Abstract
Regular blood pressure (BP) measurements are required to identify people with hypertension and to optimally manage their cardiovascular risk. Analyses of data from the 2000–2001 Canadian Community Health Survey showed that most adult Canadians have had a BP assessment in the previous 2 years and few have never had one. Large numbers of persons without BP recordings were observed, however, among persons who were younger, were male, who did not have either a regular doctor or physician contact in the previous year, who were recent immigrants or visible minorities (nonwhite and non‐Aboriginal), and who spoke neither French nor English. Common reasons reported for not having a BP assessment included believing it was not necessary and simply not getting around to it. Education programs targeting those at risk as well as more convenient BP screening may improve awareness and testing.
(J Clin Hypertens. 2007;9:944–951)
Hypertension affects approximately 25% of the adult population worldwide. 1 , 2 , 3 , 4 The prevalence of hypertension increases markedly with age, and the lifetime residual risk of developing hypertension is >90% even in persons with normal blood pressure (BP) at age 65. 4 , 5 Hypertension is an important modifiable risk factor for cardiovascular disease and the most common attributable risk for mortality in developed nations. 6 Although treatment of hypertension is associated with more than a 30% to 45% reduction in cardiovascular events, 7 , 8 many individuals are still unaware that they have hypertension, possibly because they do not have their BP measured regularly. 3 , 6 , 9 , 10
In Canada, 9 of 10 adults have their BP assessed at least annually, 11 and approximately 98% of adult Canadians have had at least 1 BP measurement. 12 As part of the effort to improve detection of hypertension, we determined the characteristics of adult Canadians who reported never having or infrequently having a BP assessment. We also examined the self‐reported reasons Canadians indicated for not having their BP measured. Since assessment of BP is the foundation for the detection of hypertension, understanding the characteristics associated with not having BP measured is important. Such information might be used to identify high‐risk populations and to develop more targeted interventions and education programs.
METHODS
Study Population
We derived data from the Canadian Community Health Survey (CCHS) cycle 1.1, a national health survey of household residents aged 12 years or older in all Canadian provinces and territories. The survey excluded populations on Indian reserves, Canadian forces bases, and some remote areas. A multiple stage and complex sampling methodology was employed to locate households in 136 health regions across Canada. One respondent per household was selected randomly for a telephone interview or an in‐person interview. The survey oversampled youth and populations in some regions. A detailed description of the sampling frame and design methodology of CCHS can be found at http://www.statcan.ca/english/concepts/health/index.htm.
Study Variables
All respondents were asked, “Have you ever had your BP checked?” Patients responding “yes” to the question were further asked, “When was the last time?” Under the time question, a period category was provided to respondents for selection, including <6 months ago, 6 months to <1 year ago, 1 year to <2 years ago, 2 years to <5 years ago, and ≥5 years ago. Using these 2 survey questions, we identified respondents who had never had BP measured and those who had but had not had a BP measurement within the past 2 years. Self‐reported reasons for not having BP measured were also collected from respondents of these 2 groups by providing a list of potential answers to respondents (eg, did not think it was necessary, had a language problem, cost, have not gotten around to it). Specific self‐reported reasons that were not on the provided category were also collected.
Sociodemographic characteristics of respondents included sex, age, household income, education level, language spoken, marital status, birth place, length of stay in Canada since immigration, urban/rural location, and ethnicity. Health status‐related variables included self‐rated health, number of physician consultations in the 12 months before the survey, and having a regular doctor. Income was categorized into 4 groups based on total household income and the number of people living in the household. The lowest‐income group was defined as total household income <$15,000 and 1 or 2 household residents, a total household income <$20,000 and 3 or 4 household residents, or a total household income <$30,000 and ≥5 household residents. The lower‐middle income group was defined as having a total household income between $15,000 and $29,999 and 1 or 2 household residents, total household income between $20,000 and $39,999 and 3 or 4 household residents, or total household income between $30,000 and $59,999 and ≥5 household residents. The upper‐middle income group was defined as total household income between $30,000 and $59,999 and 1 or 2 household residents, total household income between $40,000 and $79,999 and 3 or 4 household residents, or a total household income between $60,000 and $79,999 and ≥5 household residents. The highest‐income group was defined as having a total household income >$60,000 and 1 or 2 household residents or a total household income >$80,000 and ≥3 residents.
