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Abstract

OBJECTIVES

We aimed to assess the hypertension (HTN) awareness and associated factors in France.

METHODS

We conducted a cross-sectional analysis using data from the CONSTANCES population-based cohort involving 87,808 volunteer participants included between 2012 and 2018. HTN was defined as average blood pressure (BP) over 140/90 or use of BP medication, awareness as self-reported HTN. Multivariable logistic regression models were used to identify the associated factors.

RESULTS

Overall, 27,160 hypertensive participants (men = 16,569) above 18 years old were analyzed. Hypertension awareness rate was 37.5%. In the multivariable regression model, awareness was predicted by female gender, age, prior cardiovascular disease (CVD), presence of diabetes mellitus (DM), presence of chronic kidney disease (CKD), level of education, and obesity or overweight. Older participants (P < 0.001), females (P < 0.001), participants with comorbidities (P < 0.001), were more likely to be aware when compared with younger participants, males and participants without comorbidities, respectively. The unawareness among participants without cardiometabolic factors (CMF, i.e., CVD, DM, CKD) was higher than participants with CMF (67% vs. 41%, respectively, P < 0.001). Moreover, some differences appeared in both genders in the association between awareness of HTN and health and lifestyle factors.

CONCLUSION

Our findings show that HTN awareness is low. Particular attention should be given to young men without comorbidities as these characteristics were predictors of poor awareness. Immediate action is required to improve HTN awareness in France.

awareness, blood pressure, epidemiology, France, hypertension, risk factors

Cardiovascular diseases (CVD) are still identified by the WHO as the primary cause of total mortality worldwide and hypertension (HTN) is recognized as the leading risk factor cause for CVD.1 Hypertension affects more than 1 billion people and is projected to reach 1.56 billion by 2025.2 However, less than 50% of the affected population in many countries are aware of their high blood pressure (BP) status.3 Such awareness is crucial to control and treat HTN and is also key to individuals making changes to their lifestyle and dietary habits. That vary considerably between countries and population groups within countries.3

In order to further improve BP control, it is critical to understand the characteristics of those who are not aware of their HTN so that new strategies can be targeted and tailored to the needs of high-risk subgroups in each country.

To our knowledge, few studies evaluated the rate and the factors associated with HTN awareness in France from a large population-based perspective. The French nationwide, large CONSTANCES cohort4 represents a major opportunity to provide further epidemiologic data on this subject. Therefore, we conducted this study to estimate rate of awareness of HTN according to gender; and investigate the association of sociodemographic, health, and lifestyle factors with the awareness of HTN.

METHODS

Study design and study population

This ancillary study is a cross-sectional analysis using data from the CONSTANCES cohort. Details about the study design and methods have been previously published.4,5 In brief, CONSTANCES is an ongoing prospective cohort that started in 2012 and included 200,000 participants by 2019. Adults aged 18–69 at inclusion were randomly selected from the National Health Insurance Fund that covers salaried workers, professionally active or retired and their dependents (more than 85% of the French population).

Data collection

At enrollment, volunteer participants completed self-administered questionnaires where social, demographic, health information including personal history of diseases and events, and lifestyle behavior characteristics were gathered. In addition, they presented to the nearest of the 22 selected health-screening centers (HSCs) located throughout France, to benefit from a comprehensive health examination whereby medical, paraclinical exams, anthropometric measurements, and biologic tests were performed. All participants signed an informed consent and the CONSTANCES cohort was authorized by the French National Data Protection Authority (Commission nationale de l’informatique et des libertés) and approved by the Institutional Review Board of the National Institute for Medical Research-Institut national de la santé et de la recherche médicale (French National Institute of Health and Medical Research).

Study participants

Between February 2012 and January 2018, a total of 87,808 volunteer participants were recruited and linked to the French health insurance administrative database. Of them 27,160 were found to be hypertensive. We therefore analyzed 27,160 hypertensive participants.

Measurements and definitions

Hypertension.

BP measurements were taken during the clinical examination at the HSC based on standardized operational procedures.6 Systolic BP (SBP) and diastolic BP (DBP) were measured in each arm at 2 minutes interval after 5 minutes of rest and using an automated oscillometric sphygmomanometer. The arm giving the highest SBP was considered the reference arm and a third BP measure was taken after 1 minute of rest, the average of these two measurements was considered. BP measurement method in our study is fairly similar to other previous cohorts in France mentioned in this article.7–9 Hypertension was defined as a SBP ≥140 mm Hg, or a DBP ≥90 mm Hg, or use of antihypertensive medication. Awareness of HTN was defined as self-report of any prior diagnosis of HTN by a health care professional among the population defined as having HTN.

Covariates.

