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Revista MHSalud® (ISSN: 1659-097X) Vol. 6. No. 1. Julio, 2009.


Hipertensión en el personal de la Universidad Estatal a Distancia de Costa Rica

MSO Lourdes Arce Espinoza1, M.Sc. Julián Monge­Nájera2
1Nurse, Medical Services, Costa Rican State University for Distance Education
(Universidad Estatal a Distancia­UNED), larce@uned.ac.cr
2Researcher, Office of the Vice President for Research, UNED, julianmonge@gmail.com
San José, Costa Rica


The prevalence of Arterial Hypertension (AHT) has increased worldwide and preventive measures areinsufficient since only one third of the population is being treated. AHT is the primary cause of morbidity andmortality in the world. In this article is presented the first study on hypertension levels of personnel of aDistance Education university based on the analysis of all medical consultations in the Costa Rican StateUniversity for Distance Education (Universidad Estatal a Distancia-UNED) as of December 15, 2007 (1,526medical files). The population studied ranges from 20 to 70 years of age and is comprised of residents of theGreater Metropolitan Area (Costa Rica) with varied socioeconomic and academic levels. The StatgraphicsCenturion XV software and the chi-square test were used to analyze variables such as treatment administered,sex, age, and type of work. Only 45 patients knew that they suffered from hypertension prior to theirconsultation with the university medical service and 136 were treated with Enalapril and Hydrochlorothiazide.The number of hypertensive patients is higher among those who have worked at the institution for more than 20years, especially in those holding higher positions. No marked differences were found between men andwomen. It is concluded that the existence of a university medical service has permitted faculty and staff tosatisfactorily control their blood pressure.

KEYWORDS: Hypertension, outpatient service, distance education, university personnel, Costa Rica.


La prevalencia de la Hipertensión Arterial (HTA) se ha incrementado en todo el mundo y las accionespreventivas resultan insuficientes, ya que solamente un tercio total de esta población está controlada. La HTAes la primera causa de morbilidad y mortalidad mundial. En este artículo se presenta el primer estudio sobrelos niveles de hipertensión en el personal de una universidad a distancia, mediante el análisis del total deconsultas en la Universidad Estatal a Distancia de Costa Rica al 15 de diciembre del 2007 (1526 expedientesmédicos). La población estudiada se encuentra en edades comprendidas entre los 20 a 70 años, residentes delGran Área Metropolitana, con nivel socioeconómico y preparación académica variable. Se analizó la relaciónentre la HTA y las variables tratamiento, sexo, edad y tipo de trabajo, usando la prueba chi-cuadrado. Solo 45de los pacientes conocían de su problema de hipertensión antes de llegar a consulta en el servicio médicoinstitucional y 136 pacientes reciben tratamientos que incluyen Enalapril e Hidroclorotiazida. La cantidad depacientes hipertensos es máxima entre quienes tienen más de 20 años de trabajar en la institución,especialmente si ocupan altos puestos. No hubo marcadas diferencias entre mujeres y hombres. Se concluyeque la existencia de un servicio médico interno ha permitido que la población de la universidad mantengacontrolada satisfactoriamente su presión arterial.

PALABRAS CLAVES: hipertensión, consulta externa, educación a distancia, personal de universidad, Costa Rica.


Arterial hypertension (AHT) is a chronic disease that is usually asymptomatic and is characterized by the elevation of the systolic blood pressure (SBP) above 120 mmHg and/or diastolic blood pressure (DBP) above 80 mmHg. The prevalence of arterial hypertension has  increased  between  3%  and  18%  worldwide  between  1999  and  2002. Preventive programs and measures are insufficient since only one third of this population is being treated (Haijar and Kotchen, 2006).

AHT is the primary cause of morbidity and mortality worldwide, with 7.1 million deaths in
2006 (Holguin, Correa, Arrivillaga, Cáceres, and Varela, 2006).  It is caused by the sum of modifiable   (overweight,   sodium   consumption   above   1.5   grams   per   day,   alcohol consumption, physical inactivity, smoking, and a diet rich in fats) as well as non­modifiable risk factors (gender, ethnic group, age, and heritage) (Huerta, 2001; Vásquez, Fernández, Álvarez, Roselló, and Pérez, 2006;  Li et al, 2005).