Ethnicity data were obtained by asking, “People living in Canada come from many different cultural and racial backgrounds. Are you . . .?” The possible responses were white, Chinese, South Asian, black, Latin American, Southeast Asian, West Asian, Japanese, Korean, Filipino, Arab, Aboriginal, and other. Because of small sample sizes in some ethnic groups, we grouped ethnicity into whites, Aboriginal, and visible minorities (the remaining ethnic groups). Individuals who described themselves as being both white and having another ethnicity were classified as white. Self‐rated health status was measured by the categories of poor, fair, good, very good, and excellent.
Statistical Analysis
Characteristics of the study population were described with descriptive statistics. Proportions of “never having BP assessed” and “not having BP assessed within the past 2 years” were stratified by study variables. Proportions were weighted using sampling weights as advised by Statistics Canada to account for the complex sampling procedure used in CCHS. Two logistic regression models were developed to test the association between demographic and health‐related variables and BP measurement: one for those who had never had their BP checked and another for those who had not had it checked in the past 2 years. We calculated the 95% confidence intervals of odds ratios using bootstrap macros provided by Statistics Canada to account for the design effect of the survey. Based on the logistic model results, we quantified the high‐risk groups of not taking BP using stratified analysis.
RESULTS
The present study was limited to data on respondents who agreed to release their information to Canadian provincial and federal governments (125,574 of a total of 131,535 participants who were surveyed) and were aged 20 years and older. Of 108,649 respondents aged 20 years and older, we excluded 3189 participants who did not have data on BP measurement (because they refused to answer the BP check question or they did not know whether they had ever had their BP checked) and other sociodemographic variables, with the exception of including respondents who did not report income or physical activity. The resulting dataset included 105,460 participants for the analysis.
Of the study population, 51.0% were women. A majority of respondents had a postsecondary education level (57.8%) and were white (87.0%) (Table I).
Table I.
Characteristics of the Study Population in the Canadian Community Health Survey, 2001
| Variable | %of 105,460 Respondents a |
|---|---|
| Sex | |
| Male | 49.0 |
| Female | 51.0 |
| Age, y | |
| 20–39 | 39.5 |
| 40–59 | 38.8 |
| 60 or older | 21.6 |
| Education level | |
| <Secondary | 22.2 |
| Secondary | 20.0 |
| Postsecondary | 57.8 |
| %of 96,345 Respondents b | |
| Household incomeb | |
| Low income | 11.2 |
| Low middle income | 21.9 |
| Upper middle income | 35.8 |
| High income | 31.0 |
| Ethnicity | |
| White | 87.0 |
| Aboriginal | 1.0 |
| Chinese | 3.2 |
| South Asian | 2.6 |
| Other Asian | 2.8 |
| Black | 1.6 |
| Latin American | 0.6 |
| Other | 1.2 |
| aThe percentage was weighted to account for the sampling design effect. bNo. for income is different because those who did not state their income were excluded. | |
Only 2.6% of the adult respondents reported never having had their BP assessed (Table II). This response was more common among respondents who were aged 20 to 39 years (4.9%), male (3.9%), had never married (6.9%), those who spoke neither French nor English (5.5%), immigrated to Canada <10 years before the survey (7.4%), were visible ethnic minorities (3.5%–8.1%), did not have a regular doctor (7.0%), or did not have any physician contact in the past year (6.8%).
Table II.