Alcohol consumption was determined considering the quantity and type of alcoholic beverages consumed the previous week.10 We defined alcohol consumption in men as never/light (0–3 glass/week, i.e., 0–30 g/week), moderate (4–21 glass/week, i.e., 40–210 g/week), and heavy drinkers (>21 glass/week, i.e., >210 g/week). Similarly, alcohol consumption in women was defined as never/light (0–2 glass/week, i.e., 0–20 g/week), moderate (3–14 glass/week, i.e., 30–140 g/week), and heavy drinkers (>14 glass/week, i.e., >140 g/week).11 Physical activity was assessed through questions related to the type and frequency of leisure time/sports and transferring (walking, biking,. . .) activities,12 then a score of 0–6 was calculated and physical activity level was classified as sedentary (0–2), moderately active (3–4), and highly active (5–6). Dietary assessment was done through a validated 52 items food frequency questionnaire from which a DASH (dietary approach to stop hypertension) score was constructed based on food groups described by Fung et al.13 BMI (kg/m2) was calculated at the HSC. Weight and height were measured with a scale and a measuring rod without shoes, respectively.

Education level was collected according to the International Standard Classification of Education14 and was then classified into three levels: high school diploma or less (13 years of education), undergraduate degree (14–16 years of education), and postgraduate degree (17 years of education). Household monthly income was categorized into less than 1000; 1000–2099; 2100–4199; at least 4200 euros per month. Diabetes mellitus (DM) status was based on either self-reported type II diabetes, receiving anti-diabetic medication, or a fasting blood glucose concentration greater than or equal to 7 mmol/l. Dyslipidemia was defined as having hypercholesterolemia and/or hypertriglyceridemia. Pre-existing CVD was considered as any self-reported previous diagnosis of angina pectoris, myocardial infarction, cerebrovascular accident, or peripheral artery disease. Chronic kidney disease (CKD) was defined as decreased renal function (creatinine clearance <60 ml/min calculated by the Cockroft–Gault equation) for more than 3 months. Smoking status (i.e., nonsmoker, former smoker, or current smoker) was self-reported.

Statistical analysis

Descriptive analysis was performed using counts and percentages or mean SD. Each characteristic was compared between hypertensive subjects with and without awareness of HTN using logistic regressions. A P < 5% was used to infer statistical significance and to indicate covariate should be kept in multivariate models. The univariate analyses to identify variables associated with sex differences and hypertension awareness as well as the analyses repeated within sex strata, used the χ 2-square, Student’s t tests, where appropriate. For the multivariate analysis, the factors identified as potentially important by the univariate analyses (P < 0.05) were further entered into logistic regression analysis using backward selection to determine independent predictors of awareness of hypertension. We conducted tests for interaction using χ 2-square tests. Adjusted odds ratios (ORa) were presented along with 95% confidence interval (CI), all statistical analyses were performed with R version 3.5.1 software.

RESULTS

Baseline characteristics of the participants

Table 1 shows the characteristics of the study population by gender. Among 27,160 hypertensive participants included in the analysis, 61% were men and 59% were women. The mean age of the participants was 56.02 and three-quarters of them were 50 or older. The mean SBP and DBP were higher among men (respectively, 148.48 ±  13.55 and 85.87  ±  9.2  mm Hg) compared with women (respectively, 145.15  ±  15.70 and 83.57  ±  9.68  mm Hg). Women were older (57.56 ±  10.08 years vs. men 55.04 ±  11.77 years), less obese (26.68 ±  5.53 kg/m2 vs. men 27.25 ±  4.11 kg/m2), with healthier diet (DASH score 29.06 ±  3.79 vs. men 26.88 ± 4.14) and higher levels of physical activity compared than men (vigorous to intense activity 32.1% vs. men 29.9%). Men were more educated (graduate 26.3% vs. women 20.8%), wealthier (very high income 29.3% vs. women 23.2%), were more frequently smokers (15.5% vs. women 11.6%), and exhibited a greater degree of alcohol intake (high alcohol consumption 17.7% vs. women 9.4%) than women. The prevalence of history of DM, dyslipidemia, and preexisting CVD among men were higher than those among women (respectively, 11%, 51.5%, 7.7% vs. women 6.9%, 46.2%, 3.4%). All these differences were statistically significant (P < 0.001 for all).

Table 1.

