Prevalence of hypertension and possible risk factors of hypertension unawareness among individuals aged 30–75 years from two Panamanian provinces: Results from population-based cross-sectional studies, 2010 and 2019

Angela Isabel Del Rio; Ilais Moreno Velásquez; Reina Roa; Roger Montenegro Mendoza; Jorge Motta; Hedley K Quintana

doi:10.1371/journal.pone.0276222

. 2022 Nov 28;17(11):e0276222. doi: 10.1371/journal.pone.0276222

Prevalence of hypertension and possible risk factors of hypertension unawareness among individuals aged 30–75 years from two Panamanian provinces: Results from population-based cross-sectional studies, 2010 and 2019

Angela Isabel Del Rio ^1,^2,^*, Ilais Moreno Velásquez ^1,³, Reina Roa ^1,², Roger Montenegro Mendoza ¹, Jorge Motta ¹, Hedley K Quintana ¹

Editor: Taeyun Kim⁴

PMCID: PMC9704556 PMID: 36441768

Abstract

Background

Recent estimates of hypertension in Panama remain unknown. We aim to describe the variation in prevalence and unawareness of hypertension in two Panamanian provinces using two different cross-sectional population-based studies and to investigate risk factors associated with hypertension unawareness.

Methods

Data were derived from a sub-national study conducted in the provinces of Panama and Colon (PREFREC-2010 [2,733 participants]) and from a nationally representative study (ENSPA-2019), in which we restricted our analyses to the same provinces (4,653 participants). Individuals aged 30–75 years who had (a) self-reported history of hypertension or (b) blood pressure (BP) ≥140/90mmHg or (c) a combination or both were classified as hypertensive. Participants with BP≥140/90mmHg who denied a history of hypertension were considered unaware of the condition. Multivariable logistic regression models were used to estimate the association between risk factors and unawareness, expressed as odds ratios (OR) and 95% confidence interval (CI).

Findings

In 2010, the prevalence and unawareness of hypertension in men were 51.6% (95% CI: 45.7–57.5) and 32.3% (25.4–40.1), respectively, and in women 46.0% (42.1–49.9) and 16.1% (12.6–20.4), respectively. In 2019, the prevalence and unawareness of hypertension in men were 46.5% (42.1–51.0) and 52.3% (45.9–58.6), and in women 42.1% (39.6–44.7) and 33.3% (29.8–37.0). Men (2010 and 2019), age <50 years (2010 and 2019), having no/primary education (2010), and living in a non-urban region (2019) were positively associated with hypertension unawareness, whereas obesity (2010), physical inactivity (2010), family history of hypertension (2019), and BP assessment in the year before study enrollment (2010 and 2019) were inversely associated with hypertension unawareness.

Interpretation

Benefits of a decrease in the prevalence of hypertension are being undermined by an increase in hypertension unawareness. Actions should be encouraged to strengthen the implementation of the existing healthcare program for cardiovascular risk factor control.

Introduction

Cardiovascular disease (CVD) is a major global health concern, causing more deaths than all other causes combined [1]. CVD was responsible for 77.0% of deaths in the Americas in 2000, a percentage that increased to 81.0% in 2016 [2]. Due to this burden of disease, strategies targeting social, economic, and political determinants, as well as control of major cardiovascular risk factors, need to be implemented.

Hypertension is one of the most important modifiable risk factors for premature CVD, with most of the increase occurring in low- and middle-income countries (LMICs) [3, 4]. Variation in hypertension risk factors, such as obesity, high-sodium diet, excessive alcohol consumption, and physical inactivity, may explain some of the CVD heterogeneity between countries [3]. In addition, most people with hypertension do not have symptoms, making screening for its detection necessary [5]. Studies from 2000–2010 have shown a substantial increase in hypertension awareness in high-income countries (HIC), whereas in LMICs the increase has been slight [6]. However, since 2010, a plateau and even a decrease in hypertension awareness has been identified in HIC [7–9], as well as in LMICs [10, 11].

Panama, an upper-middle-income country [12] and the second fastest-growing country in the Americas region in terms of gross domestic product (GDP) per capita [13], faces great disparities in the distribution of wealth (Gini Index of 49.8) [14]. These disparities are also observed in health conditions among ethnic groups, as well as in different geographic areas [15–17]. The country has experienced a demographic and epidemiological transition associated with a double burden of disease (non-communicable diseases (NCDs) and infectious diseases) [18]. However, NCD-related risk factors such as hypertension predominates with a prevalence among adults of 42.3% (according to the National Health Survey of Panama (ENSPA) in 2019) [19]. Furthermore, stroke and ischemic heart disease (IHD) were the leading causes of mortality in 2019 (41.9 per 100,000 population and 41.8 per 100,000 population, respectively) [20].

Starting in 2014, a healthcare program was implemented, which focused on a multipronged approach to NCDs control, including promotion, prevention, and early detection of hypertension and other cardiovascular risk factors [21]. However, there are no recent data on the country’s prevalence of hypertension to estimate the effectiveness of this healthcare program.

We aim (1) to describe the variation in the prevalence and unawareness of hypertension in two Panamanian provinces in two different population-based cross-sectional studies, conducted in 2010 and in 2019, and (2) to investigate the possible risk factors associated with hypertension unawareness.

Materials and methods

Study population

The PREFREC (2010) study

The PREFREC study (Spanish language for "Prevalence of Cardiovascular Risk Factors associated with CVD"), n = 3,590, is a sub-national, cross-sectional, descriptive study conducted between October 2010 and January 2011, designed to estimate the prevalence of well-known risk factors associated with CVDs in the provinces of Panama and Colon, where 57.4% of the total country population resided when the survey was implemented. The study included citizens older than 18 years who lived permanently in private housing of urban, rural, and indigenous areas. A complex sampling technique (three-stages, stratified, and randomized) was used. Further details regarding PREFREC have been described earlier [22]. In the present study, we included participants aged between 30 and 75 years (n = 2,733), out of them 67.5% were women (Fig 1).

Fig 1 — SBP = systolic blood pressure. DBP = diastolic blood pressure. *Denominator for the prevalence of hypertension. **Numerator for the prevalence of hypertension and the denominator for the prevalence of hypertension unawareness.

The ENSPA (2019) study

The ENSPA study (Spanish language for "National Health Survey of Panama"), n = 28,483, is a cross-sectional, nationwide population-based study conducted between June and December 2019, designed to investigate the population’s general health status and disease conditions. The study included individuals of all ages who resided permanently in private housing in rural, urban, and indigenous areas (0–14 years: n = 10,486; ≥15 years: n = 17 997). The sample design was a three-stage, stratified, and by conglomerates. The representativeness of the results is at the district level (second-level administrative division) in the entire country, except in the Panama and San Miguelito districts (province of Panama) where it has representativeness of corregimiento (third-level administrative division). Further details regarding ENSPA are described on its website in the Spanish language [23]. For the present study, we included participants living in the provinces of Panama and Colon whose age was between 30 and 75 years, (n = 4,653) (Fig 1).

Both studies were conducted by the Gorgas Memorial Institute of Health Research, the Ministry of Health of Panama (MoH), and the INEC (Spanish language for "National Institute of Statistics and Census"). The sampling design was calculated using population projections from the two latest National Censuses (2000 for the PREFREC (2010) study and 2010 for the ENSPA (2019) study) for both studies when the data collection took place [24].

Data collection

Participants answered a questionnaire in Spanish through in-person interviews, which collected information on demographics, socioeconomic, medical and family history, lifestyle, and anthropometric measurements (including blood pressure). Weight, height, and blood pressure (BP) were undertaken using standardized instruments.

Outcome assessment

Outcome variables were assessed using self-reported medical history of hypertension and BP measurements.

Participants’ self-reported medical history was based on the question (presented in both surveys): have you ever been told by a physician that you have hypertension, also called high blood pressure? (The fragment, also called high blood pressure was solely present in the PREFREC study).

Participants’ BP measurements were considered to be the average of the second and third BP measurement. In the PREFREC (2010) study, BP measurements have been previously described [25]. In brief, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured three times in a sitting position after a minimum of five minutes of rest and recorded with a five-minute interval between each other, using an electronic device (American Diagnostic Corporation model 6013). Measurements were performed in the right arm. In the ENSPA (2019) study, following the WHO Stepwise Approach to Surveillance (STEPS) [26], SBP and DBP were measured three times in a sitting position after fifteen minutes of rest and recorded with a three-minute interval between each other, using an electronic device (OMRON model HEM-7120). Measurements were performed in the left arm.

Hypertension was defined as (a) having a self-reported medical history of hypertension or (b) having a mean SBP ≥140 and/or DBP ≥90 mmHg (regardless of their self-reported medical history of hypertension) or (c) a combination of both [27]. This sample constituted our study population for estimating the prevalence of hypertension unawareness. Unawareness of hypertension was defined as having a mean SBP ≥140 and/or DBP ≥90 mmHg and no self-reported medical history of hypertension. We excluded participants who denied self-reported medical history of hypertension and were also missing the second and/or third BP measurement(s) (n = 120 in the PREFREC study; n = 487 in the ENSPA study) (Fig 1).

Exposure variables

Demographic and socioeconomic characteristics included age (years), sex (men/women), ethnicity (Afro-Panamanian, Caucasian, Mestizo, Indigenous, or others), region (urban, non-urban), education (no/primary education, secondary education, and higher education), and monthly family income (MFI) (<250 Panamanian balboas (PAB), 250–999 PAB, and ≥1,000 PAB).

A wide range of established risk factors for hypertension was evaluated. Smoking tobacco consumption was classified into current smokers, ex-smoker, or non-smokers. Body mass index (BMI) was obtained by dividing the participant’s weight measurement in kilograms by the square of their height in meters squared and categorized into underweight (<18.5 kg/m²), normal weight (18.5 to 24.9 kg/m²), overweight (25 to 29.9 kg/m²), and obesity (≥30 kg/m²) [28]. Physical inactivity was assessed in the PREFREC (2010) study when they reported doing less than 150 minutes of certain activities per week. In the ENSPA (2019) study, physical inactivity among study participants was defined if the metabolic equivalents per minute (METs-minute) per week calculated using the GPAQ (General Practice Assessment of Quality) were less than 600 [29]. Family history of hypertension was recorded when first- and/or second-degree relatives were reported to have the condition. Self-reported medical history of diabetes was defined if the participant answered positively to the question, have you been told by a physician that you have diabetes?

Healthcare-related factors like BP assessment in the year before study enrollment (assessed in both studies) and health check-up in the year before study enrollment (assessed in the ENSPA (2019) study) were evaluated. The S1 Table shows the definitions of the exposure variables used in the present study.

Statistical analysis

Continuous variables are presented as median and interquartile range (IQR). Categorical variables are presented as percentages with the corresponding 95% confidence intervals (CIs). Both categorical and continuous variables assessed the total population of the provinces of Panama and Colon when the respective study took place using the expansion weights calculated and provided by the INEC. Results are then presented weighted (N). Missing data were excluded from the analysis.