Proportion of Adult Canadians Who Reported Never Having BP Assessed or Not Having BP Assessed Within the Past 2 Years Before the Canadian Community Health Survey, 2001 (N=105,460)
| Characteristic | Never Had BP Assessment | No BP Assessment in the Past 2 Years | ||
|---|---|---|---|---|
| %a | OR (95% CI) | %a | OR (95% CI) | |
| Overall | 2.6 | — | 9.0 | — |
| Sex | ||||
| Female | 1.4 | 1.0 | 5.9 | 1.0 |
| Male | 3.9 | 2.0 (1.8–2.5) | 12.4 | 1.6 (1.5–1.7) |
| Age, y | ||||
| 20–39 | 4.9 | 3.9 (3.0–5.3) | 12.3 | 2.4 (2.1–2.7) |
| 40–59 | 1.5 | 1.9 (1.4–2.6) | 8.8 | 1.9 (1.7–2.1) |
| 60 or older | 0.6 | 1.0 | 3.5 | 1.0 |
| Marital status | ||||
| Married/common‐law | 1.6 | 1.0 | 8.2 | 1.0 |
| Widowed/separated/divorced | 1.3 | 1.4 (1.1–1.8) | 6.6 | 1.2 (1.0–1.3) |
| Never married | 6.9 | 2.8 (2.4–3.3) | 13.4 | 1.3 (1.1–1.4) |
| Education level | ||||
| <Secondary | 2.4 | 1.6 (1.3–2.0) | 7.5 | 1.1 (1.0–1.2) |
| Secondary | 3.6 | 1.7 (1.4–2.0) | 9.9 | 1.2 (1.1–1.3) |
| Postsecondary | 2.4 | 1.0 | 9.3 | 1.0 |
| Household incomeb | ||||
| Low income | 3.2 | 1.0 | 8.5 | 1.0 |
| Low middle income | 2.9 | 0.9 (0.7–1.1) | 9.2 | 1.1 (1.0–1.2) |
| Upper middle income | 2.5 | 0.8 (0.6–0.9) | 9.5 | 1.0 (0.9–1.1) |
| High income | 1.8 | 0.6 (0.5–0.8) | 8.8 | 0.8 (0.7–0.9) |
| Language spoken | ||||
| English/French/both | 2.5 | 1.0 | 9.1 | 1.0 |
| Neither | 5.5 | 1.9 (1.2–3.2) | 6.0 | 1.0 (0.7–1.4) |
| Time since immigration | ||||
| Born in Canada | 2.3 | 1.0 | 9.5 | 1.0 |
| 0–9 years | 7.4 | 1.2 (0.9–1.7) | 8.6 | 0.8 (0.6–1.0) |
| ≥10 years | 2.5 | 1.1 (0.9–1.5) | 7.1 | 1.1 (0.9–1.3) |
| Ethnicity | ||||
| White | 2.1 | 1.0 | 9.2 | 1.0 |
| Aboriginal | 4.7 | 1.2 (0.8–1.7) | 9.4 | 0.7 (0.6–0.9) |
| Visible minority | 2.3 (1.7–3.0) | 1.1 (0.9–1.3) | ||
| Chinese | 8.0 | 8.4 | ||
| South Asian | 5.2 | 5.4 | ||
| Other Asian | 6.1 | 6.8 | ||
| Black | 3.8 | 7.8 | ||
| Latin American | 3.5 | 11.5 | ||
| Other | 8.1 | 8.6 | ||
| Residence type | ||||
| Urban | 2.6 | 1.0 | 8.9 | 1.0 |
| Rural | 2.5 | 0.8 (0.7–1.0) | 9.5 | 1.0 (0.9–1.0) |
| Self‐rated health status | ||||
| Fair/poor | 0.9 | 1.0 | 3.3 | 1.0 |
| Excellent/very good/good | 2.9 | 1.8 (1.3–2.4) | 9.9 | 1.6 (1.4–1.9) |
| Having a regular doctor | ||||
| Yes | 1.8 | 1.0 | 6.2 | 1.0 |
| No | 7.0 | 2.2 (1.9–2.5) | 23.9 | 2.3 (2.1–2.5) |
| Physician consultations in the past year | ||||
| 0 | 6.8 | 6.4 (4.8–8.5) | 28.0 | 13.9 (12.0–16.0) |
| 1–3 | 2.0 | 1.9 (1.4–2.5) | 5.5 | 2.5 (2.2–2.9) |
| ≥4 | 0.8 | 1.0 | 1.8 | 1.0 |
| aThe percentage was weighted to account for sampling design effect. bAn additional category called “missing on income” for respondents who did not report income was included in logistic models but is not shown in the table. Abbreviations: BP, blood pressure; CI, confidence interval; OR, risk‐adjusted odds ratio. | ||||
Among respondents who had a previous BP assessment (Table II), 9.0% reported not having a BP assessed within the past 2 years before the survey. The proportion was higher among respondents who were male (12.4%), aged 20 to 39 years (12.3%), and never married (13.4%) and those who were in good health (9.9%), did not have a regular doctor (23.9%), or did not have any physician contact in the past year (28.0%). There was little variation across ethnic groups in the proportion who had a recent BP measurement.
After risk adjustment (Table II), never having had a BP assessment or not having had one within the 2 years before the survey was significantly associated with male sex, younger age, never being married, having less than a postsecondary education, having a low to low‐middle income, reporting good to excellent health status, not having a regular physician, and having fewer physician consultations in the year before the survey. In addition, never having had a BP assessment was significantly associated with visible minority status and speaking a language other than English or French. These 2 variables were not significantly associated with a recent BP assessment.
