This study provides important evidence about the burden of hypertension in China. Over a quarter (27.6%) of Chinese adults had hypertension, but only 55.7% of the hypertensive patients were aware of their disease, and 83% of those who were aware of their hypertension took antihypertensive medication treatment. Among those who were treated, only 43.8% had their hypertension controlled. Overall, only 20.3% of participants with hypertension achieved controlled blood pressure. Being female, of older age, a high socioeconomic status, and a healthy lifestyle were associated with a higher rate of hypertension awareness, treatment, and control. Low hypertension treatment and control rates and large variations of these rates across different subgroups highlight the urgent need for more effective and affordable strategies for hypertension control in China.
Our findings on hypertension awareness, treatment, and control are consistent with similar studies.(14) As shown in Supplemental table 1, we compared the prevalence, awareness, treatment, and control of hypertension among Chinese adults from two waves of CHNS (2001 and 2011) and from the International Collaborative Study of Cardiovascular Disease in ASIA (InterASIA 2000-2001). We would like to evidence what are the improvements in hypertension prevalence, awareness, treatment and control over ten years interval in the same survey and another coetaneous study. This comparison reveals that progress has been made in hypertension awareness, treatment, and control. For example, the hypertension awareness and treatment rates in the present study were more than two times greater than those seen a decade earlier(15) and the control rate was substantially higher than that reported in the InterASIA study.(16)
Despite the progress, awareness, treatment, and control of hypertension in China were still lower than the global average level,(17, 18) and they were much worse than those in developed countries.(19, 20) According to a systematic review based on data from 35 countries, the hypertension awareness and control rates in China were even lower than the average level of many developing countries.(21) The poor performance in hypertension control in China may be caused by, among others, unequal socioeconomic status, which limits access to basic health care facilities and primary health care practitioners, and the prevalence of related risk factors in the general population.(22, 23)
The low hypertension control rate may be impacted by two factors. First, BP screening was not included in many primary health care service practices yet, even though it has been required by government health programs. Second, the lack of appropriate antihypertensive medication may partly explain the low control rate. Therefore, the direct and intuitive implication would be that a more intensive education program and interventions should be launched to strengthen outpatient and community-based screening for hypertension. In addition, more standardized and comprehensive hypertension treatment guidelines must be released to improve the knowledge of primary care physicians in China who prescribe evidence-based medications to obtain the optimal control of hypertension management.
Our multivariate logistic regression analysis identified several factors being associated with awareness, treatment, and control of hypertension in China. Consistent with other studies,(24-26) we found that women were more likely to be aware of their hypertension and receiving treatment than men. The control rate did not differ by sex among those who received medication treatment. In accordance with evidence from other studies,(8, 27, 28) urban residence and older age were associated with higher awareness, treatment, and control rates. A potential reason is that urban residents are more wary of their health, and so does the elderly population. Participants in Eastern China had higher rates of hypertension awareness, treatment, and control compared to those in Central China, which is likely due to the fact that Eastern China has an advantage in economic development and, thus, has more health care resources.(29, 30)
Being an ethnic minority was shown to be associated with lower rates of hypertension awareness, treatment, and control. This difference may be attributed to variations in genetics, culture, and lifestyles between ethnic minorities and the majority Han ethnicity. A higher education level was found to be associated with a higher hypertension control rate. This result was consistent with a study based on data collected from adults in Southern China,(31) but was different from what was reported by the CHPSNE study.(32) The disparity may reflect differences in the study sample and treatment of hypertension in these studies.
Our results showed that having overweight and obesity was positively associated with higher rates of hypertension awareness and treatment, which was consistent with several other studies.(33, 34) However, obesity was associated with a lower control rate among patients receiving medication treatment. This could be explained by poor adherence to medical treatment among subjects with a suboptimal body weight.(35, 36) In addition, our study found that several lifestyle factors were associated with hypertension outcomes. The awareness and control rates were greater among former smokers and lower among current smokers and drinkers. The reasons behind these associations require further investigation that is beyond the scope of this study.
Our study has several limitations. First, cross-sectional data analysis does not support causal inferences between risk factors and hypertension outcomes. Second, blood pressure was not measured on separate occasions. Since the definition of hypertension was partly based on the blood pressure measurement, the absolute hypertension burden might be overestimated. Third, the CHNS did not capture non-pharmacological treatment strategies such as lifestyle modifications.
In conclusion, this study adds to the growing evidence that China suffers from a serious hypertension burden. Hypertension awareness, treatment, and control rates are still low compared to global averages and even compared to the average rates in many developing countries. The situation is worse among certain population groups, such as those who live in rural areas and underdeveloped regions. Substantial effort and resources—such as increasing physician-training programs and expanding screening services—are needed to alleviate the burden and hypertension and, eventually, improve population health in China.