To examine the association of each exposure variable with hypertension unawareness, its respective odds ratios (OR) with their 95% CIs were calculated by applying unconditional logistic regression models. Crude and multivariable logistic regression models were performed to address potential confounding bias. The first adjusted model (model A) accounted for the demographic factors (sex, age, and ethnicity), established risk factors for hypertension (tobacco consumption, BMI categories, physical inactivity, family history of hypertension, and self-reported medical history of diabetes), and BP assessment in the year before study enrollment. Then, in a second model (model B) the socioeconomic determinants (region, MFI, and education) were added to model A. In addition, we included in the (S2 and S3 Tables) crude and multivariable logistic regression models using merged data from both studies (both PREFREC and ENSPA) in which the prevalence of hypertension (S2 Table) and the prevalence of hypertension unawareness (S3 Table) were the outcome variables, respectively, with the aforementioned predictor variables together with the study period as an additional predictor (being PREFREC the reference level).

Prevalence tables are presented stratified by sex. Data were analyzed using SPSS V.20.0 software and R program version 4.0.0 with the survey package version 4.0.

Ethical statement

Studies were approved by the National Bioethics Committee of the Gorgas Memorial Institute of Health Studies and conducted following the Declaration of Helsinki. All participants signed an informed consent to be enrolled in the study.

Results

Demographic and socioeconomic characteristics

Overall, the predominant ethnicity was mestizo (men: 60.4% in PREFREC (2010) and 47.5% in ENSPA (2019), women: 60.7% in PREFREC (2010) and 49.4% in ENSPA (2019)), and most individuals lived in an urban region (Table 1). According to the education levels, fewer participants reported having no education/primary education in ENSPA (2019), compared to PREFREC (2010) (26.8% vs 20.3% for men; 32.1% vs 23.0% for women). In contrast, more participants reported having secondary education (an increase of 13.9 percentage points for men and 8.3 percentage points for women). Fewer men reported having higher education (28.7% vs 21.4%), while a slight increase was present in women (21.3% vs 22.1%) (Table 1). Regarding MFI, fewer women reported MFI of <250 PAB in the ENSPA (2019), compared to the PREFREC (2010) (31.7% vs 23.9%), whereas MFI of 250–999 PAB and MFI of ≥1,000 PAB increased by 8.3% and 2.4%, respectively. Among men, MFI of <250 PAB remained unchanged (20.0%), MFI of 250–999 PAB decreased by 5.7%, and MFI of ≥1,000 PAB increased by 6.0% (Table 1).

Table 1. Distribution of baseline characteristics in individuals aged between 30 and 75 years by sex and the study year (PREFREC 2010 and ENSPA 2019) in the provinces of Panama and Colon.

	Men		Women
Demographic and socioeconomic characteristics	PREFREC 2010	ENSPA 2019	PREFREC 2010	ENSPA 2019
Demographic and socioeconomic characteristics	(N = 255 481)	(N = 666 752)	(N = 531 325)	(N = 677 584)
Age, years
Median (IQR)	52.0 (40.0–62.0)	50.0 (40.0–61.0)	48.0 (39.0–58.0)	48.0 (38.0–60.0)
Ethnicity–% (95% CI)
Mestizo	60.4 (54.7–65.9)	47.5 (42.4–51.6)	60.7 (57.0–64.2)	49.4 (46.9–51.8)
Afro-Panamanian	17.9 (13.9–22.6)	24.8 (21.2–28.9)	20.4 (17.7–23.3)	20.5 (18.6–22.5)
Caucasian	12.7 (9.3–17.0)	21.2 (17.9–24.9)	14.0 (11.5–16.8)	21.1 (19.2–23.3)
Indigenous	2.8 (1.3–6.2)	4.3 (3.0–6.0)	3.1 (2.0–4.8)	5.3 (4.2–6.7)
Others	6.3 (3.9–10.0)	2.2 (1.3–3.7)	1.9 (1.1–3.5)	3.6 (2.8–4.8)
Region–% (95% CI)
Urban	85.3 (82.9–87.4)	79.5 (76.5–82.2)	87.6 (86.2–88.9)	82.0 (80.3–83.5)
Non-urban	14.7 (12.6–17.1)	20.5 (17.8–23.5)	12.4 (11.1–13.8)	18.0 (16.5–19.7)
Education–% (95% CI)
No/primary education	26.8 (22.4–31.8)	20.3 (17.4–23.4)	32.1 (28.7–35.7)	23.0 (21.0–25.0)
Secondary education	44.5 (38.8–50.2)	58.4 (54.2–62.4)	46.7 (42.9–50.5)	55.0 (52.5–57.4)
Higher education	28.7 (23.6–34.5)	21.4 (18.0–25.1)	21.3 (18.4–24.5)	22.1 (20.1–24.2)
Monthly Family Income–% (95% CI)
<250 PAB	19.3 (15.9–23.8)	19.2 (16.3–22.5)	31.7 (28.4–35.3)	23.9 (22.0–26.0)
250–999 PAB	64.3 (58.8–69.3)	58.6 (54.4–62.6)	55.5 (51.7–59.3)	61.0 (58.6–63.4)
≥1,000 PAB	16.2 (12.4–20.8)	22.2 (18.8–26.0)	12.7 (10.3–15.7)	15.1 (13.3–17.0)
Established risk factors for hypertension–% (95% CI)
Tobacco consumption
Current smoker	11.7 (8.6–15.8)	7.6 (5.7–10.0)	3.9 (2.6–5.7)	2.4 (1.7–3.3)
Ex-smoker	47.0 (41.3–52.7)	4.2 (2.9–6.2)	15.7 (13.1–18.6)	1.0 (0.6–1.6)
Non-smoker	41.3 (35.8–47.0)	88.2 (85.3–90.6)	80.5 (77.3–83.3)	96.6 (95.6–97.4)
BMI categories¹
Underweight	1.4 (0.5–3.7)	1.4 (0.7–2.6)	1.1 (0.6–1.9)	1.5 (1.0 – 2.3)
Normal weight	40.7 (35.2–46.5)	23.6 (20.2–27.4)	26.3 (23.1–29.7)	18.3 (16.4–20.4)
Overweight	32.7 (27.7–38.1)	41.1 (36.8–45.6)	37.3 (33.7–41.1)	31.1 (28.8–33.5)
Obesity	25.2 (20.5–30.5)	33.8 (29.7–38.2)	35.3 (31.8–39.0)	49.1 (46.5–51.7)
Physical inactivity	20.4 (16.4–25.1)	52.5 (48.2–56.7)	12.3 (10.1–15.0)	66.9 (64.4–69.3)
Family history of hypertension	64.0 (58.2–69.4)	37.1 (33.2–41.1)	74.4 (71.0–77.5)	46.0 (43.5–48.4)
Self-reported medical history of diabetes	10.1 (7.3–13.8)	4.9 (3.5–6.8)	9.5 (7.5–11.9)	8.6 (7.3–10.2)
Hypertension–% (95% CI)
Yes	51.6 (45.7–57.5)	46.5 (42.1–51.0)	46.0 (42.1–49.9)	42.1 (39.6–44.7)
Hypertension unawareness²	32.3 (25.4–40.1)	52.3 (45.9–58.6)	16.1 (12.6–20.4)	33.3 (29.8–37.0)
Healthcare-related factors–% (95% CI)
BP assessment in the year before study enrollment	73.9 (68.7–78.5)	34.9 (31.0–39.0)	79.8 (76.6–82.7)	40.2 (37.8–42.6)
At least a health check-up in the year before study enrollment	NA	57.2 (53.0–61.2)	NA	68.5 (66.2–70.8)
BP assessment³	NA	48.2 (42.7–53.7)	NA	49.6 (46.7–52.6)

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N = weighted study population. IQR = interquartile range. PAB = Panamanian balboa. BP = blood pressure. NA = not applicable. BMI = body mass index. MFI = monthly family income. SBP = systolic blood pressure. DBP = diastolic blood pressure. % = percentages. CIs = confidence intervals.

¹According to World Health Organization (WHO).

²SBP/DBP ≥140/90 mmHg and no self-reported medical history of hypertension.

³BP assessment among those with at least a health check-up in the year before study enrollment. Missing data on the PREFREC 2010 study: BP measurements (N = 83 177; 11%), MFI (N = 8 675; 7.8%). Missing data on the ENSPA 2019 study: BP measurements (N = 167 088; 12%), MFI (N = 65 961; 5%), physical inactivity (N = 259 434; 19%), BMI (N = 164 047; 12%).

Established risk factors for hypertension

The prevalence of current and ex-smokers in PREFREC (2010) was 11.7% and 47.0% in men, respectively, and among women 3.9% and 15.7%, respectively. In the ENSPA (2019) study, the prevalence of current smokers was 7.6% for men and 2.4% for women, whereas the prevalence of ex-smokers was 4.2% in men and 1.0% in women. Regarding BMI, we found that the prevalence of overweight in men was 32.7% (95% CI: 27.7–38.1) in PREFREC (2010) and 41.1% (95% CI: 36.8–45.6) in ENSPA (2019). In contrast, among women, obesity was present in 35.3% (95% CI: 31.8–39.0) of participants in PREFREC (2010) and in 49.1% (95% CI: 46.5–51.7) in ENSPA (2019). Physical inactivity in PREFREC (2010) was present in 20.4% and 12.3% of men and women, respectively, and in ENSPA (2019), it accounted for 52.5% of men and 66.9% of women (Table 1).

Hypertension

In the PREFREC (2010), the prevalence of hypertension and hypertension unawareness in men were 51.6% (95% CI: 45.7–57.5) and 32.3% (95% CI: 25.4–40.1), respectively, and in women 46.0% (95% CI: 42.1–49.9) and 16.1% (95% CI: 12.6–20.4), respectively (Table 1 and Fig 2). In the ENSPA (2019), the prevalence of hypertension and hypertension unawareness in men were 46.5% (95% CI: 42.1–51.0) and 52.3% (95% CI: 45.9–58.6), respectively, and in women 42.1% (95% CI: 39.6–44.7) and 33.3% (95% CI: 29.8–37.0), respectively (Table 1 and Fig 2). As shown in the S2 and S3 Tables, after merging all data from both studies and adjusting for all other variables, there was a 21% borderline decrease in the odds of having hypertension in the ENSPA (2019) study compared to the PREFREC study (ENSPA OR: 0.79; 95% CI: 0.62–1.02), but a 70% increase in the odds of being unaware (ENSPA OR: 1.70; 95% CI: 1.15–2.51), respectively.

Fig 2 — BP = blood pressure. The PREFREC (2010) study: men (n = 834 [N = 255 481]), women (n = 1 899 [N = 531 326]). The ENSPA (2019) study: men (n = 1 317 [N = 666 751]), women (n = 3 334 [N = 677 584]).

Healthcare-related factors

We found that fewer men reported having a BP assessment in the year before study enrollment in the ENSPA (2019) study compared to the PREFREC (2010) study (73.9% [95% CI: 68.7–78.5] in PREFREC (2010) vs 34.9% [95% CI: 31.0–39.0] in ENSPA (2019)). Similarly, women displayed a decrease from 79.8% (95% CI: 76.6–82.7) in PREFREC (2010) to 40.2% (95% CI: 37.8–42.6) in ENSPA (2019) (Fig 3). Additionally, in ENSPA (2019), 57.2% of men and 68.5% of women had a health check-up in the year before study enrollment. Amongst them, 48.2% of men and 49.6% of women reported having their BP assessed the year before study enrollment.