Characteristics of the hypertensive patients, CONSTANCES cohort 2012–2018

CharacteristicsAllWomenMenPa
N27,16010,59116,569
Age groups (years)<0.001
 18–392,796 (10.3)697 (6.6)2,099 (12.7)
 40–494,182 (15.4)1,466 (13.8)2,716 (16.4)
 50–597,842 (28.9)3,171 (29.9)4,671 (28.2)
 ≥6012,340 (45.4)5,257 (49.6)7,083 (42.7)
Familial status<0.001
 Couple20,683 (76.2)7,519 (71.0)13,164 (79.4)
Education level<0.001
 High school10,526 (38.8)3,997 (37.7)6,529 (39.4)
 Undergraduate9,985 (36.8)4,360 (41.2)5,625 (33.9)
 Graduate6,562 (24.2)2,202 (20.8)4,360 (26.3)
Household income<0.001
 Very high (>4,200€/month)7,315 (26.9)2,456 (23.2)4,859 (29.3)
 High13,283 (48.9)5,235 (49.4)8,048 (48.6)
 Medium5,376 (19.8)2,410 (22.8)2,966 (17.9)
 Low (<1,000€/month)1,186 (4.4)490 (4.6)696 (4.2)
BMI27.03 (4.72)26.68 (5.53)27.25 (4.11)<0.001
DASH score27.73 (4.15)29.06 (3.79)26.88 (4.14)<0.001
Physical activity<0.001
 None or low2,636 (9.7)854 (8.1)1,782 (10.8)
 Mild to moderate16,411 (60.4)6,332 (59.8)10,079 (60.8)
 Vigorous to intense8,113 (29.9)3,405 (32.1)4,708 (28.4)
Smoking<0.001
 Nonsmoker11,417 (44.4)5,641 (60.4)5,776 (39.1)
 Current smoker3,597 (14.0)1,162 (11.6)2,435 (15.5)
 Former smoker10,718 (41.7)3,232 (32.2)7,486 (47.7)
Alcohol consumption<0.001
 Never/light4,127 (15.2)2,263 (21.4)1,864 (11.2)
 Moderate19,099 (70.3)7,331 (69.2)11,768 (71.0)
 High3,934 (14.5)997 (9.4)2,937 (17.7)
Diabetes2,561 (9.4)735 (6.9)1,826 (11)<0.001
Dyslipidemia13,417 (49.4)4,891 (46.2)8,526 (51.5)<0.001
CKD226 (0.8)85 (0.8)141 (0.9)0.719
Pre-existing CVD1,638 (6.0)362 (3.4)1,276 (7.7)<0.001
Systolic BP147.18 (14.52)145.15 (15.70)148.48 (13.55)<0.001
Diastolic BP84.98 (9.45)83.57 (9.68)85.87 (9.20)
Awareness of HTN10,189 (37.5)4,455 (42.1)5,734 (34.6)<0.001
CharacteristicsAllWomenMenPa
N27,16010,59116,569
Age groups (years)<0.001
 18–392,796 (10.3)697 (6.6)2,099 (12.7)
 40–494,182 (15.4)1,466 (13.8)2,716 (16.4)
 50–597,842 (28.9)3,171 (29.9)4,671 (28.2)
 ≥6012,340 (45.4)5,257 (49.6)7,083 (42.7)
Familial status<0.001
 Couple20,683 (76.2)7,519 (71.0)13,164 (79.4)
Education level<0.001
 High school10,526 (38.8)3,997 (37.7)6,529 (39.4)
 Undergraduate9,985 (36.8)4,360 (41.2)5,625 (33.9)
 Graduate6,562 (24.2)2,202 (20.8)4,360 (26.3)
Household income<0.001
 Very high (>4,200€/month)7,315 (26.9)2,456 (23.2)4,859 (29.3)
 High13,283 (48.9)5,235 (49.4)8,048 (48.6)
 Medium5,376 (19.8)2,410 (22.8)2,966 (17.9)
 Low (<1,000€/month)1,186 (4.4)490 (4.6)696 (4.2)
BMI27.03 (4.72)26.68 (5.53)27.25 (4.11)<0.001
DASH score27.73 (4.15)29.06 (3.79)26.88 (4.14)<0.001
Physical activity<0.001
 None or low2,636 (9.7)854 (8.1)1,782 (10.8)
 Mild to moderate16,411 (60.4)6,332 (59.8)10,079 (60.8)
 Vigorous to intense8,113 (29.9)3,405 (32.1)4,708 (28.4)
Smoking<0.001
 Nonsmoker11,417 (44.4)5,641 (60.4)5,776 (39.1)
 Current smoker3,597 (14.0)1,162 (11.6)2,435 (15.5)
 Former smoker10,718 (41.7)3,232 (32.2)7,486 (47.7)
Alcohol consumption<0.001
 Never/light4,127 (15.2)2,263 (21.4)1,864 (11.2)
 Moderate19,099 (70.3)7,331 (69.2)11,768 (71.0)
 High3,934 (14.5)997 (9.4)2,937 (17.7)
Diabetes2,561 (9.4)735 (6.9)1,826 (11)<0.001
Dyslipidemia13,417 (49.4)4,891 (46.2)8,526 (51.5)<0.001
CKD226 (0.8)85 (0.8)141 (0.9)0.719
Pre-existing CVD1,638 (6.0)362 (3.4)1,276 (7.7)<0.001
Systolic BP147.18 (14.52)145.15 (15.70)148.48 (13.55)<0.001
Diastolic BP84.98 (9.45)83.57 (9.68)85.87 (9.20)
Awareness of HTN10,189 (37.5)4,455 (42.1)5,734 (34.6)<0.001

Data are presented as the mean followed by standard deviation for quantitative variables and for categorical variables as numbers followed by percentage. Abbreviations: BMI, body mass index; BP, blood pressure, CKD, chronic kidney disease; CVD, cardiovascular disease; DASH, dietary approach to stop hypertension; HTN, hypertension; N, number of participants.

aP value: difference between men and women.

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Table 1.