The stratified analysis by 4 significant factors (ie, sex, age group, ethnicity, and having a regular doctor) is presented in Table III. The highest‐risk group for never having had a BP assessment was Aboriginal young men (aged 20–39 years) who did not have a regular physician (18.4%). The highest‐risk group for not having BP assessed in the 2 years before the survey was Aboriginal men aged 60 years and older who did not have a regular doctor (40.9%).
Table III.
Subgroups of Canadians at Highest Risk for Not Receiving a BP Assessmenta
| Sex | Age Group, y | Ethnicity | Have a Regular Doctor | BP Never Measured, % | BP Not Measured Within 2 Years, % |
|---|---|---|---|---|---|
| Male | 20–39 | White | Yes | 4.8 | 14.3 |
| Male | 20–39 | White | No | 9.9 | 26.5a |
| Male | 20–39 | Aboriginal | Yes | 6.6 | 9.2 |
| Male | 20–39 | Aboriginal | No | 18.4a | 15.2 |
| Male | 20–39 | Visible minority | Yes | 9.9 | 9.1 |
| Male | 20–39 | Visible minority | No | 14.2a | 22.1a |
| Male | 40–59 | White | Yes | 0.8 | 8.5 |
| Male | 40–59 | White | No | 5.2 | 28.5a |
| Male | 40–59 | Aboriginal | Yes | 1.5 | 5.5 |
| Male | 40–59 | Aboriginal | No | 6.4 | 22.8a |
| Male | 40–59 | Visible minority | Yes | 4.2 | 5.2 |
| Male | 40–59 | Visible minority | No | 12.9a | 21.8a |
| Male | 60 or older | White | Yes | 0.4 | 2.5 |
| Male | 60 or older | White | No | 4.8 | 28.9a |
| Male | 60 or older | Aboriginal | Yes | 0.0 | 1.6 |
| Male | 60 or older | Aboriginal | No | 2.4 | 40.9a |
| Male | 60 or older | Visible minority | Yes | 1.5 | 0.5 |
| Male | 60 or older | Visible minority | No | 15.6a | 8.5 |
| Female | 20–39 | White | Yes | 1.5 | 5.8 |
| Female | 20–39 | White | No | 3.3 | 15.9 |
| Female | 20–39 | Aboriginal | Yes | 1.0 | 8.6 |
| Female | 20–39 | Aboriginal | No | 6.3 | 15.6 |
| Female | 20–39 | Visible minority | Yes | 5.1 | 5.6 |
| Female | 20–39 | Visible minority | No | 12.3a | 17.2 |
| Female | 40–59 | White | Yes | 0.4 | 4.5 |
| Female | 40–59 | White | No | 2.4 | 23.7a |
| Female | 40–59 | Aboriginal | Yes | 0.1 | 2.6 |
| Female | 40–59 | Aboriginal | No | 6.8 | 15.0 |
| Female | 40–59 | Visible minority | Yes | 3.3 | 3.3 |
| Female | 40–59 | Visible minority | No | 4.4 | 13.2 |
| Female | 60 or older | White | Yes | 0.3 | 1.7 |
| Female | 60 or older | White | No | 3.0 | 25.1a |
| Female | 60 or older | Aboriginal | Yes | 0.0 | 1.0 |
| Female | 60 or older | Aboriginal | No | 15.9a | 20.5a |
| Female | 60 or older | Visible minority | Yes | 0.5 | 1.5 |
| Female | 60 or older | Visible minority | No | 1.0 | 19.4 |
| a≥10% had never had blood pressure (BP) assessed or ≥20% had not had BP assessed in the 2 years before the survey. Visible minority includes nonwhite and non‐Aboriginal persons, such as Chinese, South Asian, other Asian, black, and Latin American persons. | |||||
The self‐reported reasons for never having had BP assessed or not having a BP assessment in the 2 years before the survey were similar (Table IV). The main reasons were that respondents did not think a BP measurement was necessary and they had not gotten around to it. Fewer respondents indicated other reasons, including that their doctors thought it was not necessary. The distribution of the most common reasons did not vary appreciably by sex, age, education level, or ethnicity.
Table IV.