Fig 3 — BP = blood pressure. The PREFREC (2010) study: men (n = 834 [N = 255 481]), women (n = 1 899 [N = 531 326]). The ENSPA (2019) study: men (n = 1 317 [N = 666 751]), women (n = 3 334 [N = 677 584]).

Risk factors associated with unawareness of hypertension

Table 2 shows the crude and adjusted analysis for the associations between each exposure variable and hypertension unawareness, stratified by the study year. Regarding demographic factors, men were more likely to be unaware, compared with women, in the PREFREC (2010) (OR: 2.31; 95% CI: 1.29–4.12) and in the ENSPA (2019) (OR: 2.09; 95% CI: 1.37–3.17) (model B in Table 2). Whereas individuals aged <50 years were more likely to be unaware, compared with those aged ≥50 years, in PREFREC (2010) (OR: 1.84; 95% CI: 1.06–3.17) and in ENSPA (2019) (OR: 2.43; 95% CI: 1.57–3.76) (model B in Table 2). No association with ethnicity was found (S4 and S5 Tables).

Table 2. Crude and adjusted logistic regression analysis of hypertension unawareness (SBP/DBP ≥140/90 mmHg without a self-reported medical history of hypertension) in hypertensive individuals aged between 30 and 75 years by the study year (PREFREC 2010 and ENSPA 2019) in the provinces of Panama and Colon.

Odds ratio (OR) and 95% confidence intervals (CIs).

	PREFREC 2010			ENSPA 2019
	Crude analysis OR (95% CI)	Adjusted analysis		Crude analysis	Adjusted analysis
	Crude analysis OR (95% CI)	OR (95% CI)		OR (95% CI)	OR (95% CI)
		Model A	Model B		Model A	Model B
Demographic Factors
Sex
Women (reference)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)
Men	2.49	2.30	2.31	2.19	2.13	2.09
Men	(1.60–3.89)	(1.33–3.96)	(1.29–4.12)	(1.62–2.97)	(1.42–3.20)	(1.37–3.17)
Age group
≥50 years (reference)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)
<50 years	1.69	1.68	1.84	2.22	2.29	2.43
<50 years	(1.07–2.65)	(1.01–2.80)	(1.06–3.17)	(1.60–3.09)	(1.54–3.40)	(1.57–3.76)
Established risk factors for hypertension
Tabaco consumption
Non-smoker	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)
Ex-smoker	1.28	0.90	0.81	0.89	1.34	1.24
Ex-smoker	(0.78–2.10)	(0.50–1.62)	(0.45–1.47)	(0.37–2.12)	(0.38–4.72)	(0.33–4.68)
Current smoker	1.64	0.56	0.56	1.53	0.94	0.73
Current smoker	(0.66–4.10)	(0.16–1.95)	(0.16–1.97)	(0.68–3.42)	(0.34–2.58)	(0.27–1.98)
Body mass index categories¹
Underweight	3.38	2.62	2.36	0.69	0.89	0.88
Underweight	(0.88–12.98)	(0.52–13.11)	(0.46–12.01)	(0.11–4.49)	(0.24–3.35)	(0.24–3.32)
Normal weight	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)
Overweight	0.70	0.64	0.63	0.96	1.09	1.16
Overweight	(0.41–1.18)	(0.37–1.09)	(0.36–1.10)	(0.60–1.54)	(0.65–1.85)	(0.68–1.98)
Obesity	0.45	0.45	0.48	0.60	0.79	0.76
Obesity	(0.25–0.80)	(0.24–0.84)	(0.25–0.91)	(0.39–0.94)	(0.47–1.34)	(0.44–1.29)
Physical inactivity
No (reference)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)
Yes	0.54	0.47	0.43	0.95	0.92	0.88
Yes	(0.29–0.99)	(0.25–0.88)	(0.22–0.84)	(0.68–1.33)	(0.61–1.39)	(0.57–1.36)
Family history of hypertension
No (reference)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)
Yes	0.51	0.60	0.62	0.17	0.18	0.18
Yes	(0.31–0.83)	(0.35–1.00)	(0.36–1.06)	(0.11–0.24)	(0.12–0.27)	(0.11–0.27)
Self-reported medical history of diabetes
No (reference)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)
Yes	0.85	1.00	1.09	0.31	0.57	0.55
Yes	(0.45–1.60)	(0.51–2.00)	(0.54–2.19)	(0.18–0.54)	(0.32–1.02)	(0.31–1.00)
BP assessment in the year before study enrollment
No (reference)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)	1 (ref)
Yes	0.31	0.48	0.46	0.25	0.35	0.35
Yes	(0.18–0.54)	(0.27–0.86)	(0.25–0.87)	(0.18–0.36)	(0.23–0.52)	(0.23–0.53)
Socioeconomic Factors
Region
Urban (reference)	1 (ref)		1 (ref)	1 (ref)		1 (ref)
Non-urban	1.41		0.94	1.78		1.63
Non-urban	(0.99–2.01)		(0.60–1.47)	(1.27–2.50)		(1.03–2.60)
Education
Higher education	1 (ref)		1 (ref)	1 (ref)		1 (ref)
Secondary education	0.79		1.39	1.49		1.42
Secondary education	(0.43–1.46)		(0.74–2.64)	(0.94–2.37)		(0.71–2.81)
No/primary education	1.19		2.27	1.13		0.95
No/primary education	(0.65–2.18)		(1.06–4.86)	(0.69–1.85)		(0.45–1.99)
Monthly Family Income
≥1,000 PAB	1 (ref)		1 (ref)	1 (ref)		1 (ref)
250–999 PAB	0.90		0.69	1.68		1.39
250–999 PAB	(0.45–1.78)		(0.33–1.48)	(1.08–2.65)		(0.68–2.81)
<250 PAB	0.32		0.62	1.69		1.00
<250 PAB	(0.42–1.70)		(0.26–1.50)	(1.03–2.75)		(0.47–2.10)

Open in a new tab

SBP = systolic blood pressure. DBP = diastolic blood pressure. OR = odds ratio. CIs = confidence intervals. BP = blood pressure. BMI = body mass index. PAB = Panamanian Balboa.

Model A = adjusted by sex, age group, ethnicity, BMI categories, physical inactivity, family history of hypertension, self-reported medical history of diabetes, tobacco consumption, and BP assessment in the year before study enrollment.

Model B = further adjusted by region, education, and monthly family income.

¹According to World Health Organization (WHO).

When considering hypertension risk factors, obesity was associated with lower odds of having hypertension unawareness, compared to a normal weight, in PREFREC (2010) (OR: 0.48; 95% CI: 0.25–0.91), but not in ENSPA (2019) (OR: 0.76; 95% CI: 0.44–1.29) (model B in Table 2). Similarly, physical inactivity was associated with decreased odds of having hypertension unawareness in PREFREC (2010) (OR: 0.43; 95% CI: 0.22–0.84), but not in ENSPA (2019) (OR: 0.88; 95% CI: 0.57–1.36) (model B in Table 2). Family history of hypertension had a borderline inverse association for hypertension unawareness in PREFREC (2010) (OR: 0.62; 95% CI: 0.36–1.06) and an inverse association in ENSPA (2019) (OR: 0.18; 95% CI: 0.11–0.27) (model B in Table 2). No association was found with tobacco consumption regardless of the study year, and self-reported medical history of diabetes had a borderline inverse association with hypertension unawareness in ENSPA (2019) (OR: 0.55; 95% CI: 0.31–1.00) (model B in Table 2).

Furthermore, having a BP assessment in the year before study enrollment was associated with decreased odds of being unaware in PREFREC (2010) (OR: 0.46; 95% CI: 0.25–0.87) and in ENSPA (2019) (OR: 0.35; 95% CI: 0.23–0.53) (model B in Table 2).

When examining the association between socioeconomic factors and unawareness, in PREFREC (2010), higher odds of having hypertension unawareness was found with having no/primary education (OR: 2.27; 95% CI: 1.06–4.86), compared to higher education, and in ENSPA (2019), with living in a non-urban region (OR: 1.63; 95% CI: 1.03–2.60), compared to living in an urban region (model B in Table 2).

Discussion

Our findings indicate a borderline decrease in the odds of having hypertension between the PREFREC (2010) and ENSPA (2019) studies, but an increase in the odds of being unaware of hypertension. Further, there was an increase in the prevalence of overweight and obesity in the provinces of Panama and Colon.

Panama has experienced exceptional economic growth over the past three decades, evidenced by the increase in GDP per capita, which has doubled in the last ten years [12]. This growth, in turn, has produced a rapidly expanding urbanization associated with increased migration from rural to urban areas [30, 31], which has augmented the number of people exposed to lifestyle factors related to hypertension, such as westernized dietary habits, excess sodium in the diet, harmful alcohol consumption, stress, and physical inactivity [32–34]. It is likely that these factors have contributed to the increase in the prevalence of obesity in Panama over the past three decades (from 3.8% in men and 7.6% in women, in 1982, to 16.9% in men and 23.8% in women, in 2008 [35]) and continues to rise as suggested by our study. We also found that more than half of individuals in the ENSPA (2019) study were physically inactive, a higher estimate than that reported in other countries in Latin America and the Caribbean [36].

The aforementioned findings could explain our high estimates of prevalence of hypertension compared with those reported by other countries in the Americas region [7, 9–11, 37–39]. Nevertheless, we found a decrease in the prevalence of hypertension between the PREFREC (2010) and ENSPA (2019) study, as opposed to other countries in the region, such as Peru, that reported an increasing prevalence of hypertension attributed to recent economic growth [10], whereas the prevalence in Brazil [37], Canada [7], and the United States [9] has remained unchanged. In agreement with our study, recent studies have reported a decrease in the prevalence of hypertension despite an increase in obesity [4, 11]. Our results suggest that other risk factors associated with hypertension such as salt intake, smoking, and exposure to dietary fatty acids have improved [4, 11]. For example, in the case of smoking, in 2005, Panama adopted the WHO Framework Convention on Tobacco Control. Since then, two laws were introduced: a law regulating tobacco control in 2008, and a tobacco tax increase in 2009 [40, 41]. Associated with these laws, there has been a decrease in tobacco consumption and a reduction in the incidence of acute myocardial infarction [41]. Likewise, we found an improvement in education levels: an important and well-known determinant of health [15, 32, 39, 42]. Our study suggests that as health determinants, such as education, improve and risk factors for hypertension, such as tobacco consumption, are diminished, the prevalence of hypertension as well as its potential complications are reduced.

Our results showed an increased prevalence of hypertension unawareness across both studies in the provinces of Panama and Colon. Similarly, a significant increase in the prevalence of hypertension unawareness was found in Canada [7], the United States [9], and in Peru [10]. In contrast, recent findings from other studies performed in Chile [11] and Brazil [36], showed either a plateau or a decrease in hypertension unawareness. When global trends in hypertension were examined between 1990 to 2019 in Latin America and the Caribbean, a slight decrease in hypertension unawareness was found until the mid-2000s before flattening [4]. The increase in hypertension unawareness in some countries has been attributed to reduced funding directed to hypertension programs, a fragmented healthcare system, lack of educational programs, and lack of BP screening in the younger population (18–44 years) [7, 9, 10].