The presence of AHT, together with obesity, dyslipidemia, and insulin resistance, is known as metabolic syndrome (MS).   Metabolic disorders and their relationship with AHT have been  widely  described  during the last  10  years, as well as  the increased risk  of  other coronary complications and possible mortality resulting from different combinations of risk factors (Jarvis et al, 2007; Gao, Nelson, and Tucker, K., 2007; Xiang, Nelson, and Tucker,

It has been statistically proven that women maintain better control of AHT than men (Plans, Tesserras, Pardell, and Salleras, 2002), and that with age figures increase between 20 and 30 mmHg in patients 40 years of age and those above 60 (whether normotensive or hypertensive).   After the age of 70, normotensive patients have a 90% risk of developing hypertension due to the hardening of blood vessels (Vásquez et al, 2006).

A total of 16% of hypertensive patients have not been diagnosed mainly because they have no access to health care, have low schooling (they are unable to recognize risk factors for AHT), and exhibit no symptoms (Méndez and Rosero, 2007).  In addition, popular beliefs regarding  treatment  and  ways  to  avoid  this  pathology  significantly  lower  control  rates (Wilson et al, 2002).   Cultural aspects and life styles continue to be a common problem contributing to morbidity and mortality in AHT (Han, Kim, Kang, Kim, and Kim, 2007).

Another decisive factor in AHT is stress.  Research suggests that work stress significantly contributes to AHT because it alters the normal physiological rest and recovery processes (Yang, Schnall, Jáuregui, Su, and Baker, 2006).   Although epidemiological studies relate work  stress  with  the appearance  of  AHT,  regardless  of  the  occupation,  this  statement requires further study (Rose, Newman, Bennet, and Tyroler, 1999; Rubio, Vallejo, and Martínez, 2000).

Family history or inheritance is also a determining factor in the appearance of AHT (Katzmarzyk,  Rankinen,  Perusse,  Rao,  and  Bouchard,  2001;  Goldstein,  Shapiro,  and Guthrie, 2006).  In addition, in those cases where there is no family history of AHT, some authors consider that family can be a source of stress that produces long­term adverse effects and,  consequently,  the  appearance  of  AHT.    Whether  due  to  inheritance  or  the stress produced, family could be responsible for a high percentage of risk in the appearance of AHT (Huerta, Bautista, Irigoyen, and Arrieta, 2005).

Studies on children and adolescents with a family history of AHT recognize that, in spite of the fact that levels were within the normal parameters, their variability suggests that family history is an important risk factor and, therefore, plays a significant role in the appearance of AHT during adulthood (Lawlor et al, 2005; Borges, Peres, and Horta, 2007; Barton, Gilbert, Baramme, and Granger, 2006; Hulanicka, Lipowicz, Koziel, and Kowalisko, 2007).

Statistically, stress, ire, anxiety, and depression are strongly related to AHT (Olmos et al,
1999; Jhalani et al, 2005; Yan et al, 2006).  Risk factors are the same in all ethnic groups; however, the pathology is more aggressive in patients of African descent. (Hayes et al, 2003; Holmes, Arispe, and Moy, 2005; Higginbottom, 2006).

In  Costa  Rica  arterial  hypertension  is  one  of  the  most  frequent  causes  for  medical consultation and one of the most expensive pathologies in outpatient service.  By 2060, the

senior population in Costa Rica is expected to increase to 2  million, together  with the occurrence of chronic diseases and their costs in health care (Méndez and Rosero, 2007).

In this article is presented the first study on hypertension levels of personnel of a Distance Education university.  The relationship between sex, age, and type of work is analyzed for the personnel of the Costa Rican State University for Distance Education (Universidad Estatal a Distancia­UNED). No previous studies have been made.



Medical files as a primary source of information CERTIFIED TYCOS sphygmomanometer LITTMANN stethoscope
The latter two used to take blood pressure.


Subjects included all UNED outpatients who were seen for AHT between January 14, 2002 and December 14, 2007, totaling 179 hypertensive patients: 95 women and 84 men.

The population studied was between 20 and 70 years of age (mean: 22.3 years of age) and was comprised of residents of the Greater Metropolitan Area of Costa Rica with varied socioeconomic and  academic  levels  since  the  study  included  support  personnel  (e.g., janitors), faculty (with Master’s and PhDs), department heads and other high administrative personnel.  Marital status: 140 married, 29 cohabitating, and 10 single.  The majority of the population has worked in the institution for a period between 6 months and 30 years (UNED Medical Services Archives).


Data was collected from the primary source of information in two stages. The first stage included the review of medical files (a total of 1,526) to determine which patients had been seen for AHT, totaling 179 patients.  The second stage included entering data in an Excel file.This record was used to codify and statistically analyze data (see section on Statistics).