Characteristics of the hypertensive patients, CONSTANCES cohort 2012–2018

CharacteristicsAllWomenMenPa
N27,16010,59116,569
Age groups (years)<0.001
 18–392,796 (10.3)697 (6.6)2,099 (12.7)
 40–494,182 (15.4)1,466 (13.8)2,716 (16.4)
 50–597,842 (28.9)3,171 (29.9)4,671 (28.2)
 ≥6012,340 (45.4)5,257 (49.6)7,083 (42.7)
Familial status<0.001
 Couple20,683 (76.2)7,519 (71.0)13,164 (79.4)
Education level<0.001
 High school10,526 (38.8)3,997 (37.7)6,529 (39.4)
 Undergraduate9,985 (36.8)4,360 (41.2)5,625 (33.9)
 Graduate6,562 (24.2)2,202 (20.8)4,360 (26.3)
Household income<0.001
 Very high (>4,200€/month)7,315 (26.9)2,456 (23.2)4,859 (29.3)
 High13,283 (48.9)5,235 (49.4)8,048 (48.6)
 Medium5,376 (19.8)2,410 (22.8)2,966 (17.9)
 Low (<1,000€/month)1,186 (4.4)490 (4.6)696 (4.2)
BMI27.03 (4.72)26.68 (5.53)27.25 (4.11)<0.001
DASH score27.73 (4.15)29.06 (3.79)26.88 (4.14)<0.001
Physical activity<0.001
 None or low2,636 (9.7)854 (8.1)1,782 (10.8)
 Mild to moderate16,411 (60.4)6,332 (59.8)10,079 (60.8)
 Vigorous to intense8,113 (29.9)3,405 (32.1)4,708 (28.4)
Smoking<0.001
 Nonsmoker11,417 (44.4)5,641 (60.4)5,776 (39.1)
 Current smoker3,597 (14.0)1,162 (11.6)2,435 (15.5)
 Former smoker10,718 (41.7)3,232 (32.2)7,486 (47.7)
Alcohol consumption<0.001
 Never/light4,127 (15.2)2,263 (21.4)1,864 (11.2)
 Moderate19,099 (70.3)7,331 (69.2)11,768 (71.0)
 High3,934 (14.5)997 (9.4)2,937 (17.7)
Diabetes2,561 (9.4)735 (6.9)1,826 (11)<0.001
Dyslipidemia13,417 (49.4)4,891 (46.2)8,526 (51.5)<0.001
CKD226 (0.8)85 (0.8)141 (0.9)0.719
Pre-existing CVD1,638 (6.0)362 (3.4)1,276 (7.7)<0.001
Systolic BP147.18 (14.52)145.15 (15.70)148.48 (13.55)<0.001
Diastolic BP84.98 (9.45)83.57 (9.68)85.87 (9.20)
Awareness of HTN10,189 (37.5)4,455 (42.1)5,734 (34.6)<0.001
CharacteristicsAllWomenMenPa
N27,16010,59116,569
Age groups (years)<0.001
 18–392,796 (10.3)697 (6.6)2,099 (12.7)
 40–494,182 (15.4)1,466 (13.8)2,716 (16.4)
 50–597,842 (28.9)3,171 (29.9)4,671 (28.2)
 ≥6012,340 (45.4)5,257 (49.6)7,083 (42.7)
Familial status<0.001
 Couple20,683 (76.2)7,519 (71.0)13,164 (79.4)
Education level<0.001
 High school10,526 (38.8)3,997 (37.7)6,529 (39.4)
 Undergraduate9,985 (36.8)4,360 (41.2)5,625 (33.9)
 Graduate6,562 (24.2)2,202 (20.8)4,360 (26.3)
Household income<0.001
 Very high (>4,200€/month)7,315 (26.9)2,456 (23.2)4,859 (29.3)
 High13,283 (48.9)5,235 (49.4)8,048 (48.6)
 Medium5,376 (19.8)2,410 (22.8)2,966 (17.9)
 Low (<1,000€/month)1,186 (4.4)490 (4.6)696 (4.2)
BMI27.03 (4.72)26.68 (5.53)27.25 (4.11)<0.001
DASH score27.73 (4.15)29.06 (3.79)26.88 (4.14)<0.001
Physical activity<0.001
 None or low2,636 (9.7)854 (8.1)1,782 (10.8)
 Mild to moderate16,411 (60.4)6,332 (59.8)10,079 (60.8)
 Vigorous to intense8,113 (29.9)3,405 (32.1)4,708 (28.4)
Smoking<0.001
 Nonsmoker11,417 (44.4)5,641 (60.4)5,776 (39.1)
 Current smoker3,597 (14.0)1,162 (11.6)2,435 (15.5)
 Former smoker10,718 (41.7)3,232 (32.2)7,486 (47.7)
Alcohol consumption<0.001
 Never/light4,127 (15.2)2,263 (21.4)1,864 (11.2)
 Moderate19,099 (70.3)7,331 (69.2)11,768 (71.0)
 High3,934 (14.5)997 (9.4)2,937 (17.7)
Diabetes2,561 (9.4)735 (6.9)1,826 (11)<0.001
Dyslipidemia13,417 (49.4)4,891 (46.2)8,526 (51.5)<0.001
CKD226 (0.8)85 (0.8)141 (0.9)0.719
Pre-existing CVD1,638 (6.0)362 (3.4)1,276 (7.7)<0.001
Systolic BP147.18 (14.52)145.15 (15.70)148.48 (13.55)<0.001
Diastolic BP84.98 (9.45)83.57 (9.68)85.87 (9.20)
Awareness of HTN10,189 (37.5)4,455 (42.1)5,734 (34.6)<0.001

Data are presented as the mean followed by standard deviation for quantitative variables and for categorical variables as numbers followed by percentage. Abbreviations: BMI, body mass index; BP, blood pressure, CKD, chronic kidney disease; CVD, cardiovascular disease; DASH, dietary approach to stop hypertension; HTN, hypertension; N, number of participants.

aP value: difference between men and women.