Our study identified a decrease in the prevalence of BP assessment in the year before study enrollment between the PREFREC (2010) and ENSPA (2019) study. As expected, BP assessment in the year before study enrollment was a factor strongly associated with decreased odds of having hypertension unawareness in both studies, which is consistent with previous research suggesting that the frequency of BP assessment is related to awareness [4, 9, 43–45]. Furthermore, we found that approximately half of the individuals in the ENSPA (2019) study who participated in health check-ups did not have a BP assessment, pointing to a significant flaw of these health check-ups and a lack of compliance with the national healthcare program standards [21]. Of note, the current national healthcare program states that BP levels should be measured in the right arm at every health check-up in patients 18 years or older.

Several factors were associated with decreased odds of having hypertension unawareness, including female sex, older age (≥50 years), obesity, physical inactivity, family history of hypertension, and BP assessment in the year before study enrollment. Women were less likely to be unaware, compared to men, a finding consistent with a large body of evidence on sex and health-seeking behaviors [39, 43, 45–51]. Older individuals (≥50 years) were less likely to have hypertension unawareness compared to younger individuals (<50 years). This is likely due to a higher healthcare utilization by older individuals, as other studies have suggested [32, 39, 45–49, 51, 52]. Another factor associated with a lower risk of hypertension unawareness was having a family history of hypertension, which is consistent with previous findings [43, 46, 49, 52].

Paradoxically, in the PREFREC (2010) study, obesity and physical inactivity were found to be associated with decreased odds of having hypertension unawareness. One possible explanation may be that these groups have been targeted by screening programs and have more contact with health professional [32, 39, 44, 46–52]. On the other hand, the inverse association with hypertension unawareness was not observed in the ENSPA (2019) study, suggesting a decrease in regular health check-ups or reduced screening in this group of individuals.

Socioeconomic factors related to hypertension unawareness differed across both studies. We found in the PREFREC (2010) study that having no education/primary education and in the ENSPA (2019) study that living in a non-urban region were associated with increased odds of having hypertension unawareness. The lack of association of education and unawareness in the ENSPA (2019) study could be explained by the finding of improved educational levels, when compared to the PREFREC (2010) study. Both of these socioeconomic factors have been previously recognized in many countries [10, 32, 39, 44, 46–48, 51]. However, among Chinese men and women, having a low educational level was associated with a lower risk of being unaware [52]. Additionally, compared to other studies [47, 50], we did not find an association between household income and hypertension unawareness.

Hypertension has emerged as an important risk factor in younger populations (aged 25–49 years) [53]. A previous Panamanian study reported that hypertension was the most common risk factor associated with stroke in young adults [54]. Likewise, a prospective study from China found that having early-onset hypertension (<45 years) increases CVD mortality compared with late-onset hypertension (≥65 years) [55]. Therefore, greater emphasis should be placed on screening the younger population, as stated in our national healthcare program [21].

Our study has several limitations. First, the PREFREC (2010) and ENSPA (2019) are cross-sectional study designs and thus, causality should not be inferred. Second, medical history of hypertension was based on self-reporting and there may have been reporting biases. Moreover, although both studies collected three BP measurements for each participant, these were taken during a single visit (diagnosis requires two or more visits) and in different arms. However, this is a common approach in large-scale epidemiological studies, and because of design and time constrains, measurements in both arms could not be assessed [10, 26, 46, 52, 56]. Third, in the two studies, physical inactivity was assessed with different methodologies, so we were not able to analyze variations across studies. Fourth, we did not perform a temporal analysis of trend over time. Finally, although our study was limited to two Panamanian provinces that contain around 60% of the country’s population, the results cannot be extrapolated to the whole country. Moreover, the provinces of Panama and Colon are predominantly urban, with the province of Colon having the highest concentration of people of Afro-Panamanians, who have a higher risk of hypertension and obesity compared to other ethnic groups in the country [25, 35]. The strength of this study was the large study population as well as the sampling methodology that allowed us to provide robust information.

Conclusions

Although the study found a reduction in the prevalence of hypertension, our results also showed a worrisome increase in hypertension unawareness. These findings may be due, in part, to a weakening of CVD prevention healthcare program, as evidenced by a decrease in BP assessment in the year before study enrollment when one compares the PREFREC (2010) and the ENSPA (2019) studies. In addition, almost half of study participants who reported having had a health check-up in the year prior to the ENSPA (2019) study, denied having had a BP assessment.

Our study points to the need of strengthening the CVD healthcare program implemented in 2014 [21]. Future research aiming to develop interventions to improve early diagnosis and reduce risk factors associated with hypertension is warranted. It is likely that if the finding related to hypertension unawareness is not promptly addressed, we could expect a rebound in the decrease in the prevalence of hypertension and the observed decline in CVD mortality [15, 57].

Supporting information

S1 Table. Definition of exposure variables based on the study year.

(PDF)

Click here for additional data file.^{(127.4KB, pdf)}

S2 Table. Crude and adjusted logistic regression analysis of hypertension prevalence (SBP/DBP ≥140/90 mmHg detected during the study and/or self-reported medical history of hypertension) in participants aged between 30 and 75 years in the provinces of Panama and Colon using merged data from the PREFREC (2010) and ENSPA (2019) studies.

Odds ratio (OR) and 95% confidence intervals (CIs).

(PDF)

Click here for additional data file.^{(152.1KB, pdf)}

S3 Table. Crude and adjusted logistic regression analysis of hypertension unawareness (SBP/DBP ≥140/90 mmHg without a self-reported medical history of hypertension) in hypertensive participants aged between 30 and 75 years in the provinces of Panama and Colon using merged data from the PREFREC (2010) and ENSPA (2019) studies.

Odds ratio (OR) and 95% confidence intervals (CIs).

(PDF)

Click here for additional data file.^{(152.5KB, pdf)}

S4 Table. Crude and adjusted logistic regression analysis of hypertension unawareness (SBP/DBP ≥140/90 mmHg without a self-reported medical history of hypertension) in hypertensive participants aged between 30 and 75 years in the PREFREC study in the provinces of Panama and Colon.

Odds ratio (OR) and 95% confidence intervals (CIs).

(PDF)

Click here for additional data file.^{(162.1KB, pdf)}

S5 Table. Crude and adjusted logistic regression analysis of hypertension unawareness (SBP/DBP ≥140/90 mmHg without a self-reported medical history of hypertension) in hypertensive participants aged between 30 and 75 years in the ENSPA study in the provinces of Panama and Colon.

Odds ratio (OR) and 95% confidence intervals (CIs).

(PDF)

Click here for additional data file.^{(162.1KB, pdf)}

Acknowledgments

The authors would like to thank the participants and collaborators of both studies (the PREFREC and ENSPA studies), as well as the help of Cecilio Niño with the use of statistical software (SPSS) and Emmanuel Ureña with the support in socioeconomic analysis. IMV and HQ belong to the SNI (Spanish language for "National Research System, SENACYT").

Data Availability

The datasets used and analyzed in this study contain potentially identifying information and sensitive information that is protected via Law 89/2019 as well as a mandate from the Ethics Committee. They are available on request via email to Planning directorate of the Ministry of Health at cnino@gorgas.gob.pa.

Funding Statement

This study was supported by the Ministry of Health of Panama, which provided resources from the selective excise tax on cigarettes and other tobacco products. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There was no additional external funding received for this study.

