 10.1016/s0140-6736(94)91285-8 1 Whelton PK. Epidemiology of Hypertension. Lancet. 1994;344(8915):101-6. doi: 10.1016/s0140-6736(94)91285-8. Lopez-Jaramillo P Joseph P Lopez-Lopez JP Lanas F Avezum A Diaz R Risk Factors, Cardiovascular Disease, and Mortality in South America: A PURE Substudy Eur Heart J 2022 43 30 2841 2851 10.1093/eurheartj/ehac113 2 Lopez-Jaramillo P, Joseph P, Lopez-Lopez JP, Lanas F, Avezum A, Diaz R, et al. Risk Factors, Cardiovascular Disease, and Mortality in South America: A PURE Substudy. Eur Heart J. 2022;43(30):2841-51. doi: 10.1093/eurheartj/ehac113. Lim SS Vos T Flaxman AD Danaei G Shibuya K Adair-Rohani H A Comparative Risk Assessment of Burden of Disease and Injury Attributable to 67 Risk Factors and Risk Factor Clusters in 21 Regions, 1990-2010: A Systematic Analysis for the Global Burden of Disease Study 2010 Lancet 2012 380 9859 2224 2260 10.1016/S0140-6736(12)61766-8 3 Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A Comparative Risk Assessment of Burden of Disease and Injury Attributable to 67 Risk Factors and Risk Factor Clusters in 21 Regions, 1990-2010: A Systematic Analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224-60. doi: 10.1016/S0140-6736(12)61766-8. World Health Organization Global Status Report on Noncommunicable Diseases 2014 Geneva World Health Organisation 2014 4 World Health Organization. Global Status Report on Noncommunicable Diseases 2014. Geneva: World Health Organisation; 2014. Tereshchenko LG Soliman EZ Davis BR Oparil S Risk Stratification of Sudden Cardiac Death in Hypertension J Electrocardiol 2017 50 6 798 801 10.1016/j.jelectrocard.2017.08.012 5 Tereshchenko LG, Soliman EZ, Davis BR, Oparil S. Risk Stratification of Sudden Cardiac Death in Hypertension. J Electrocardiol. 2017;50(6):798-801. doi: 10.1016/j.jelectrocard.2017.08.012. Barroso WKS Rodrigues CIS Bortolotto LA Mota-Gomes MA Brandão AA Feitosa ADM Brazilian Guidelines of Hypertension - 2020 Arq Bras Cardiol 2021 116 3 516 658 10.36660/abc.20201238 6 Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADM, et al. Brazilian Guidelines of Hypertension - 2020. Arq Bras Cardiol. 2021;116(3):516-658. doi: 10.36660/abc.20201238. Forouzanfar MH Liu P Roth GA Ng M Biryukov S Marczak L Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015 JAMA 2017 317 2 165 182 10.1001/jama.2016.19043 7 Forouzanfar MH, Liu P, Roth GA, Ng M, Biryukov S, Marczak L, et al. Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015. JAMA. 2017;317(2):165-182. doi: 10.1001/jama.2016.19043. Nilson EAF Andrade RCS Brito DA Oliveira ML Custos Atribuíveis a Obesidade, Hipertensão e Diabetes no Sistema Único de Saúde, Brasil, 2018 Rev Panam Salud Publica 2020 44 e32 10.26633/RPSP.2020.32 8 Nilson EAF, Andrade RCS, Brito DA, Oliveira ML. Custos Atribuíveis a Obesidade, Hipertensão e Diabetes no Sistema Único de Saúde, Brasil, 2018. Rev Panam Salud Publica. 