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Among the 27,160 hypertensive participants, 37.5% of participants (5,734 men (34.6%) and 4,455 women (42.1%)) were aware of their HTN status.

Factors associated with unawareness of hypertension

The association between unawareness of HTN and individual characteristics is reported in Table 2 for men and Table 3 for women. Hypertension awareness increased with age, and in every age group women had a higher age-specific rate of hypertension awareness than men (Figure 1).

Table 2.

Multivariate adjusted odds ratios (ORs) of hypertension unawareness, function of sociodemographic, health and lifestyle factors in men

FactorsUnaware of having HTNAware of having HTNORa [95% CI]aP
Age groups (years)
 18–391,911 (17.6)188 (3.3)1 (Ref)
 40–492,142 (19.8)574 (10.0)0.42 [0.35–0.50]<0.0001
 50–593,022 (27.9)1,649 (28.8)0.22 [0.18–0.26]<0.0001
 ≥603,760 (34.7)3,323 (58.0)0.14[0.12–0.17]<0.0001
Education level
 High school4,025 (37.1)2,504 (43.7)1 (Ref)
 Undergraduate3,825 (35.3)1,800 (31.4)0.91 [0.83–0.99]0.028
 Graduate2,955 (27.3)1,405 (24.5)0.89 [0.81–0.97]0.014
BMI26.60 (3.80)28.47 (4.38)0.91 [0.90–0.92]<0.0001
DASH score26.70 (4.18)27.20 (4.06)0.99 [0.98–1.00]0.4799
Smoking
 Nonsmoker3,987 (38.7)1,789 (33.2)1 (Ref)
 Current smoker1,766 (17.1)669 (12.4)1.06 [0.94–1.19]0.290
 Former smoker4,550 (44.2)2,936 (54.4)0.98 [0.90–1.06]0.714
Alcohol consumption
 Never/light1,187 (11.0)677 (11.8)1 (Ref)
 Moderate7,834 (72.3)3,934 (68.6)1.11 [0.99–1.25]0.056
 High1,814 (16.7)1,123 (19.6)1.05 [0.91–1.20]0.469
Diabetes
 Yes736 (6.8)1,090 (19.0)0.55 [0.49–0.62]<0.0001
Dyslipidemia
 Yes4,941 (45.6)3,585 (62.5)0.76 [0.70–0.82]<0.0001
CKD
 Yes42 (0.4)99 (1.7)0.29 [0.19–0.44]<0.0001
Pre-existing CVD
Yes558 (5.1)718 (12.5)0.62 [0.54–0.70]<0.0001
FactorsUnaware of having HTNAware of having HTNORa [95% CI]aP
Age groups (years)
 18–391,911 (17.6)188 (3.3)1 (Ref)
 40–492,142 (19.8)574 (10.0)0.42 [0.35–0.50]<0.0001
 50–593,022 (27.9)1,649 (28.8)0.22 [0.18–0.26]<0.0001
 ≥603,760 (34.7)3,323 (58.0)0.14[0.12–0.17]<0.0001
Education level
 High school4,025 (37.1)2,504 (43.7)1 (Ref)
 Undergraduate3,825 (35.3)1,800 (31.4)0.91 [0.83–0.99]0.028
 Graduate2,955 (27.3)1,405 (24.5)0.89 [0.81–0.97]0.014
BMI26.60 (3.80)28.47 (4.38)0.91 [0.90–0.92]<0.0001
DASH score26.70 (4.18)27.20 (4.06)0.99 [0.98–1.00]0.4799
Smoking
 Nonsmoker3,987 (38.7)1,789 (33.2)1 (Ref)
 Current smoker1,766 (17.1)669 (12.4)1.06 [0.94–1.19]0.290
 Former smoker4,550 (44.2)2,936 (54.4)0.98 [0.90–1.06]0.714
Alcohol consumption
 Never/light1,187 (11.0)677 (11.8)1 (Ref)
 Moderate7,834 (72.3)3,934 (68.6)1.11 [0.99–1.25]0.056
 High1,814 (16.7)1,123 (19.6)1.05 [0.91–1.20]0.469
Diabetes
 Yes736 (6.8)1,090 (19.0)0.55 [0.49–0.62]<0.0001
Dyslipidemia
 Yes4,941 (45.6)3,585 (62.5)0.76 [0.70–0.82]<0.0001
CKD
 Yes42 (0.4)99 (1.7)0.29 [0.19–0.44]<0.0001
Pre-existing CVD
Yes558 (5.1)718 (12.5)0.62 [0.54–0.70]<0.0001

Abbreviations: BMI, body mass index; CI, confidence interval; CKD, chronic kidney disease; CVD, cardiovascular disease; DASH, dietary approach to stop hypertension; ORa, adjusted odds ratio.

aMultivariate logistic regression model including all variables in the table.