References

1.World Health Organization. Global Status Report on noncommunicable diseases. 2014. [cited 10 June 2021]. Available from: http://apps.who.int/iris/bitstream/handle/10665/148114/9789241564854_eng.pdf?sequence=1 [Google Scholar]
2.Pan American Health Organization. Annual Report of the Director of the Pan American Sanitary Bureau 2020. Saving Lives and Improving Health and Well-Being. Washington, DC: PAHO. 2020. [Google Scholar]
3.Mills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nat Rev Nephrol 2020; 16: 223–37. doi: 10.1038/s41581-019-0244-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Zhou B, Carrillo-Larco RM, Danaei G, Riley LM, Paciorek CJ, Stevens GA, et al. Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. Lancet 2021. doi: 10.1016/S0140-6736(21)01330-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Krist AH, Davidson KW, Mangione CM, Cabana M, Caughey AB, Davis EM, et al. US Preventive Services Task Force. Screening for Hypertension in Adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA 2021; 325: 1650–56. [DOI] [PubMed] [Google Scholar]
6.Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global Disparities of Hypertension Prevalence and Control: A Systematic Analysis of Population-Based Studies From 90 Countries. Circulation 2016; 134: 441–50. doi: 10.1161/CIRCULATIONAHA.115.018912 [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Leung AA, Williams JVA, McAlister FA, Campbell NRC, Padwal RS. Worsening Hypertension Awareness, Treatment, and Control Rates in Canadian Women Between 2007 and 2017. Can J Cardiol 2020; 36: 732–739. doi: 10.1016/j.cjca.2020.02.092 [DOI] [PubMed] [Google Scholar]
8.Zhou B, Danaei G, Stevens GA, Bixby H, Taddei C, Carrillo-Larco RM, et al. Long-term and recent trends in hypertension awareness, treatment, and control in 12 high-income countries: an analysis of 123 nationally representative surveys. Lancet 2019; 394: 639–51. doi: 10.1016/S0140-6736(19)31145-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB, et al. Trends in Blood Pressure Control Among US Adults with Hypertension, 1999–2000 to 2017–2018. JAMA 2020; 324: 1190–1200. doi: 10.1001/jama.2020.14545 [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Villarreal-Zegarra D, Carrillo-Larco RM, Bernabe-Ortiz A. Short-term trends in the prevalence, awareness, treatment, and control of arterial hypertension in Peru. J Hum Hypertens 2021; 35: 462–71. doi: 10.1038/s41371-020-0361-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Passi-Solar Á, Margozzini P, Mindell JS, Ruiz M, Valencia-Hernandez CA, Scholes S. Hypertension care cascade in Chile: a serial cross-sectional study of national health surveys 2003-2010-2017. BMC Public Health 2020; 20:1397. doi: 10.1186/s12889-020-09483-x [DOI] [PMC free article] [PubMed] [Google Scholar]
12.The World Bank website. Panama Data. 2019. [cited 26 July 2021]. Available from: https://data.worldbank.org/country/PA [Google Scholar]
13.International Monetary Fund website. Report for Selected Countries and Subjects: October 2019 [cited 13 July 2021]. Available from: https://www.imf.org/en/Publications/WEO/weo-database/2019/October/weo-report?c=311,213,314,313,316,339,218,223,228,233,238,321,243,248,253,328,258,336,263,268,343,273,278,283,288,293,361,362,364,366,369,298,299,&s=NGDPRPPPPC,NGDPDPC,&sy=2010&ey=2019&ssm=0&scsm=1&scc=0&ssd=1&ssc=0&sic=0&sort=country&ds=.&br=1
14.The World Bank website. Gini Index (World Bank estimate)–Panama. 2019. [cited 18 July 2021]. Available from: https://data.worldbank.org/indicator/SI.POV.GINI?locations=PA [Google Scholar]
15.Quiel L, Moreno Velásquez I, Gómez B, Motta J, Herrera-Ballesteros V. Social determinants and cardiovascular disease mortality in Panama, 2012–2016. BMC Public Health 2019; 19:199. doi: 10.1186/s12889-019-6508-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
16.Castro F, Zúñiga J, Higuera G, Carrión Donderis M, Gómez B, Motta J. Indigenous Ethnicity and Low Maternal Education Are Associated with Delayed Diagnosis and Mortality in Infants with Congenital Heart Defects in Panama. PLOS ONE 2016; 11: e0163168. doi: 10.1371/journal.pone.0163168 [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Castro F, Shahal D, Tarajia M, et al. Baseline characteristics, survival and direct costs associated to treatment of gastric cancer patients at the National Oncology Institute of Panama from 2012 to 2015: a hospital-based observational study. BMJ Open 2017; 7:e017266. doi: 10.1136/bmjopen-2017-017266 [DOI] [PMC free article] [PubMed] [Google Scholar]
18.Pan American Health Organization. Health in the Americas+, 2017 Edition. Summary: Regional Outlook and Country Profiles. Washington, DC: PAHO. 2017. [Google Scholar]
19.The Gorgas Memorial Institute of Health Studies website. Summary sheet of non-communicable diseases. 2019. [cited 20 July 2021]. Available from: http://www.gorgas.gob.pa/SIGENSPA/documentos/5.%20Factsheet/HOJA%20RESUMEN_ENT.pdf [Google Scholar]
20.National Institute of Statistics and Census website. Deaths and mortality rate of the main causes of death in the Republic of Panama. 2019. [cited 27 May 2021]. Available from: https://inec.gob.pa/archivos/P00140176420210302150121Cuadro%2013.pdf [Google Scholar]
21.Panamanian Ministry of Health. Technical-Administrative Standards: Adult and Elderly Health Programs. 2018. [cited 5 May 2021]. Available from: https://www.educacioninterprofesional.org/sites/default/files/fulltext/2018/2018_pan_norma_adulto_adulto_mayor.pdf [Google Scholar]
22.Moreno Velásquez I, Castro F, Gómez B, Cuero C, Motta J. Chronic Kidney Disease in Panama: Results from the PREFREC Study and National Mortality Trends. Kidney Int Rep 2017; 2: 1032–41. doi: 10.1016/j.ekir.2017.05.016 [DOI] [PMC free article] [PubMed] [Google Scholar]
23.The Gorgas Memorial Institute of Health Studies website. Interactive Geographic Information System of the National Health Survey of Panama. 2019. [cited 26 July 2021]. Available from: http://gorgas.gob.pa/SIGENSPA/Inicio.htm [Google Scholar]
24.National Institute of Statistics and Census. Territorial Distribution and Internal Migration in Panama: Census 2010. [cited 10 July 2021]. Available from: https://www.inec.gob.pa/archivos/P0705547520200925152431Distribución%20Territorial%20y%20Migración%20Interna%20en%20Panamá-Censo2010_F.pdf [Google Scholar]
25.Mc Donald Posso AJ, Motta Borrel JA, Fontes F, Cruz Gonzalez CE, Pachón Burgos AA, Cumbrera Ortega A. High Blood Pressure in Panama: Prevalence, Sociodemographic and Biologic Profile, Treatment, and Control (STROBE). Medicine (Baltimore) 2014; 93: e101. [DOI] [PMC free article] [PubMed] [Google Scholar]
26.World Health Organization. The WHO STEPwise approach to noncommunicable disease risk factor surveillance. WHO STEPS Surveillance Manual; 2017. pp. 184 [cited 9 July 2021]. Available from: https://www.who.int/ncds/surveillance/steps/STEPS_Manual.pdf [Google Scholar]
27.Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension 2020; 75: 1334–57. [DOI] [PubMed] [Google Scholar]
28.Harvard T.H. Chan website. Obesity Prevention Source: Why Use BMI? [cited 27 July 2021]. Available from: https://www.hsph.harvard.edu/obesity-prevention-source/obesity-definition/obesity-definition-full-story/
29.World Health Organization. Global Physical Activity Surveillance: Analysis Guide [cited 9 July 2021]. Available from: https://www.who.int/ncds/surveillance/steps/resources/GPAQ_Analysis_Guide.pdf
30.United Nations Development Programme website. Panama in brief. 2021. [cited 12 August 2021]. Available from: https://www.pa.undp.org/content/panama/es/home/countryinfo/#Econom%C3%ADa [Google Scholar]
31.Pittí A, Gaudin Y, Hess S. Characterization of rural areas in Panama based on national statistics: social, economic and demographic approach. Mexico City: Economic Commission for Latin America and the Caribbean; 2021. 48 p. [Google Scholar]
32.Li J, Shi L, Li S, Xu L, Qin W, Wang H. Urban-rural disparities in hypertension prevalence, detection, and medication use among Chinese Adults from 1993 to 2011. Int J Equity Health 2017; 16: 50. doi: 10.1186/s12939-017-0545-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet 2012; 380: 611–9. doi: 10.1016/S0140-6736(12)60861-7 [DOI] [PubMed] [Google Scholar]
34.Ibrahim MM. Hypertension in Developing Countries: A Major Challenge for the Future. Curr Hypertens Rep 2018; 20: 38. doi: 10.1007/s11906-018-0839-1 [DOI] [PubMed] [Google Scholar]
35.Sasson M, Lee M, Jan C, Fontes F, Motta J. Prevalence and Associated Factors of Obesity among Panamanian Adults. 1982–2010. PLoS ONE 2014; 9: e91689. doi: 10.1371/journal.pone.0091689 [DOI] [PMC free article] [PubMed] [Google Scholar]
36.Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants. Lancet Glob Health 2018; 6: e1077–86. doi: 10.1016/S2214-109X(18)30357-7 [DOI] [PubMed] [Google Scholar]
37.Souza NP de, Cesse EÂP, Souza WV de, Fontbonne A, Carvalho Barreto MNS de, Le Goff M, et al. Temporal variation in prevalence, awareness and control of hypertension in urban and rural areas in Northeast Brazil between 2006 and 2016. Cad Saúde Pública 2020; 36: e00027819. doi: 10.1590/0102-311X00027819 [DOI] [PubMed] [Google Scholar]
38.Campos-Nonato I, Hernández-Barrera L, Pedroza-Tobías A, Medina C, Barquera S. Hypertension in Mexican adults: prevalence, diagnosis and type of treatment. Ensanut MC 2016. Salud Pública México 2018; 60: 233–43. [DOI] [PubMed] [Google Scholar]
39.Geldsetzer P, Manne-Goehler J, Marcus M-E, Ebert C, Zhumadilov Z, Wesseh CS, et al. The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults. Lancet 2019; 394:652–62. [DOI] [PubMed] [Google Scholar]
40.Official Digital Gazette. Law No. 13 –Which Adoption Measures to Control Tobacco and its Harmful Effects on Health. 2008. [cited 11 August 2021]. Available from: https://www.tobaccocontrollaws.org/files/live/Panama/Panama%20-%20Law%2013%20of%202008.pdf [Google Scholar]
41.Jan C, Lee M, Roa R, Herrera V, Politis M, Motta J. The Association of Tobacco Control Policies and the Risk of Acute Myocardial Infarction Using Hospital Admissions Data. PLoS ONE 2014; 9: e88784. doi: 10.1371/journal.pone.0088784 [DOI] [PMC free article] [PubMed] [Google Scholar]
42.Fernandez R.M. (2019) Gross Domestic Product and Health. In: Leal Filho W., Wall T., Azul A., Brandli L., Özuyar P. (eds) Good Health and Well-Being. Encyclopedia of the UN Sustainable Development Goals. Springer, Cham. [Google Scholar]
43.Chau K, Girerd N, Zannad F, Rossignol P, Boivin J-M. Health-related determinants of undiagnosed arterial hypertension: a population-based study. Fam Pract 2019; 36: 276–83. doi: 10.1093/fampra/cmy075 [DOI] [PubMed] [Google Scholar]
44.Zhou J, Fang S. Association between Undiagnosed Hypertension and Health Factors among Middle-Aged and Elderly Chinese Population. Int J Environ Res Public Health 2019; 16: 1214. doi: 10.3390/ijerph16071214 [DOI] [PMC free article] [PubMed] [Google Scholar]
45.Chow CK, Teo KK, Rangarajan S, Islam S, Gupta R, Avezum A, et al. Prevalence, Awareness, Treatment, and Control of Hypertension in Rural and Urban Communities in High-, Middle-, and Low-Income Countries. JAMA 2013; 310: 959–68. doi: 10.1001/jama.2013.184182 [DOI] [PubMed] [Google Scholar]
46.Li T, Song X, Wu J, Li Z, Li L, Yu Y, et al. Awareness of hypertension and related factors in northeastern China: a cross-sectional study. J Hum Hypertens 2020; 34: 43–50. doi: 10.1038/s41371-019-0263-2 [DOI] [PubMed] [Google Scholar]
47.Ahmed S, Tariqujjaman Md, Rahman MdA, Hasan MdZ, Hasan MdM. Inequalities in the prevalence of undiagnosed hypertension among Bangladeshi adults: evidence from a nationwide survey. Int J Equity Health 2019; 18: 33. doi: 10.1186/s12939-019-0930-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
48.Fenech G, Vallée A, Cherfan M, Kab S, Goldberg M, Zins M, et al. Poor Awareness of Hypertension in France: The CONSTANCES Population-Based Study. Am J Hypertens 2020; 33: 543–51. doi: 10.1093/ajh/hpaa018 [DOI] [PubMed] [Google Scholar]
49.Lee H-Y. Socioeconomic Disparities in the Prevalence, Diagnosis, and Control of Hypertension in the Context of a Universal Health Insurance System. J Korean Med Sci 2017; 32: 561–7. doi: 10.3346/jkms.2017.32.4.561 [DOI] [PMC free article] [PubMed] [Google Scholar]
50.Hasan MdM, Tasnim F, Tariqujjaman Md, Ahmed S, Cleary A, Mamun A. Examining the prevalence, correlates and inequalities of undiagnosed hypertension in Nepal: a population-based cross-sectional study. BMJ Open 2020; 10: e037592. doi: 10.1136/bmjopen-2020-037592 [DOI] [PMC free article] [PubMed] [Google Scholar]
51.Park JE, Park J-H, Chang SJ, Lee JH, Kim SY. The Determinants of and Barriers to Awareness and Treatment of Hypertension in the Korean Population. Asia Pac J Public Health 2019; 31: 121–35. doi: 10.1177/1010539518825006 [DOI] [PubMed] [Google Scholar]
52.Santosa A, Zhang Y, Weinehall L, Zhao G, Wang N, Zhao Q, et al. Gender differences and determinants of prevalence, awareness, treatment and control of hypertension among adults in China and Sweden. BMC Public Health 2020; 20: 1763. doi: 10.1186/s12889-020-09862-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
53.Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396: 1204–22. doi: 10.1016/S0140-6736(20)30925-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
54.Romero L, Cigarruista Y, Mackay P, Sánchez R, Serrano A, Vega I, et al. Factores asociados a enfermedades cerebrovasculares en adultos jóvenes. Complejo Hospitalario Metropolitano Dr. Arnulfo Arias Madrid. 2008–2012. Panamá. Revista medico científica 2013; 26; 39–48. [Google Scholar]
55.Wang C, Yuan Y, Zheng M, Pan A, Wang M, Zhao M, et al. Association of Age of Onset of Hypertension with Cardiovascular Diseases and Mortality. J Am Coll Cardiol 2020; 75: 2921–30. doi: 10.1016/j.jacc.2020.04.038 [DOI] [PubMed] [Google Scholar]
56.Bryan S, Saint-Pierre Larose M, Campbell N, Clarke J, Tremblay MS. Resting blood pressure and heart rate measurement in the Canadian Health Measures Survey, cycle 1. Health Rep 2010; 21:71–8. [PubMed] [Google Scholar]
57.Carrión Donderis M, Moreno Velásquez I, Castro F, Zúñiga J, Gómez B, Motta J. Analysis of mortality trends due to cardiovascular diseases in Panama, 2001–2014. Open Heart 2016; 3: e000510. doi: 10.1136/openhrt-2016-000510 [DOI] [PMC free article] [PubMed] [Google Scholar]