Self‐Reported Reasons (%) for Not Having Had BP Assessed Within 2 Years or Never Having Had BP Assessed
| Have Not Gotten Around to It | Think It Is Not Necessary | Doctor Thinks It Is Not Necessary | Other a | |||||
|---|---|---|---|---|---|---|---|---|
| Not Within 2 Years | Never | Not Within 2 Years | Never | Not Within 2 Years | Never | Not Within 2 Years | Never | |
| Overall | 37.0 | 33.2 | 52.6 | 49.4 | 5.0 | 11.3 | 5.4 | 6.2 |
| Sex | ||||||||
| Male | 37.7 | 34.3 | 53.7 | 50.6 | 3.8 | 8.7 | 4.9 | 6.4 |
| Female | 35.7 | 30.2 | 50.5 | 45.9 | 7.4 | 18.3 | 6.4 | 5.7 |
| Age, y | ||||||||
| 20–39 | 39.2 | 33.4 | 50.9 | 49.4 | 5.4 | 11.1 | 4.6 | 6.2 |
| 40–59 | 36.5 | 33.5 | 53.3 | 51.1 | 4.5 | 9.3 | 5.7 | 6.2 |
| 60 or older | 28.9 | 30.4 | 58.1 | 42.0 | 5.8 | 20.8 | 7.2 | 6.8 |
| Education | ||||||||
| <Secondary | 33.2 | 34.1 | 58.1 | 48.2 | 3.8 | 13.1 | 4.9 | 4.7 |
| Secondary | 40.0 | 26.6 | 50.1 | 54.5 | 4.9 | 14.0 | 5.0 | 4.8 |
| Postsecondary | 37.2 | 36.5 | 51.8 | 47.0 | 5.5 | 8.8 | 5.6 | 7.8 |
| Ethnicity | ||||||||
| White | 36.9 | 33.2 | 52.9 | 53.0 | 5.0 | 7.4 | 5.3 | 6.4 |
| Aboriginals | 28.1 | 34.1 | 50.2 | 34.5 | 8.9 | 22.1 | 12.8 | 9.3 |
| Visible minorityb | 39.5 | 33.0 | 50.2 | 42.1 | 5.3 | 19.2 | 5.0 | 5.8 |
| aIncluding personal or family responsibilities, not available or in area at time required, long waiting times, transportation or language problems, fear, and nonspecified reasons. No. of those who have ever had their blood pressure (BP) measured but have not done so in the past 2 years, 8291. No. of those who have never had their BP measured, 1450. bIncludes nonwhite and non‐Aboriginal persons, such as Chinese, South Asian, other Asian, black, and Latin American persons. | ||||||||
DISCUSSION
In our analysis of a survey representative of the Canadian population, only 2.6% of Canadians have never had their BP measured. This proportion is considerably lower than that reported by several other countries (8%–32%) and is encouraging. 13 , 14 , 15 , 16 , 17 When the proportion was further stratified by several characteristics, certain Canadian subgroups exhibited a higher proportion of never having had their BP measured than the general population (up to 18%). Characteristics of these include being male, younger, or Aboriginal or having a visible minority ethnic background and no regular physician or few physician contacts in the year before the survey.
We found that 7% of recent immigrants and 6% of those who did not speak Canada's official languages had never had their BP checked. The possible reasons for the proportions in these populations include the following: (1) some recent immigrants are likely to have come from countries or regions where there are fewer preventive services and educational programs targeting the importance of routine BP assessments, (2) new immigrants may be less familiar with Canadian health care services and may not know where or how to get their BP measured, and (3) recent immigrants are less likely to have a regular physician. The lack of information available in their own language may also be a barrier to understanding the importance of BP assessments. With the increase in immigration from many countries, multilingual and culturally sensitive educational programs need to be developed.
One potential strategy is to involve community health workers as team members in education programs. 18 Community health workers are often lay‐people who share demographic and cultural characteristics of the members of the communities and who are trained to provide health education and direct services, such as measuring BP. These workers are more likely to be trusted and may be better able to bridge the gap between health care providers and community members. 19 , 20 This approach has been shown to be promising for diverse ethnic groups 18 , 20 and can also be used in hard‐to‐reach populations, such as undocumented immigrants. A similar but modified approach can be used to reach younger people. Young adults can be trained to serve as peer health educators, assist in organizing periodic BP clinics at work sites, and to help with self‐monitoring of BP at pharmacies. 21
Almost 1 of 10 Canadians had not had a BP assessment in the 2 years before the survey but, as noted, the proportion was higher in some subgroups, such as Aboriginal men older than 60 years who did not have a regular physician (about 40%). Regular BP assessment is required, as the prevalence of hypertension increases with age. 5 , 10 Generally, there were no differences in the sociodemographic and health‐related characteristics among respondents reporting never having had a BP assessment and those reporting no recent assessment. One exception was the finding that ethnic minorities were significantly more likely to have never had their BP assessed. Previous literature has shown lower rates for other preventive health practices (eg, participation in cancer screening) among selected ethnic subgroups compared with whites in Canada. 22 , 23 Such findings may suggest a unique need for targeted interventions (as outlined above) to address the sociocultural barriers associated with utilization of preventive services, including a BP measurement, among selected minority groups.