2020;44:e32. doi: 10.26633/RPSP.2020.32. Curado DDSP Gomes DF Silva TBC Almeida PHRF Tavares NUL Areda CA Direct Cost of Systemic Arterial Hypertension and its Complications in the Circulatory System from the Perspective of the Brazilian Public Health System in 2019 PLoS One 2021 16 6 e0253063 10.1371/journal.pone.0253063 9 Curado DDSP, Gomes DF, Silva TBC, Almeida PHRF, Tavares NUL, Areda CA, et al. Direct Cost of Systemic Arterial Hypertension and its Complications in the Circulatory System from the Perspective of the Brazilian Public Health System in 2019. PLoS One. 2021;16(6):e0253063. doi: 10.1371/journal.pone.0253063. Malta DC Gonçalves RPF Machado ÍE Freitas MIF Azeredo C Szwarcwald CL Prevalence of Arterial Hypertension According to Different Diagnostic Criteria, National Health Survey Rev Bras Epidemiol 2018 21 suppl 1 e180021 10.1590/1980-549720180021.supl.1 10 Malta DC, Gonçalves RPF, Machado ÍE, Freitas MIF, Azeredo C, Szwarcwald CL. Prevalence of Arterial Hypertension According to Different Diagnostic Criteria, National Health Survey. Rev Bras Epidemiol. 2018;21(suppl 1):e180021. doi: 10.1590/1980-549720180021.supl.1. Picon RV Costa JSD Fuchs FD Olinto MTA Choudhry NK Fuchs SC Hypertension Management in Brazil: Usual Practice in Primary Care-A Meta-Analysis Int J Hypertens 2017 2017 1274168 1274168 10.1155/2017/1274168 11 Picon RV, Costa JSD, Fuchs FD, Olinto MTA, Choudhry NK, Fuchs SC. Hypertension Management in Brazil: Usual Practice in Primary Care-A Meta-Analysis. Int J Hypertens. 2017;2017:1274168. doi: 10.1155/2017/1274168. Muxfeldt ES Chedier B Rodrigues CIS Resistant and Refractory Hypertension: Two Sides of the Same Disease? J Bras Nefrol 2019 41 2 266 274 10.1590/2175-8239-jbn-2018-0108 12 Muxfeldt ES, Chedier B, Rodrigues CIS. Resistant and Refractory Hypertension: Two Sides of the Same Disease? J Bras Nefrol. 2019;41(2):266-274. doi: 10.1590/2175-8239-jbn-2018-0108. Margolis KL Asche SE Bergdall AR Dehmer SP Groen SE Kadrmas HM Effect of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Control: A Cluster Randomized Clinical Trial JAMA 2013 310 1 46 56 10.1001/jama.2013.6549 13 Margolis KL, Asche SE, Bergdall AR, Dehmer SP, Groen SE, Kadrmas HM, et al. Effect of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Control: A Cluster Randomized Clinical Trial. JAMA. 2013;310(1):46-56. doi: 10.1001/jama.2013.6549. Jo SH Kim SA Park KH Kim HS Han SJ Park WJ Self-Blood Pressure Monitoring is Associated with Improved Awareness, Adherence, and Attainment of Target Blood Pressure Goals: Prospective Observational Study of 7751 Patients J Clin Hypertens 2019 21 9 1298 1304 10.1111/jch.13647 14 Jo SH, Kim SA, Park KH, Kim HS, Han SJ, Park WJ. Self-Blood Pressure Monitoring is Associated with Improved Awareness, Adherence, and Attainment of Target Blood Pressure Goals: Prospective Observational Study of 7751 Patients. J Clin Hypertens. 2019;21(9):1298-304. doi: 10.1111/jch.13647. Almeida GO Aidar FJ Matos DG Almeida PF Neto Melo EV Barreto JAS Filho Non-Targeted Self-Measurement of Blood Pressure: Association with Self-Medication, Unscheduled Emergency Visits and Anxiety Medicina 2021 57 1 75 75 10.3390/medicina57010075 15 Almeida GO, Aidar FJ, Matos DG, Almeida PF Neto, Melo EV, Barreto JAS Filho, et al. Non-Targeted Self-Measurement of Blood Pressure: Association with Self-Medication, Unscheduled Emergency Visits and Anxiety. Medicina. 2021;57(1):75. doi: 10.3390/medicina57010075. Casiglia E Tikhonoff V Albertini F Palatini P Poor Reliability of Wrist Blood Pressure Self-Measurement at Home: A Population-Based Study Hypertension 2016 68 4 896 903 10.1161/HYPERTENSIONAHA.116.07961 16 Casiglia E, Tikhonoff V, Albertini F, Palatini P. Poor Reliability of Wrist Blood Pressure Self-Measurement at Home: A Population-Based Study. Hypertension. 