May Measurement Month 2022: an analysis of blood pressure screening results from Slovenia

Abstract

The May Measurement Month (MMM) campaign was carried out in Slovenia in 2022 with the aim of raising awareness of raised blood pressure (BP). Here, we report on the findings of the campaign. Adults aged ≥18 years were recruited opportunistically mainly at pharmacies and health care facilities across all regions of the country and in some public places (such as the sports event Tek ob žici). Three seated BP readings were taken for each participant, along with completion of a questionnaire on demographics, lifestyle factors, and comorbidities. Hypertension was defined as a systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg or being on antihypertensive medication. Controlled BP was defined as being on antihypertensive medication with a BP < 140/90 mmHg. Multiple imputation was used to estimate any missing BP readings. In total, 2181 were screened, with a mean age of 59.2 years and 62.2% of whom were female. Of all participants, 1154 (52.9%) had hypertension, of whom 880 (76.3%) were aware, and 683 (59.2%) were on antihypertensive medication. Of those on antihypertensive medication, 333 (48.8%) had controlled BP, and of all participants with hypertension, 28.9% had controlled BP. Of all those screened, 263 (12.1%) participants had diabetes, 59 (2.7%) a history of stroke, and 61 (2.8%) a history of myocardial infarction. The MMM campaign in Slovenia identified significant numbers of participants with either untreated or inadequately treated hypertension. All were given healthy lifestyle advice and were referred to their general practitioners for further evaluation and treatment.

Introduction

Raised blood pressure (BP) is one of the largest contributors to the global burden of disease.¹

Epidemiological data on the prevalence of hypertension in Slovenia are still scarce. The last epidemiological study was performed in 2009 and estimated the prevalence at 64.3%,² but it had methodological limitations (small response rate and suboptimal age distribution). Taking into account reports from other countries and the characteristics of individual surveys, the best estimates were presented in the Ribnica study for the younger part of population (prevalence of 9% in those aged 18–38 years)³ and CINDI for the adult population (prevalence of 40% in those aged 25–64 years).⁴ Cardiovascular disease mortality represents 45.7% of all-cause mortality in Slovenia, which is slightly below the European average (48.9%).⁵

May Measurement Month (MMM) was initiated in 2017 by the International Society of Hypertension (ISH) and has since run annually, except for 2020 due to the COVID-19 pandemic. In 2022, the MMM campaign continued, with an aim of continuing to raise awareness of the dangers of raised BP and included 757 350 participants worldwide.⁶

Slovenia participated in MMM in 2017, 2018, and 2019. Each year, we found a persisting low level of awareness and high proportions of individuals with inadequately controlled BP.^7-9 In this paper, we report on the findings of the MMM22 campaign in Slovenia.

Methods

May Measurement Month is a cross-sectional opportunistic survey of consenting adults aged 18 years or over. The programme in Slovenia was co-ordinated by the Slovenian Hypertension Society over the months of May and June. Screening sites were set up in pharmacies, health care facilities across the country, and public spaces (e.g. city park during the large sports event Tek ob žici and shopping malls) in the two largest cities of Ljubljana and Maribor. All volunteers were professionals with knowledge of correct BP measurements. The campaign was advertised via media (radio and TV and interviews with doctors from the Department of Hypertension, University Medical Centre, Ljubljana).

In accordance with the standard MMM protocol, participants ideally had three seated BP readings measured at 1 min intervals.⁶ Automated oscillometric devices with upper arm cuffs were used to measure BP. A questionnaire was also completed, collecting information on demographics, comorbidities, lifestyle risk factors, and antihypertensive medication use. Hypertension was defined as a raised BP (a systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg based on the mean of the second and third readings), or being on antihypertensive medication. Controlled BP was defined as being on medication with a BP < 140/90 mmHg. Participants found to have raised BP were provided with diet and lifestyle advice and referred to their general practitioners for further evaluation and treatment initiation if needed.