Ethical Aspects

This study was approved by the Office of the Vice President for Research at UNED, the division  that  oversees  the  ethical  and  administrative  aspects  of  the  research  projects conducted at the institution.  Patient consent was not necessary since this was a posteriori analysis of institutional statistical data in which patients were not subjected to experimental treatments and no individualized data was used (this analysis is similar to the institutional statistics published by the Costa Rican Social Security Administration).

Statistical Analysis

An Excel spreadsheet and the Statgraphics Centurion XV statistical software were used to group and analyze the data. In addition, a descriptive­quantitative methodology was applied to  present  the  distribution  of  patients  by  sex,  age,  treatment,  and  type  of  work. The hypothesis was tested through the chi­square contingency test, which measures relationship between variables. The m­regression was utilized for the relationship between age, sex, position, and hypertenson.i The rejection value for the hypothesis was 0.05.


From the 1,526 individuals with a medical file, 179 were seen for AHT (12 %).

Distribution of UNED Personnel by Gender and Arterial Hypertension Background

Only 45 patients knew of their AHT problem before consultation at the institutional medical service. Ratio does not differ between women and men (X2=0.05, degrees of freedom=1, p=0.8231; Graph 1).


Antihypertensive Therapy

There is a complex variety of administered treatments.  From the total number of patients, 69 men and 67 women receive treatment including Enalapril, Hydrochlorothiazide or a combination of the two.   The remaining 26 women and 17 men receive other types of treatment (Table 1).


Most male patients were not treated with beta blockers, which have been associated with erectile dysfunction, but have rather received a slightly higher proportion of Enalapril and Hydrochlorothiazide than women.  However, in this respect the difference between women and men is only slightly significant (Fisher’s Exact Test, p=0.0497; data grouped in two categories as required by the test: 1=Enalapril, Hydrochlorothiazide or both; 2=Other. Graph 2).


Relationship between Seniority, Age, Sex, and Hypertension in UNED Personnel

Twenty  four  percent  of  the patients  that  have  worked  for  more than  20  years  in  the institution are hypertensive. This value is similar for those who been less than 10 years (23%) in the University. On the contrary, hypertension rate does not exceed 8% in those who have worked at UNED for 11 to 20 years (Table 2). The majority of hypertensive patients are above 40 years of age. No differences were found between women and men (Table 2) (X2=1.7, degrees of freedom=2, p=0.4274).


Relationship between Arterial Hypertension and Occupation of UNED Personnel

The hypertensive patient ratio is related to the type of occupation (Table 3) since those who are  department  heads  and  hold  other  high  positions  have  a  higher  hypertension  rate (X2=6.76,  degrees  of  freedom=4,  p<0.05). The  forgoing  is  confirmed  by  a  multiple regression that crossed sex, age, and position as possible predictors of hypertension, which indicated that position is the associated variable (R2=0.0487; p 0.001; N=1,526 patients).


Ninety percent of UNED hypertensive employees monitor their blood pressure at least once a month when they receive their check up or when they pick up their hypertension treatment. A total of 10% check their blood pressure at least twice a year because they monitor it at other health institutions and their blood pressure is taken when they go to the doctor for other reasons (L. Arce, personal observation).


Distribution by Sex and Arterial Hypertension Background

Most of the AHT cases were detected by the medical service personnel at UNED as only 45 patients  knew of their  condition before working at the University. Their pathology is currently  controlled  at  UNED. The  foregoing  shows  an  advantage  of  offering  health services in the institution.  Easy access to such services permitted detection of the majority of the cases and control within the population.

Based on the literature, epidemiological data indicates that the risk of suffering from AHT is higher in men than in women and that the symptoms for this pathology start to appear at the age of 45 (men) and 55 (women).  However, it should be remembered that some cases are asymptomatic and it is diagnosed by controlling blood pressure (BP) (Plans et al, 2002).  No significant differences were found in this study in the AHT rate between men and women. A  possibility  could  be  that  UNED  female  personnel  visit  the  medical  services  more frequently for checkups, family planning, prenatal care, etc., which increases both the probability of discovering this pathology and women’s recorded AHT rate to the same level as men’s.

Antihypertensive Therapy for Men and Women

There are many combinations of antihypertensive treatments. These are prescribed after conducting medical tests and controlling blood pressure and depend on the person’s physiological response, medical history, and results from a medical examination.

According to Grimm et al (1996), most patients are treated with Enalapril and a diuretic, or other therapeutic combinations, without any prescription differences between men and women.  Although the use of antihypertensive medication, specifically beta blockers such as Propranolol and Atenolol, has been associated with erectile dysfunction, there exists controversy in this respect.   For instance, the Treatment of Mild Hypertension Study (TOMHS) conducted in 1996 analyzed 902 hypertensives that were taking diuretics, beta blockers, ACE inhibitors, alpha blockers, or calcium antagonists.  After a four­year follow up, erectile dysfunction was related to the age of the patient rather than to the type of drug used (Grimm et al, 1996).  In the case of UNED, only a small percent of the population uses this medication and none of the patients has reported it as a side effect.