In every situation in which men did not have a regular physician, there were, as expected, higher proportions of not having BP assessed. Having a regular physician was also important for some subgroups of women. It is also possible that there are specific health beliefs or other characteristics of people who do not see a physician that may be associated with lack of BP measurements. Simply providing greater access to physicians may not resolve the issue. Because there may be a global shortage of physicians, developing programs to assess BP that rely on nurses, other health care practitioners, or trained observers may represent possible solutions. 24 , 25 , 26 Most BP measurements, however, have traditionally been done at physician offices; promoting primary care physicians' awareness of the need to do regular BP assessments is important. 27 , 28
There were no substantial differences between the reasons provided by those who had never had BP measured and those who had not had a recent measurement. About half did not think that BP measurement was necessary and about a third had not gotten around to having BP taken. Several reports have indicated a lack of public awareness of the importance of hypertension and misconceptions about hypertension. 11 , 29 , 30 These findings indicate that education on the need for ongoing BP assessments is important. Education programs should specifically address the risk of untreated hypertension and the need for BP assessments in younger adults, men, minorities, and those with lower‐income levels. Education programs need to encompass healthy populations, as many do not believe they are at risk for hypertension. 11
Interestingly, the third most common reason that individuals reported that they had never had a BP measurement was that their doctors thought it was not necessary. This self‐reported reason only captures the perspective of the respondent and may not reflect thoughts or recommendations of their physicians. It is possible that some physicians may tell patients who have normal BP levels and who are younger that regular BP measurements are not necessary. Patients may misunderstand this recommendation. Further, there may be sociocultural and environmental factors that may influence the patient‐physician interaction 31 , 32 , 33 , 34 and may result in inconsistencies in self‐reported responses regarding preventive health recommendations communicated by the physician. Further research is required to clarify the frequency of physicians not recommending BP assessments compared with patients misunderstanding physicians' recommendations about medical care.
LIMITATIONS
Our study has several limitations. The CCHS is a cross‐sectional telephone survey and, thus, data are subject to recall bias and interpretation difficulties regarding causality. The CCHS also did not sample adults admitted to hospitals, homeless persons, and populations on Indian reserves and Canadian forces bases. Inpatients are more likely to have their BP measured, while the homeless and populations on Indian reserves are not. The CCHS was also not designed to capture the beliefs and attitudes of people toward BP measurement; this study provides limited insight as to why some people think BP measurement is not necessary. A recent survey found widespread lack of knowledge and misconceptions about hypertension in the Canadian population, 11 however, suggesting that lack of public knowledge is a substantial contributor to inadequate BP assessment. A recent survey in the United States, though, has indicated a high degree of understanding of the risks and importance of elevated BP. 35
Because measurement of BP is the foundation of efforts to treat and control hypertension, it is important to develop additional programs for those at risk. Many countries have reported much higher proportions of the population who have never had their BP recorded, 13 , 14 while others have reported a similar or lower proportion. 16 , 17 Even countries with low proportions, such as Canada, should assess the characteristics of persons whose BP is not being recorded.
Disclosures:
The conduct of this study was financially supported by the Public Health Agency of Canada. Dr Quan is supported by Alberta Heritage Foundation for Medical Research Population Investigator and Canadian Institutes of Health Research New Investigator awards. Dr Maxwell receives salary support from the Canadian Institutes of Health Research‐Institute of Aging and the Alberta Heritage Foundation for Medical Research. Dr Campbell is supported by the Canadian Chair in Hypertension Prevention and Control (Canadian Hypertension Society, Canadian Institutes of Health Research, Sanofi Aventis). Dr Campbell has been paid fees for speaking and for consulting by most pharmaceutical companies in Canada that produce trade medications to lower blood pressure. In addition, Dr Campbell has received research funds from Pfizer Canada, Sanofi‐Aventis, Servier, and Bristol‐Myers‐Squibb for research on the epidemiology of hypertension. He is also an unpaid consultant, committee member, and chair of committees for the Public Health Agency of Canada and the Heart and Stroke Foundation of Canada.
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