Data were collected locally via paper forms that were transferred to excel sheets and submitted to the central MMM team for cleaning and analysis. In cases where any BP reading was missing, to ensure comparability between participants, the average of the second and third readings was estimated by multiple imputation using chained equations, based on global data as described previously.⁶ For comparison with other countries participating in MMM, results are also presented after age and sex standardization using the World Health Organization world standard population, and assuming an equal gender split.¹⁰ The study was approved by National Ethics Committee, and all the participants gave written informed consent.

Results

In total, 2181 were screened during MMM22 in Slovenia. The mean (standard deviation) age was 59.2 (15.9) years, and 1356 (62.2%) were female. All were reported to be of White ethnicity. Of all participants, four (0.2%) reported never having had a BP measured before.

Multiple imputation was used to estimate missing BP readings for 461 (21.1%) participants missing data on the first, second, or third BP reading. Of all participants, 1154 (52.9%) were found to have hypertension, of whom 880 (76.3%) were aware, and 683 (59.2%) were on antihypertensive medication (Table 1). Of those on antihypertensive medication, 333 (48.8%) had controlled BP, and of all hypertensives, 333 (28.9%) had controlled BP. Of participants who were not taking antihypertensive medication, 471 (31.5%) were found to have raised BP. In total, 821 (37.6%) were found to have either untreated or inadequately treated hypertension. After age and sex standardization, 784 (36.8%) were found to have hypertension, of whom 509 (64.9%) were aware, 353 (45.0%) were on antihypertensive medication, and 149 (19.0%) were controlled (Table 1).

Table 1.

Total participants and numbers with hypertension, awareness, on medication, and with controlled blood pressure, before and after age and sex standardization

	Total participants	Number (%) with hypertension	Number (%) of hypertensives aware	Number (%) of hypertensives on medication	Number (%) of those on medication with controlled BP	Number (%) of all hypertensives with controlled BP
Actual	2181	1154 (52.9)	880 (76.3)	683 (59.2)	333 (48.8)	333 (28.9)
Standardized	2134a	784 (36.8)	509 (64.9)	353 (45.0)	149 (42.2)	149 (19.0)

^aStandardized total lower than actual total, as 47 participants did not have information recorded on age or sex.

In total, 263 (12.1%) participants reported having diabetes, 59 (2.7%) a previous stroke, and 61 (2.8%) a previous myocardial infarction and 689 (31.6%) reported taking statins.

Discussion

The MMM22 programme identified a total of 821 (37.6%) participants with untreated or inadequately treated hypertension, highlighting the scale of hypertension in Slovenia. In total, 1154 (52.9%) were found to have hypertension. The rate of awareness remains inadequate (23.7% unaware) and the control of BP is very low (51.2% of those on medication and 71.1% of all hypertensives have uncontrolled BP) despite the fact that our health system is well regulated and accessible and there is no co-payment for most of the medicines used to treat hypertension. Results do not differ significantly from previous MMM campaigns.

Strengths and limitations

A strength of the MMM campaign is the use of a standardized protocol across countries, which aids comparability of findings. Participants in MMM were recruited opportunistically using convenience sampling and as a result, prevalence estimates should not be interpreted as estimates of national prevalence. Hypertension was defined based on three BP readings at a single visit for pragmatic reasons that is not the optimal method of diagnosis at the individual level as recommended in guidelines.¹¹ Consequently, the rate of hypertension detected is likely to represent an overestimate.

The majority of measurements was collected in health care facilities and pharmacies that is reflected in the age of the sample and consequently may lead to an overestimate of the population prevalence of hypertension.

Conclusion

The MMM22 campaign, consistent with previous MMM campaigns, again revealed a substantial number of people with unknown hypertension or poorly controlled BP. Due to methodological limitations, the sample cannot be considered representative of the entire Slovenian population, but it nonetheless gives an impression of the BP awareness and control in our country. Results demonstrate the need for such campaigns to further raise awareness and thereby improve BP control and reduce future CV morbidity and mortality.

Funding

Krka, d.d., Novo mesto, Slovenia, and Servier, Slovenia. For this campaign, we also received 10 Omron BP from Omron and the MMM organizers.

Data availability

Data are not publicly available but access can be requested with permission from the MMM Management Board, on request through the MMM website: maymeasure.org.