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Table 2.

Multivariate adjusted odds ratios (ORs) of hypertension unawareness, function of sociodemographic, health and lifestyle factors in men

FactorsUnaware of having HTNAware of having HTNORa [95% CI]aP
Age groups (years)
 18–391,911 (17.6)188 (3.3)1 (Ref)
 40–492,142 (19.8)574 (10.0)0.42 [0.35–0.50]<0.0001
 50–593,022 (27.9)1,649 (28.8)0.22 [0.18–0.26]<0.0001
 ≥603,760 (34.7)3,323 (58.0)0.14[0.12–0.17]<0.0001
Education level
 High school4,025 (37.1)2,504 (43.7)1 (Ref)
 Undergraduate3,825 (35.3)1,800 (31.4)0.91 [0.83–0.99]0.028
 Graduate2,955 (27.3)1,405 (24.5)0.89 [0.81–0.97]0.014
BMI26.60 (3.80)28.47 (4.38)0.91 [0.90–0.92]<0.0001
DASH score26.70 (4.18)27.20 (4.06)0.99 [0.98–1.00]0.4799
Smoking
 Nonsmoker3,987 (38.7)1,789 (33.2)1 (Ref)
 Current smoker1,766 (17.1)669 (12.4)1.06 [0.94–1.19]0.290
 Former smoker4,550 (44.2)2,936 (54.4)0.98 [0.90–1.06]0.714
Alcohol consumption
 Never/light1,187 (11.0)677 (11.8)1 (Ref)
 Moderate7,834 (72.3)3,934 (68.6)1.11 [0.99–1.25]0.056
 High1,814 (16.7)1,123 (19.6)1.05 [0.91–1.20]0.469
Diabetes
 Yes736 (6.8)1,090 (19.0)0.55 [0.49–0.62]<0.0001
Dyslipidemia
 Yes4,941 (45.6)3,585 (62.5)0.76 [0.70–0.82]<0.0001
CKD
 Yes42 (0.4)99 (1.7)0.29 [0.19–0.44]<0.0001
Pre-existing CVD
Yes558 (5.1)718 (12.5)0.62 [0.54–0.70]<0.0001
FactorsUnaware of having HTNAware of having HTNORa [95% CI]aP
Age groups (years)
 18–391,911 (17.6)188 (3.3)1 (Ref)
 40–492,142 (19.8)574 (10.0)0.42 [0.35–0.50]<0.0001
 50–593,022 (27.9)1,649 (28.8)0.22 [0.18–0.26]<0.0001
 ≥603,760 (34.7)3,323 (58.0)0.14[0.12–0.17]<0.0001
Education level
 High school4,025 (37.1)2,504 (43.7)1 (Ref)
 Undergraduate3,825 (35.3)1,800 (31.4)0.91 [0.83–0.99]0.028
 Graduate2,955 (27.3)1,405 (24.5)0.89 [0.81–0.97]0.014
BMI26.60 (3.80)28.47 (4.38)0.91 [0.90–0.92]<0.0001
DASH score26.70 (4.18)27.20 (4.06)0.99 [0.98–1.00]0.4799
Smoking
 Nonsmoker3,987 (38.7)1,789 (33.2)1 (Ref)
 Current smoker1,766 (17.1)669 (12.4)1.06 [0.94–1.19]0.290
 Former smoker4,550 (44.2)2,936 (54.4)0.98 [0.90–1.06]0.714
Alcohol consumption
 Never/light1,187 (11.0)677 (11.8)1 (Ref)
 Moderate7,834 (72.3)3,934 (68.6)1.11 [0.99–1.25]0.056
 High1,814 (16.7)1,123 (19.6)1.05 [0.91–1.20]0.469
Diabetes
 Yes736 (6.8)1,090 (19.0)0.55 [0.49–0.62]<0.0001
Dyslipidemia
 Yes4,941 (45.6)3,585 (62.5)0.76 [0.70–0.82]<0.0001
CKD
 Yes42 (0.4)99 (1.7)0.29 [0.19–0.44]<0.0001
Pre-existing CVD
Yes558 (5.1)718 (12.5)0.62 [0.54–0.70]<0.0001

Abbreviations: BMI, body mass index; CI, confidence interval; CKD, chronic kidney disease; CVD, cardiovascular disease; DASH, dietary approach to stop hypertension; ORa, adjusted odds ratio.

aMultivariate logistic regression model including all variables in the table.

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Table 3.