PLoS One. doi: 10.1371/journal.pone.0276222.r001

Decision Letter 0

Taeyun Kim

23 Jun 2022

PONE-D-21-34832Prevalence and diagnosis of hypertension and possible risk factors of undiagnosed hypertension among individuals aged 30–75 years from two Panamanian provinces: Results from population-based cross-sectional studies, 2010 and 2019.PLOS ONE

Dear Dr. Del Rio,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Please submit your revised manuscript by Aug 07 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Taeyun Kim

Academic Editor

PLOS ONE

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2. Thank you for stating in your Funding Statement:

“This study was supported by the Ministry of Health of Panama, which provided resources from the selective excise tax on cigarettes and other tobacco products. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

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Reviewers' comments:

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The paper actually does not define prevalence of hypertension and undiagnosed hypertension, and Figure 1 makes the situation more confusing. Those with hypertension are defined as having BP ≥ 140/90 mmHg or self-reported hypertension, where the denominator of the prevalence is presumed to be the entire population. For undiagnosed hypertension, the numerator is those without a self-report of a hypertension but with BP ≥ 140/90 mmHg, but the denominator of prevalence estimate is not clear (i.e., is it the entire population or just the population with a self-report of hypertension). The figure shows that approximately half of the population is excluded from the estimation of uncontrolled hypertension, largely because they are “within self-reported medical history and measured SBP/DBP < 140/90.” This suggests that the prevalence of undiagnosed hypertension is restricted to those with a self-report; however, it makes no sense at all to exclude those with controlled hypertension! That the prevalence of hypertension and undiagnosed hypertension in men is 46.5% and 52.3% suggests again that the prevalence of undiagnosed hypertension is restricted to those with a self-reported hypertension (how else could a larger proportion of participants have undiagnosed hypertension than have hypertension). That these prevalence estimates are shifting denominators is not clearly explained and will confuse many readers (perhaps even including this reviewer?).

In a closely related issue, the numbers in the numerator and denominator of the prevalence estimates are not provided in either the text or tables, and would help the reader understand what is being calculated. Please provide the “n”.

The finding of a decreased prevalence of hypertension but an increased prevalence of undiagnosed hypertension is surprising. The populations in the two waves of the assessments are quite different, for example those in the ENSPA had a quite different distribution of education (with a larger number with secondary education, but fewer in either the low or high educated groups), had higher income, were more likely non-urban, and were more likely obese and physically inactive. The paper would be substantially strengthened to see if the differences in the prevalence of hypertension and undiagnosed hypertension are attributable to these differences (which can be assessed in a multivariable model including all data and estimating the odds of positive prevalence after adjustment for the other factors).

Reviewer #2: thank you for your great data about national prevalance of hypertension.

I don't understand that half of the individuals who participated in health check-ups did not have a BP assessment.

It would be helpful to understand better if you add a description of Panama's health screening system.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

**********

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2022 Nov 28;17(11):e0276222. doi: 10.1371/journal.pone.0276222.r002

Author response to Decision Letter 0

23 Jul 2022

Reply to Reviewer #1:

Thank you for taking the time for reading the submitted manuscript. We apologize that in the previous version of the manuscript, the prevalence calculations for hypertension and for undiagnosed hypertension were not defined. To clarify this issue, we have first, changed the term "undiagnosed hypertension" to "unawareness of hypertension" throughout the revised manuscript.

In our manuscript, hypertension was defined as (a) having a self-reported medical history of hypertension or (b) having a mean SBP ≥140 and/or DBP ≥90 mmHg (regardless of their self-reported medical history of hypertension) or (c) a combination of both. This sample constituted our study population for estimating the prevalence of hypertension unawareness. Unawareness of hypertension was defined as having a mean SBP ≥140 and/or DBP ≥90 mmHg and no self-reported medical history of hypertension.

Following the Reviewer suggestions, we have now:

1. Renamed the title to:

"Prevalence of hypertension and possible risk factors for hypertension unawareness among individuals aged 30–75 years from two Panamanian provinces: Results from population-based cross-sectional studies, 2010 and 2019."

2. Rewrote the Method section between the lines 153 to 159 as follows:

"Hypertension was defined as (a) having a self-reported medical history of hypertension or (b) having a mean SBP ≥140 and/or DBP ≥90 mmHg (regardless of their self-reported medical history of hypertension) or (c) a combination of both [27]. This sample constituted our study population for estimating the prevalence of hypertension unawareness. Unawareness of hypertension was defined as having a mean SBP ≥140 and/or DBP ≥90 mmHg and no self-reported medical history of hypertension. We excluded participants who denied self-reported medical history of hypertension and were also missing the second and/or third BP measurement(s) (n=120 in the PREFREC study; n=487 in the ENSPA study) (Fig 1)."

3. Edited the abstract under the Method section as follows:

"Individuals aged 30–75 years who had (a) self-reported history of hypertension or (b) blood pressure (BP) ≥140/90mmHg or (c) a combination or both were classified as hypertensive. Participants with BP≥140/90mmHg who denied a history of hypertension were considered unaware of the condition."

4. Modified Figure 1; where we wrote down the weighted and unweighted number of participants with hypertension with and without self-reported medical history of hypertension.

We agree with the Reviewer that the point of merging study data further strengthens the manuscript. The authors initially proposed to do so. However, due to different methodologies used in PREFREC 2010 (measuring the blood pressure in the right arm) and ENSPA 2019 (measuring it in the left arm), as we mentioned in Manuscript lines 143–151, we decided not to merge both databases for analysis. According to the literature, BP readings in the right side are higher than left ones.

Instead, our approach was to perform analysis looking for possible risk factors associated with hypertension unawareness in the PREFREC (2010) and ENSPA (2019) study, separately (Table 2); and our point estimates were consistent for many of the factors analyzed. For example, we found similar points estimates for sex (men were more likely to have unawareness) and for blood pressure assessment in the year before study enrollment (protective factor in both studies); whereas age <50 years had a higher point estimate in the ENSPA (2019) study, independent of the same median age in the study populations.

Furthermore, we found that individuals with no/primary education were more likely to be unaware in the PREFREC (2010) study, but no association was found in the ENSPA (2019) study; this finding could be due to fewer individual reporting no/primary education in the ENSPA (2019) study. Interestingly, in the PREFREC (2010) study, we found decreased odds for unawareness in obese and physical inactive individuals, whereas obesity was not associated to our outcome of interest in ENSPA (2019) study. Other possible factors were discussed in more detail in the Discussion section.

Despite the decision not to show the merge data from both studies, for editorial purposes, we performed logistic regression models to assess the change over time of hypertension and its unawareness with the adjustments for the model A and B shown in Manuscript Table 2, using the PREFREC study as the reference. Hypertension decreased 20% between both studies with borderline significance (Model A= OR: 0.82 [95% CI: 0.64–1.04]; Model B= 0.79 [0.62–1.02]). On the other hand, hypertension unawareness increased between 70-80% during the same period (Model A= OR: 1.81 [95% CI: 1.25–2.63]; Model B= 1.70 [1.15–2.51]).

Reply to Reviewer #2:

The authors thank you for your comment. Panama's health screening system is based on national technical-administrative standards published in 2018. According to these standards, blood pressure should be screened on any patient attending a healthcare facility aged 18 years or older. However, we found a lack of adherence to the aforementioned standards, since half of the participants stated that attended an annual check-up denied having blood pressure measures taken in the same period of time.

Following your suggestion, we added the following statement in the revised manuscript (Lines 348 and 349) to make clear the Panamanian standards on hypertension screening:

"Of note, the current national healthcare program states that BP levels should be measured in the right arm at every health check-up in patients 18 years or older."

THE COMPLETE RESPONSE TO REVIEWERS IS ATTACH IN THE "ATTACH FILES" SECTION.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(151.8KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0276222.r003

Decision Letter 1

Taeyun Kim

11 Aug 2022

PONE-D-21-34832R1Prevalence of hypertension and possible risk factors of hypertension unawareness among individuals aged 30–75 years from two Panamanian provinces: Results from population-based cross-sectional studies, 2010 and 2019.PLOS ONE

Dear Dr. Del Rio,

Please submit your revised manuscript by Sep 25 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Taeyun Kim

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: The attempt of the authors to be responsive to the previous suggestions are appreciated, particularly the specificity in providing the definitions for hypertension and unawareness of hypertension. The authors also followed the suggestion to provide multivariable modeling for predictors of hypertension; however, unfortunately this reviewer must not have been clear in the suggestion. The lead sentence of the discussion is “… findings indicate a decline in the prevalence of hypertension between the PREFREC (2010) and 299 ENSPA (2019) studies, and an increase in the prevalence of hypertension unawareness.” The discussion follows that this may be attributable changes in exposures including increases in obesity and changes in urban/rural status. The difference could also be potentially attributed to including a lower education in ENSPA than PREFREC and much higher levels of physical inactivity. The suggestion that was apparently not clear in the previous review was to consider one multivariable model that included the data from both surveys, where the prevalence of hypertension and the prevalence of unawareness of hypertension is predicted with the period/survey as a predictor variable. This would allow the assessment of whether the odds of hypertension, and the odds of unawareness of hypertension, was different between the two surveys after adjustment for the changes in the population characteristics. While the paper is interesting as it stands, this would directly assess if there are differences in the prevalence of hypertension, and in the prevalence of unawareness of hypertension, after adjustment for differences in the individuals in the two studies.

Reviewer #2: I am very happy to be able to do this review. It's a very interesting topic and I think it's a logical conclusion overall.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

PLoS One. 2022 Nov 28;17(11):e0276222. doi: 10.1371/journal.pone.0276222.r004

Author response to Decision Letter 1

16 Aug 2022

Reply to Reviewer #1:

Thank you for the time invested in revising and improving the manuscript.