2016;68(4):896-903. doi: 10.1161/HYPERTENSIONAHA.116.07961. Mourtzinis G Manhem K Kahan T Schiöler L Isufi J Ljungman C Socioeconomic Status Affects Achievement of Blood Pressure Target in Hypertension: Contemporary Results from the Swedish Primary Care Cardiovascular Database Scand J Prim Health Care 2021 39 4 519 526 10.1080/02813432.2021.2004841 17 Mourtzinis G, Manhem K, Kahan T, Schiöler L, Isufi J, Ljungman C, et al. Socioeconomic Status Affects Achievement of Blood Pressure Target in Hypertension: Contemporary Results from the Swedish Primary Care Cardiovascular Database. Scand J Prim Health Care. 2021;39(4):519-26. doi: 10.1080/02813432.2021.2004841. Sandoval D Nazzal C Romero T Clinical, Socioeconomic, and Psychosocial Factors Associated with Blood Pressure Control and Adherence: Results from a Multidisciplinary Cardiovascular National Program Providing Universal Coverage in a Developing Country Int J Hypertens 2018 2018 5634352 5634352 10.1155/2018/5634352 18 Sandoval D, Nazzal C, Romero T. Clinical, Socioeconomic, and Psychosocial Factors Associated with Blood Pressure Control and Adherence: Results from a Multidisciplinary Cardiovascular National Program Providing Universal Coverage in a Developing Country. Int J Hypertens. 2018;2018:5634352. doi: 10.1155/2018/5634352. Nadrowski P Podolecka E Pajak A Dorynska A Drygas W Bielecki W How Does the risk of cardiovascular death and cardiovascular risk factor profiles differ between Socioeconomic Classes in Poland: A Country in Transition Cardiol J 2019 26 5 493 502 10.5603/CJ.a2018.0003 19 Nadrowski P, Podolecka E, Pajak A, Dorynska A, Drygas W, Bielecki W, et al. How Does the risk of cardiovascular death and cardiovascular risk factor profiles differ between Socioeconomic Classes in Poland: A Country in Transition. Cardiol J. 2019;26(5):493-502. doi: 10.5603/CJ.a2018.0003. Costa SM Lima CA Nobre ALCSD Vieira DMA Leal ALR Hypertension Bearers with High Risk/Big Risk of Cardiovascular Diseases and Socioeconomic and Health Indicators Rev Assoc Med Bras 2018 64 7 601 610 10.1590/1806-9282.64.07.601 20 Costa SM, Lima CA, Nobre ALCSD, Vieira DMA, Leal ALR. Hypertension Bearers with High Risk/Big Risk of Cardiovascular Diseases and Socioeconomic and Health Indicators. Rev Assoc Med Bras. 2018;64(7):601-10. doi: 10.1590/1806-9282.64.07.601. Conill EM A Historical and Conceptual Model for Primary Health Care: Challenges for the Organization of Primary Care and the Family Health Strategy in Large Brazilian Cities Cad Saude Publica 2008 24 Suppl 1 S7 S16 10.1590/s0102-311x2008001300002 21 Conill EM. A Historical and Conceptual Model for Primary Health Care: Challenges for the Organization of Primary Care and the Family Health Strategy in Large Brazilian Cities. Cad Saude Publica. 2008;(24 Suppl 1):S7-16. doi: 10.1590/s0102-311x2008001300002. Sharma AM Wittchen HU Kirch W Pittrow D Ritz E Göke B High Prevalence and Poor Control of Hypertension in Primary Care: Cross-Sectional Study J Hypertens 2004 22 3 479 486 10.1097/00004872-200403000-00009 22 Sharma AM, Wittchen HU, Kirch W, Pittrow D, Ritz E, Göke B, et al. High Prevalence and Poor Control of Hypertension in Primary Care: Cross-Sectional Study. J Hypertens. 2004;22(3):479-86. doi: 10.1097/00004872-200403000-00009.