Multivariate adjusted odds ratios (ORs) of hypertension unawareness function of sociodemographic, health, and lifestyle factors in women

FactorsUnaware of having HTNAware of having HTNORa [95% CI]aP
Age groups (years)
 18–39553 (9.0)144 (3.2)1 (Ref)
 40–491,015 (16.5)451 (10.1)0.59 [0.47–0.75]<0.0001
 50–591,866 (30.4)1,305 (29.3)0.36 [0.29–0.44]<0.0001
 ≥602,702 (44.0)2,555 (57.4)0.26 [0.21–0.32]<0.0001
Education level
 High school2,099 (34.2)1,898 (42.6)1 (Ref)
 Undergraduate2,595 (42.3)1,765 (39.6)1.06 [0.96–1.16]0.223
 Graduate1,424 (23.2)778 (17.5)1.23 [1.09–1.40]0.001
Household income (€)
 2,100–4,200 per month3,002 (48.9)2,233 (50.1)1 (Ref)
 ≥4,200 per month1,531 (25.0)925 (20.8)1.08 [0.96–1.20]0.159
 <1,000 per month264 (4.3)226 (5.1)1.03 [0.83–1.28]0.748
 1,000–2,100 per month1,339 (21.8)1,071 (24.0)1.05 [0.94–1.17]0.324
BMI25.91 (5.22)27.73 (5.77)0.94 [0.94–0.95]<0.0001
Physical activity
 None or low439 (7.2)415 (9.3)1 (Ref)
 Mild to moderate3,663 (59.7)2,669 (59.9)1.25 [1.07–1.46]0.004
 Vigorous to intense2,034 (33.1)1,371 (30.8)1.39 [1.17–1.64]<0.0001
Smoking
 Nonsmoker3,245 (55.5)2,396 (57.2)1 (Ref)
 Current smoker722 (12.3)440 (10.5)0.98 [0.85–1.13]0.824
 Former smoker1,881 (32.2)1,351 (32.3)1.02 [0.93–1.12]0.556
Alcohol consumption
 Never/light1,233 (20.1)1,030 (23.1)1 (Ref)
 Moderate4,318 (70.4)3,013 (67.6)1.12 [1.01–1.24]0.027
 High585 (9.5)412 (9.2)1.19 [1.01–1.40]0.035
Diabetes
 Yes253 (4.1)482 (10.8)0.52 [0.44–0.62]<0.0001
Dyslipidemia
 Yes2,582 (42.1)2,309 (51.8)0.94 [0.87–1.03]0.240
CKD
 Yes27 (0.4)58 (1.3)0.33 [0.19–0.53]<0.0001
Pre-existing CVD
 Yes150 (2.4)212 (4.8)0.60 [0.48–0.76]<0.0001
FactorsUnaware of having HTNAware of having HTNORa [95% CI]aP
Age groups (years)
 18–39553 (9.0)144 (3.2)1 (Ref)
 40–491,015 (16.5)451 (10.1)0.59 [0.47–0.75]<0.0001
 50–591,866 (30.4)1,305 (29.3)0.36 [0.29–0.44]<0.0001
 ≥602,702 (44.0)2,555 (57.4)0.26 [0.21–0.32]<0.0001
Education level
 High school2,099 (34.2)1,898 (42.6)1 (Ref)
 Undergraduate2,595 (42.3)1,765 (39.6)1.06 [0.96–1.16]0.223
 Graduate1,424 (23.2)778 (17.5)1.23 [1.09–1.40]0.001
Household income (€)
 2,100–4,200 per month3,002 (48.9)2,233 (50.1)1 (Ref)
 ≥4,200 per month1,531 (25.0)925 (20.8)1.08 [0.96–1.20]0.159
 <1,000 per month264 (4.3)226 (5.1)1.03 [0.83–1.28]0.748
 1,000–2,100 per month1,339 (21.8)1,071 (24.0)1.05 [0.94–1.17]0.324
BMI25.91 (5.22)27.73 (5.77)0.94 [0.94–0.95]<0.0001
Physical activity
 None or low439 (7.2)415 (9.3)1 (Ref)
 Mild to moderate3,663 (59.7)2,669 (59.9)1.25 [1.07–1.46]0.004
 Vigorous to intense2,034 (33.1)1,371 (30.8)1.39 [1.17–1.64]<0.0001
Smoking
 Nonsmoker3,245 (55.5)2,396 (57.2)1 (Ref)
 Current smoker722 (12.3)440 (10.5)0.98 [0.85–1.13]0.824
 Former smoker1,881 (32.2)1,351 (32.3)1.02 [0.93–1.12]0.556
Alcohol consumption
 Never/light1,233 (20.1)1,030 (23.1)1 (Ref)
 Moderate4,318 (70.4)3,013 (67.6)1.12 [1.01–1.24]0.027
 High585 (9.5)412 (9.2)1.19 [1.01–1.40]0.035
Diabetes
 Yes253 (4.1)482 (10.8)0.52 [0.44–0.62]<0.0001
Dyslipidemia
 Yes2,582 (42.1)2,309 (51.8)0.94 [0.87–1.03]0.240
CKD
 Yes27 (0.4)58 (1.3)0.33 [0.19–0.53]<0.0001
Pre-existing CVD
 Yes150 (2.4)212 (4.8)0.60 [0.48–0.76]<0.0001

Abbreviations: BMI, body mass index; CI, confidence interval; CKD, chronic kidney disease; CVD, cardiovascular disease; ORa, adjusted odds ratio.