Seniority, Age, and Sex Ratio

With age, individuals tend to gain weight.  Aging and the loss of elasticity in blood vessels, intensified in women by the decreased levels of estrogens (Molina, 2007), is coherent with the increase in hypertensive cases after the age of 40.

Occupation and Arterial Hypertension

Even though AHT is associated with a number of modifiable and non­modifiable factors, it is the sum of those factors that causes this pathology.  The stress produced by the complex functions of being the head of a department (Olmos et al, 1999; Jhalani et al, 2005; Yan et al, 2006) explains the reason why those who hold these positions have the highest AHT percentages at UNED.


The following conclusions are drawn from the results obtained:

  1. Easy access to an institutional medical service has permitted the detection of a significant  number  of  previously  unknown  hypertensive  cases  as  well  as  the adequate treatment for patients.
  2. Most patients are treated with Enalapril and Hydrochlorothiazide and no erectile dysfunction problems have been reported when beta blockers are used.
  3. There is not a defined pattern indicating that hypertension clearly increases with years of service.
  4. An important ratio of hypertensive patients is noted for men and women older than 40.
  5. Department heads present more hypertension cases. Acknowledgements

We would like to thank Carolina Morales and Daniel Villalobos for editing a previous draft.


Barton, A. J., Gilbert, L., Baramme, J., & Granger, T. (2006). Cardiovascular Risk in
Hispanic and non Hispanic Preschoolers. Nursing Research, 55, 172­179.

Borges, L. M., Peres, M. A., & Horta, B. L. (2007). Prevalence of High Blood Pressure among School Children in Cuiabá, Midwestern Brazil. Revista de Saúde Pública, 41, 530­538.

Gao,  X.,  Nelson,  M.,  &  Tucker,  K.  (2007).  Television  Viewing  is  Associated  with Prevalence of Metabolic Syndrome in Hispanic Elders. Diabetes Care, 30, 694­700.

Goldstein, I. B., Shapiro, D., & Guthrie, D. (2006). Ambulatory Blood Pressure and Family History of Hypertension in Healthy Men and Women. American Journal of Hypertension, 19, 486­491.

Grimm,   R.   H.,   Grandits,   G., &  Svendsen,   K.   (1996).   Sexual   Problems   and Antihypertensive Drugs Treatment: Results of the Treatment of Mild Hypertension Study (TOMHS). Journal of Urology, 155, 634­644.

Haijar, I. K., & Kotchen, Ta. (2006). Hypertension: Trends in Prevalence, Incidence and
Control. Annual Review of Public Health, 27, 465­490.

Han, H. R., Kim, K. B., Kang, J. J.,  Kim, E. Y., & Kim, M. T. (2007). Knowledge, Beliefs and Behaviors about Hypertension Control among Middle­Aged Korean Americans with Hypertension. Journal of Community Health, 32, 324­342.

Hayes, D. K., Denny, C. H., Keenan, N. L., Croft, J. B., Sundaram, A. A., & Greenlund, K.
J. (2003). Racial/Ethnic and Socioeconomic Differences in Multiple Risk Factors for Heart Disease and Stroke in Women: Behavioral Risk Factor Surveillance System. Journal of Women Health, 15, 1000­1008.

Higginbottom, G. M. (2006). Pressure of Life: Ethnicity as Mediating Factor in Mild­Life and Older People, Experience of High Blood Pressure. Sociology of Health and Illness, 28, 583­610.

Holguin, L., Correa, D., Arrivillaga, M., Cáceres, D., & Varela, M. (2006). Treatment Compliance in Arterial Hypertension: Efficacy a Biopsychosocial Intervention Program. Universitas Psychologica, 5, 535­548.

Holmes, J. S., Arispe, I. E., & Moy, E. (2005). Heart Disease and Prevention: Race and Age Differences in Heart Disease Prevention, Treatment and Mortality. Medical Care, 43, 33­41.

Huerta,  R.  B.  (2001).  Factores  de  riesgo  para  la  hipertensión  arterial.  Archivos de Cardiología de México, 7, 208­210.

Huerta, D., Bautista, L., Irigoyen, A. y Arrieta, R. (2005). Estructura familiar y factores de  riesgo  cardiovascular  en  pacientes  con  Hipertensión  Arterial.  Archivos de Medicina Familiar, 7, 87­92.