Following the Reviewer's suggestions, the authors now support the claim that there were changes of hypertension prevalence and its awareness between both studies. We added multivariable logistic regression models of the prevalence of hypertension and hypertension unawareness using merged data from both studies:

In consequence, the following fragment under the statistical analysis heading was added:

"In addition, we included in the Supporting Information (S2 and S3 Tables) crude and multivariable logistic regression models using merged data from both studies (both PREFREC and ENSPA) in which the prevalence of hypertension (S2 Table) and the prevalence of hypertension unawareness (S3 Table) were the outcome variables, respectively, with the aforementioned predictor variables together with the study period as an additional predictor (being PREFREC the reference level)."

The following fragment was added to the results section:

"As shown in the S2 and S3 Tables, after merging all the data from both studies and adjusting for all other variables, there was a 21% borderline decrease in the prevalence of hypertension (ENSPA OR: 0.79 [95% CI: 0.62–1.02], PREFREC as reference), but a 70% increase in hypertension unawareness (ENSPA OR: 1.70 [95% CI: 1.15–2.51], PREFREC as reference), respectively."

Reply to Reviewer #2:

The authors are grateful for your time and interest in publishing the manuscript.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(27.3KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0276222.r005

Decision Letter 2

Taeyun Kim

22 Aug 2022

PONE-D-21-34832R2Prevalence of hypertension and possible risk factors of hypertension unawareness among individuals aged 30–75 years from two Panamanian provinces: Results from population-based cross-sectional studies, 2010 and 2019.PLOS ONE

Dear Dr. Del Rio,

==============================

Please submit your revised manuscript by Oct 06 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Taeyun Kim

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Dear authors.

I appreciate your great efforts in this work.

I believe this study is almost ready for publication.

Please amend your comment regarding the statistical statement about the OR, which was raised from a Reviewer.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

**********

6. Review Comments to the Author

Reviewer #1: Thank you for adding the requested analysis, it does allow for the quantification of whether temporal changes are present. My only additional comment is that you note " ... there was a 21% borderline decrease in the prevalence of hypertension (ENSPA OR: 0.79 [95% CI: 0.62–1.02], PREFREC as reference), but a 70% increase in hypertension unawareness (ENSPA OR: 1.70 [95% CI: 1.15–2.51], PREFREC as reference), respectively." This is an incorrect statement, as logistic regression provides odds ratios (not relative risks), so it needs to state that the odds (not prevelence) of hypertension were 21% lower and 70% higher respectively.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

PLoS One. 2022 Nov 28;17(11):e0276222. doi: 10.1371/journal.pone.0276222.r006

Author response to Decision Letter 2

8 Sep 2022

We again thank you for the time invested in revising and improving the manuscript.

Following the Reviewer's suggestion, the Results and the Discussion sections were rewritten to reflect that logistic regression models represent changes in the adjusted odds between ENSPA and PREFREC studies.

Lines 251 to 255 from the Results section were edited as follows:

"As shown in the S2 and S3 Tables, after merging all data from both studies and adjusting for all other variables, there was a 21% borderline decrease in the odds of having hypertension in the ENSPA (2019) study compared to the PREFREC study (ENSPA OR: 0.79; 95% CI: 0.62–1.02), but a 70% increase in the odds of being unaware (ENSPA OR: 1.70; 95% CI: 1.15–2.51), respectively."

Lines 306 to 307 from the Discussion section were edited as follows:

"Our findings indicate a borderline decrease in the odds of having hypertension between the PREFREC (2010) and ENSPA (2019) studies, but an increase in the odds of being unaware of hypertension."

Journal Requirements:

The Reference list was revised at the request of the journal. All references were complete and correct, except reference 52 which has been updated, but did not alter the analysis of our discussion. Therefore, no changes have been made to the reference list.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(26.9KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0276222.r007

Decision Letter 3

Taeyun Kim

4 Oct 2022

Prevalence of hypertension and possible risk factors of hypertension unawareness among individuals aged 30–75 years from two Panamanian provinces: Results from population-based cross-sectional studies, 2010 and 2019.

PONE-D-21-34832R3

Dear Dr. Del Rio,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Taeyun Kim

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0276222.r008

Acceptance letter

Taeyun Kim

11 Oct 2022

PONE-D-21-34832R3

Dear Dr. Del Rio:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Taeyun Kim

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Table. Definition of exposure variables based on the study year.

(PDF)

Click here for additional data file.^{(127.4KB, pdf)}

Odds ratio (OR) and 95% confidence intervals (CIs).

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Odds ratio (OR) and 95% confidence intervals (CIs).

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Odds ratio (OR) and 95% confidence intervals (CIs).

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Odds ratio (OR) and 95% confidence intervals (CIs).

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Data Availability Statement

[pone.0276222.ref001] 1.World Health Organization. Global Status Report on noncommunicable diseases. 2014. [cited 10 June 2021]. Available from: http://apps.who.int/iris/bitstream/handle/10665/148114/9789241564854_eng.pdf?sequence=1 [Google Scholar]

[pone.0276222.ref002] 2.Pan American Health Organization. Annual Report of the Director of the Pan American Sanitary Bureau 2020. Saving Lives and Improving Health and Well-Being. Washington, DC: PAHO. 2020. [Google Scholar]

[pone.0276222.ref003] 3.Mills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nat Rev Nephrol 2020; 16: 223–37. doi: 10.1038/s41581-019-0244-2 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref004] 4.Zhou B, Carrillo-Larco RM, Danaei G, Riley LM, Paciorek CJ, Stevens GA, et al. Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. Lancet 2021. doi: 10.1016/S0140-6736(21)01330-1 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref005] 5.Krist AH, Davidson KW, Mangione CM, Cabana M, Caughey AB, Davis EM, et al. US Preventive Services Task Force. Screening for Hypertension in Adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA 2021; 325: 1650–56. [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref006] 6.Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global Disparities of Hypertension Prevalence and Control: A Systematic Analysis of Population-Based Studies From 90 Countries. Circulation 2016; 134: 441–50. doi: 10.1161/CIRCULATIONAHA.115.018912 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref007] 7.Leung AA, Williams JVA, McAlister FA, Campbell NRC, Padwal RS. Worsening Hypertension Awareness, Treatment, and Control Rates in Canadian Women Between 2007 and 2017. Can J Cardiol 2020; 36: 732–739. doi: 10.1016/j.cjca.2020.02.092 [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref008] 8.Zhou B, Danaei G, Stevens GA, Bixby H, Taddei C, Carrillo-Larco RM, et al. Long-term and recent trends in hypertension awareness, treatment, and control in 12 high-income countries: an analysis of 123 nationally representative surveys. Lancet 2019; 394: 639–51. doi: 10.1016/S0140-6736(19)31145-6 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref009] 9.Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB, et al. Trends in Blood Pressure Control Among US Adults with Hypertension, 1999–2000 to 2017–2018. JAMA 2020; 324: 1190–1200. doi: 10.1001/jama.2020.14545 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref010] 10.Villarreal-Zegarra D, Carrillo-Larco RM, Bernabe-Ortiz A. Short-term trends in the prevalence, awareness, treatment, and control of arterial hypertension in Peru. J Hum Hypertens 2021; 35: 462–71. doi: 10.1038/s41371-020-0361-1 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref011] 11.Passi-Solar Á, Margozzini P, Mindell JS, Ruiz M, Valencia-Hernandez CA, Scholes S. Hypertension care cascade in Chile: a serial cross-sectional study of national health surveys 2003-2010-2017. BMC Public Health 2020; 20:1397. doi: 10.1186/s12889-020-09483-x [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref012] 12.The World Bank website. Panama Data. 2019. [cited 26 July 2021]. Available from: https://data.worldbank.org/country/PA [Google Scholar]

[pone.0276222.ref013] 13.International Monetary Fund website. Report for Selected Countries and Subjects: October 2019 [cited 13 July 2021]. Available from: https://www.imf.org/en/Publications/WEO/weo-database/2019/October/weo-report?c=311,213,314,313,316,339,218,223,228,233,238,321,243,248,253,328,258,336,263,268,343,273,278,283,288,293,361,362,364,366,369,298,299,&s=NGDPRPPPPC,NGDPDPC,&sy=2010&ey=2019&ssm=0&scsm=1&scc=0&ssd=1&ssc=0&sic=0&sort=country&ds=.&br=1

[pone.0276222.ref014] 14.The World Bank website. Gini Index (World Bank estimate)–Panama. 2019. [cited 18 July 2021]. Available from: https://data.worldbank.org/indicator/SI.POV.GINI?locations=PA [Google Scholar]

[pone.0276222.ref015] 15.Quiel L, Moreno Velásquez I, Gómez B, Motta J, Herrera-Ballesteros V. Social determinants and cardiovascular disease mortality in Panama, 2012–2016. BMC Public Health 2019; 19:199. doi: 10.1186/s12889-019-6508-8 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref016] 16.Castro F, Zúñiga J, Higuera G, Carrión Donderis M, Gómez B, Motta J. Indigenous Ethnicity and Low Maternal Education Are Associated with Delayed Diagnosis and Mortality in Infants with Congenital Heart Defects in Panama. PLOS ONE 2016; 11: e0163168. doi: 10.1371/journal.pone.0163168 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref017] 17.Castro F, Shahal D, Tarajia M, et al. Baseline characteristics, survival and direct costs associated to treatment of gastric cancer patients at the National Oncology Institute of Panama from 2012 to 2015: a hospital-based observational study. BMJ Open 2017; 7:e017266. doi: 10.1136/bmjopen-2017-017266 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref018] 18.Pan American Health Organization. Health in the Americas+, 2017 Edition. Summary: Regional Outlook and Country Profiles. Washington, DC: PAHO. 2017. [Google Scholar]

[pone.0276222.ref019] 19.The Gorgas Memorial Institute of Health Studies website. Summary sheet of non-communicable diseases. 2019. [cited 20 July 2021]. Available from: http://www.gorgas.gob.pa/SIGENSPA/documentos/5.%20Factsheet/HOJA%20RESUMEN_ENT.pdf [Google Scholar]

[pone.0276222.ref020] 20.National Institute of Statistics and Census website. Deaths and mortality rate of the main causes of death in the Republic of Panama. 2019. [cited 27 May 2021]. Available from: https://inec.gob.pa/archivos/P00140176420210302150121Cuadro%2013.pdf [Google Scholar]

[pone.0276222.ref021] 21.Panamanian Ministry of Health. Technical-Administrative Standards: Adult and Elderly Health Programs. 2018. [cited 5 May 2021]. Available from: https://www.educacioninterprofesional.org/sites/default/files/fulltext/2018/2018_pan_norma_adulto_adulto_mayor.pdf [Google Scholar]

[pone.0276222.ref022] 22.Moreno Velásquez I, Castro F, Gómez B, Cuero C, Motta J. Chronic Kidney Disease in Panama: Results from the PREFREC Study and National Mortality Trends. Kidney Int Rep 2017; 2: 1032–41. doi: 10.1016/j.ekir.2017.05.016 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref023] 23.The Gorgas Memorial Institute of Health Studies website. Interactive Geographic Information System of the National Health Survey of Panama. 2019. [cited 26 July 2021]. Available from: http://gorgas.gob.pa/SIGENSPA/Inicio.htm [Google Scholar]

[pone.0276222.ref024] 24.National Institute of Statistics and Census. Territorial Distribution and Internal Migration in Panama: Census 2010. [cited 10 July 2021]. Available from: https://www.inec.gob.pa/archivos/P0705547520200925152431Distribución%20Territorial%20y%20Migración%20Interna%20en%20Panamá-Censo2010_F.pdf [Google Scholar]

[pone.0276222.ref025] 25.Mc Donald Posso AJ, Motta Borrel JA, Fontes F, Cruz Gonzalez CE, Pachón Burgos AA, Cumbrera Ortega A. High Blood Pressure in Panama: Prevalence, Sociodemographic and Biologic Profile, Treatment, and Control (STROBE). Medicine (Baltimore) 2014; 93: e101. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref026] 26.World Health Organization. The WHO STEPwise approach to noncommunicable disease risk factor surveillance. WHO STEPS Surveillance Manual; 2017. pp. 184 [cited 9 July 2021]. Available from: https://www.who.int/ncds/surveillance/steps/STEPS_Manual.pdf [Google Scholar]

[pone.0276222.ref027] 27.Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension 2020; 75: 1334–57. [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref028] 28.Harvard T.H. Chan website. Obesity Prevention Source: Why Use BMI? [cited 27 July 2021]. Available from: https://www.hsph.harvard.edu/obesity-prevention-source/obesity-definition/obesity-definition-full-story/

[pone.0276222.ref029] 29.World Health Organization. Global Physical Activity Surveillance: Analysis Guide [cited 9 July 2021]. Available from: https://www.who.int/ncds/surveillance/steps/resources/GPAQ_Analysis_Guide.pdf

[pone.0276222.ref030] 30.United Nations Development Programme website. Panama in brief. 2021. [cited 12 August 2021]. Available from: https://www.pa.undp.org/content/panama/es/home/countryinfo/#Econom%C3%ADa [Google Scholar]

[pone.0276222.ref031] 31.Pittí A, Gaudin Y, Hess S. Characterization of rural areas in Panama based on national statistics: social, economic and demographic approach. Mexico City: Economic Commission for Latin America and the Caribbean; 2021. 48 p. [Google Scholar]

[pone.0276222.ref032] 32.Li J, Shi L, Li S, Xu L, Qin W, Wang H. Urban-rural disparities in hypertension prevalence, detection, and medication use among Chinese Adults from 1993 to 2011. Int J Equity Health 2017; 16: 50. doi: 10.1186/s12939-017-0545-7 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref033] 33.Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet 2012; 380: 611–9. doi: 10.1016/S0140-6736(12)60861-7 [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref034] 34.Ibrahim MM. Hypertension in Developing Countries: A Major Challenge for the Future. Curr Hypertens Rep 2018; 20: 38. doi: 10.1007/s11906-018-0839-1 [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref035] 35.Sasson M, Lee M, Jan C, Fontes F, Motta J. Prevalence and Associated Factors of Obesity among Panamanian Adults. 1982–2010. PLoS ONE 2014; 9: e91689. doi: 10.1371/journal.pone.0091689 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref036] 36.Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants. Lancet Glob Health 2018; 6: e1077–86. doi: 10.1016/S2214-109X(18)30357-7 [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref037] 37.Souza NP de, Cesse EÂP, Souza WV de, Fontbonne A, Carvalho Barreto MNS de, Le Goff M, et al. Temporal variation in prevalence, awareness and control of hypertension in urban and rural areas in Northeast Brazil between 2006 and 2016. Cad Saúde Pública 2020; 36: e00027819. doi: 10.1590/0102-311X00027819 [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref038] 38.Campos-Nonato I, Hernández-Barrera L, Pedroza-Tobías A, Medina C, Barquera S. Hypertension in Mexican adults: prevalence, diagnosis and type of treatment. Ensanut MC 2016. Salud Pública México 2018; 60: 233–43. [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref039] 39.Geldsetzer P, Manne-Goehler J, Marcus M-E, Ebert C, Zhumadilov Z, Wesseh CS, et al. The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults. Lancet 2019; 394:652–62. [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref040] 40.Official Digital Gazette. Law No. 13 –Which Adoption Measures to Control Tobacco and its Harmful Effects on Health. 2008. [cited 11 August 2021]. Available from: https://www.tobaccocontrollaws.org/files/live/Panama/Panama%20-%20Law%2013%20of%202008.pdf [Google Scholar]

[pone.0276222.ref041] 41.Jan C, Lee M, Roa R, Herrera V, Politis M, Motta J. The Association of Tobacco Control Policies and the Risk of Acute Myocardial Infarction Using Hospital Admissions Data. PLoS ONE 2014; 9: e88784. doi: 10.1371/journal.pone.0088784 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref042] 42.Fernandez R.M. (2019) Gross Domestic Product and Health. In: Leal Filho W., Wall T., Azul A., Brandli L., Özuyar P. (eds) Good Health and Well-Being. Encyclopedia of the UN Sustainable Development Goals. Springer, Cham. [Google Scholar]

[pone.0276222.ref043] 43.Chau K, Girerd N, Zannad F, Rossignol P, Boivin J-M. Health-related determinants of undiagnosed arterial hypertension: a population-based study. Fam Pract 2019; 36: 276–83. doi: 10.1093/fampra/cmy075 [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref044] 44.Zhou J, Fang S. Association between Undiagnosed Hypertension and Health Factors among Middle-Aged and Elderly Chinese Population. Int J Environ Res Public Health 2019; 16: 1214. doi: 10.3390/ijerph16071214 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref045] 45.Chow CK, Teo KK, Rangarajan S, Islam S, Gupta R, Avezum A, et al. Prevalence, Awareness, Treatment, and Control of Hypertension in Rural and Urban Communities in High-, Middle-, and Low-Income Countries. JAMA 2013; 310: 959–68. doi: 10.1001/jama.2013.184182 [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref046] 46.Li T, Song X, Wu J, Li Z, Li L, Yu Y, et al. Awareness of hypertension and related factors in northeastern China: a cross-sectional study. J Hum Hypertens 2020; 34: 43–50. doi: 10.1038/s41371-019-0263-2 [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref047] 47.Ahmed S, Tariqujjaman Md, Rahman MdA, Hasan MdZ, Hasan MdM. Inequalities in the prevalence of undiagnosed hypertension among Bangladeshi adults: evidence from a nationwide survey. Int J Equity Health 2019; 18: 33. doi: 10.1186/s12939-019-0930-5 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref048] 48.Fenech G, Vallée A, Cherfan M, Kab S, Goldberg M, Zins M, et al. Poor Awareness of Hypertension in France: The CONSTANCES Population-Based Study. Am J Hypertens 2020; 33: 543–51. doi: 10.1093/ajh/hpaa018 [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref049] 49.Lee H-Y. Socioeconomic Disparities in the Prevalence, Diagnosis, and Control of Hypertension in the Context of a Universal Health Insurance System. J Korean Med Sci 2017; 32: 561–7. doi: 10.3346/jkms.2017.32.4.561 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref050] 50.Hasan MdM, Tasnim F, Tariqujjaman Md, Ahmed S, Cleary A, Mamun A. Examining the prevalence, correlates and inequalities of undiagnosed hypertension in Nepal: a population-based cross-sectional study. BMJ Open 2020; 10: e037592. doi: 10.1136/bmjopen-2020-037592 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref051] 51.Park JE, Park J-H, Chang SJ, Lee JH, Kim SY. The Determinants of and Barriers to Awareness and Treatment of Hypertension in the Korean Population. Asia Pac J Public Health 2019; 31: 121–35. doi: 10.1177/1010539518825006 [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref052] 52.Santosa A, Zhang Y, Weinehall L, Zhao G, Wang N, Zhao Q, et al. Gender differences and determinants of prevalence, awareness, treatment and control of hypertension among adults in China and Sweden. BMC Public Health 2020; 20: 1763. doi: 10.1186/s12889-020-09862-4 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref053] 53.Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396: 1204–22. doi: 10.1016/S0140-6736(20)30925-9 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0276222.ref054] 54.Romero L, Cigarruista Y, Mackay P, Sánchez R, Serrano A, Vega I, et al. Factores asociados a enfermedades cerebrovasculares en adultos jóvenes. Complejo Hospitalario Metropolitano Dr. Arnulfo Arias Madrid. 2008–2012. Panamá. Revista medico científica 2013; 26; 39–48. [Google Scholar]

[pone.0276222.ref055] 55.Wang C, Yuan Y, Zheng M, Pan A, Wang M, Zhao M, et al. Association of Age of Onset of Hypertension with Cardiovascular Diseases and Mortality. J Am Coll Cardiol 2020; 75: 2921–30. doi: 10.1016/j.jacc.2020.04.038 [DOI] [PubMed] [Google Scholar]

[pone.0276222.ref056] 56.Bryan S, Saint-Pierre Larose M, Campbell N, Clarke J, Tremblay MS. Resting blood pressure and heart rate measurement in the Canadian Health Measures Survey, cycle 1. Health Rep 2010; 21:71–8. [PubMed] [Google Scholar]

[pone.0276222.ref057] 57.Carrión Donderis M, Moreno Velásquez I, Castro F, Zúñiga J, Gómez B, Motta J. Analysis of mortality trends due to cardiovascular diseases in Panama, 2001–2014. Open Heart 2016; 3: e000510. doi: 10.1136/openhrt-2016-000510 [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Prevalence of hypertension and possible risk factors of hypertension unawareness among individuals aged 30–75 years from two Panamanian provinces: Results from population-based cross-sectional studies, 2010 and 2019

Angela Isabel Del Rio

Ilais Moreno Velásquez

Reina Roa

Roger Montenegro Mendoza

Jorge Motta

Hedley K Quintana

Roles

Abstract

Background

Methods

Findings

Interpretation

Introduction

Materials and methods

Study population

The PREFREC (2010) study

Fig 1. Flow chart of selected participants.

The ENSPA (2019) study

Data collection

Outcome assessment

Exposure variables

Statistical analysis

Ethical statement

Results

Demographic and socioeconomic characteristics

Table 1. Distribution of baseline characteristics in individuals aged between 30 and 75 years by sex and the study year (PREFREC 2010 and ENSPA 2019) in the provinces of Panama and Colon.

Established risk factors for hypertension

Hypertension

Fig 2. Prevalence and unawareness of hypertension stratified by sex and the study year.

Healthcare-related factors

Fig 3. BP assessment in the year before study enrollment stratified by sex and the study year.

Risk factors associated with unawareness of hypertension

Discussion

Conclusions

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Taeyun Kim

Roles

Author response to Decision Letter 0

Decision Letter 1

Taeyun Kim

Roles

Author response to Decision Letter 1

Decision Letter 2

Taeyun Kim

Roles

Author response to Decision Letter 2

Decision Letter 3

Taeyun Kim

Roles

Acceptance letter

Taeyun Kim

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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