Hulanicka, B., Lipowicz, A., Koziel, S., & Kowalisko, A. (2007). Relationship between Early Puberty and the Risk of Hypertension, Overweight at Age 50: Evidence for a Modified Barker Hypothesis among Polish Youth. Economics and Human Biology, 5, 48­60.

Jhalani, J., Goyal, T., Clemow, L., Schwartz, J. E., Pickering, T. G., & Gerin, W. (2005). Anxiety and Outcome Expectations Predict the White Coat Effect. Blood Pressure Monitoring, 10, 317­319.

Jarvis, C., Hayman, L. L., Braun, L., Schwertz, D., Ferrans, C., & Piano, M. (2007). Cardiovascular Risk Factors and Metabolic Syndrome in Alcohol and Nicotine­ Dependent Men and Women. Journal of Cardiovascular Nursing, 22, 429­435.

Katzmarzyk, P. T., Rankinen, T., Perusse, L., Rao, D. D. C., & Bouchard, C. (2001). Familial Risk of High Blood Pressure in the Canadian Population. American Journal of Human Biology, 13, 620­625.

Lawlor, D, A., O’Callaghan, M. J., Mamun, A. A., Williams, G. M., Bor, W., & Najman, J.
M.   (2005).   Socioeconomic   Position   Cognitive   Function   and   Clustering   of Cardiovascular Risk Factors in Adolescence: Findings from the Mater University Study of Pregnancy and its Outcomes. Psychosomatic Medicine, 67, 862­868.

Li, W., Liu, L. S., Puente, J. G., Li, Y. S., Jiang, X. J., Jin, S. G., Ma, H., Kong, L. Z., Ma, L.
M., He, X. Y., Ma, S. X., & Chen, C. M. (2005). Hypertension and Health ­Related Quality of Life: An Epidemiological Study in Patients Attending Hospital Clinics in China. Journal of Hypertension, 23, 1667­1676.

Méndez,  Ch.  E.  y  Rosero­Bixby,  L.  (2007).  Prevalencia  de  hipertensión  en  adultos mayores de Costa Rica. Población y Salud de Mesoamérica, 5, 1­9.

Molina, D. R. (2007). Manual de hipertensión arterial en la práctica clínica de atención primaria: factores que influyen en su prevalencia. Revista de la Sociedad Andaluza de Medicina Familiar, 14, 1­4.

Olmos, O., Coromina, E., Morales, M., Torres, P., Coviello, A. y Grosse, A. (1999). El examen oral como prueba de estrés en una población de estudiantes y su incidencia sobre la presión arterial. Revista de la Federación de Argentina de Cardiología, 28, 87­90.

Plans,  P.,  Tesserras,  R.,  Pardell.  H. y  Salleras,  L.  (2002).  Epidemiología  de  la hipertensión arterial en la población adulta de Cataluña, España. Revista Médica Clínica, 98, 369­372.

Rose, K. M., Newman, B., Bennet, T., & Tyroler, H. A. (1999). The Association between Extent of Employment and Hypertension among Women Participants of the Second National Health and Nutrition Survey. Women and Health, 29, 13­29.

Rubio, C., Vallejo, D. y Martínez, F. (2000). Cardiología y Medicina del Trabajo: un enfoque  sobre  factores  condicionantes  en  el  desarrollo  de  ciertas  cardiopatías. Revista Medicina del Trabajo, 1, 75­82.

Vásquez, A., Fernández, M., Álvarez, N., Roselló, Y. y Pérez, M. (2006). Percepción de la hipertensión como factor de riesgo, Aporte del día mundial de lucha contra la hipertensión. Revista Cubana Médica, 45, 1­10.

Wilson, R. P., Freeman, A., Kazda, M. J., Andrews, T. C., Berry, L., Vaeth, P. A., & Victor, R.
G. (2002). Lay Beliefs about High Blood Pressure in a Low to Middle Income Urban African­American Community: An Opportunity for Improving Hypertension Control. American Journal of Medicine, 112, 26­30.

Xiang, G., Nelson, M. E., & Tucker, K. L. (2007). Television Viewing is Associated with
Prevalence of Metabolic Syndrome in Hispanic Elders. Diabetes Care, 30, 694­700.

Yang, H., Schnall, P., Jáuregui, M., Su, T. y Baker, D. (2006). Exceso de trabajo e hipertensión arterial. Revista Hipertensión, 48, 1­7.

Reception date: June 17, 2008.
Correction date:
October 23, 2008.
Acceptance date: October 23, 2008.
Publication date: July 31, 2009.

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