*Multivariate logistic regression model including all variables in the table.

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Table 3.

Multivariate adjusted odds ratios (ORs) of hypertension unawareness function of sociodemographic, health, and lifestyle factors in women

FactorsUnaware of having HTNAware of having HTNORa [95% CI]aP
Age groups (years)
 18–39553 (9.0)144 (3.2)1 (Ref)
 40–491,015 (16.5)451 (10.1)0.59 [0.47–0.75]<0.0001
 50–591,866 (30.4)1,305 (29.3)0.36 [0.29–0.44]<0.0001
 ≥602,702 (44.0)2,555 (57.4)0.26 [0.21–0.32]<0.0001
Education level
 High school2,099 (34.2)1,898 (42.6)1 (Ref)
 Undergraduate2,595 (42.3)1,765 (39.6)1.06 [0.96–1.16]0.223
 Graduate1,424 (23.2)778 (17.5)1.23 [1.09–1.40]0.001
Household income (€)
 2,100–4,200 per month3,002 (48.9)2,233 (50.1)1 (Ref)
 ≥4,200 per month1,531 (25.0)925 (20.8)1.08 [0.96–1.20]0.159
 <1,000 per month264 (4.3)226 (5.1)1.03 [0.83–1.28]0.748
 1,000–2,100 per month1,339 (21.8)1,071 (24.0)1.05 [0.94–1.17]0.324
BMI25.91 (5.22)27.73 (5.77)0.94 [0.94–0.95]<0.0001
Physical activity
 None or low439 (7.2)415 (9.3)1 (Ref)
 Mild to moderate3,663 (59.7)2,669 (59.9)1.25 [1.07–1.46]0.004
 Vigorous to intense2,034 (33.1)1,371 (30.8)1.39 [1.17–1.64]<0.0001
Smoking
 Nonsmoker3,245 (55.5)2,396 (57.2)1 (Ref)
 Current smoker722 (12.3)440 (10.5)0.98 [0.85–1.13]0.824
 Former smoker1,881 (32.2)1,351 (32.3)1.02 [0.93–1.12]0.556
Alcohol consumption
 Never/light1,233 (20.1)1,030 (23.1)1 (Ref)
 Moderate4,318 (70.4)3,013 (67.6)1.12 [1.01–1.24]0.027
 High585 (9.5)412 (9.2)1.19 [1.01–1.40]0.035
Diabetes
 Yes253 (4.1)482 (10.8)0.52 [0.44–0.62]<0.0001
Dyslipidemia
 Yes2,582 (42.1)2,309 (51.8)0.94 [0.87–1.03]0.240
CKD
 Yes27 (0.4)58 (1.3)0.33 [0.19–0.53]<0.0001
Pre-existing CVD
 Yes150 (2.4)212 (4.8)0.60 [0.48–0.76]<0.0001
FactorsUnaware of having HTNAware of having HTNORa [95% CI]aP
Age groups (years)
 18–39553 (9.0)144 (3.2)1 (Ref)
 40–491,015 (16.5)451 (10.1)0.59 [0.47–0.75]<0.0001
 50–591,866 (30.4)1,305 (29.3)0.36 [0.29–0.44]<0.0001
 ≥602,702 (44.0)2,555 (57.4)0.26 [0.21–0.32]<0.0001
Education level
 High school2,099 (34.2)1,898 (42.6)1 (Ref)
 Undergraduate2,595 (42.3)1,765 (39.6)1.06 [0.96–1.16]0.223
 Graduate1,424 (23.2)778 (17.5)1.23 [1.09–1.40]0.001
Household income (€)
 2,100–4,200 per month3,002 (48.9)2,233 (50.1)1 (Ref)
 ≥4,200 per month1,531 (25.0)925 (20.8)1.08 [0.96–1.20]0.159
 <1,000 per month264 (4.3)226 (5.1)1.03 [0.83–1.28]0.748
 1,000–2,100 per month1,339 (21.8)1,071 (24.0)1.05 [0.94–1.17]0.324
BMI25.91 (5.22)27.73 (5.77)0.94 [0.94–0.95]<0.0001
Physical activity
 None or low439 (7.2)415 (9.3)1 (Ref)
 Mild to moderate3,663 (59.7)2,669 (59.9)1.25 [1.07–1.46]0.004
 Vigorous to intense2,034 (33.1)1,371 (30.8)1.39 [1.17–1.64]<0.0001
Smoking
 Nonsmoker3,245 (55.5)2,396 (57.2)1 (Ref)
 Current smoker722 (12.3)440 (10.5)0.98 [0.85–1.13]0.824
 Former smoker1,881 (32.2)1,351 (32.3)1.02 [0.93–1.12]0.556
Alcohol consumption
 Never/light1,233 (20.1)1,030 (23.1)1 (Ref)
 Moderate4,318 (70.4)3,013 (67.6)1.12 [1.01–1.24]0.027
 High585 (9.5)412 (9.2)1.19 [1.01–1.40]0.035
Diabetes
 Yes253 (4.1)482 (10.8)0.52 [0.44–0.62]<0.0001
Dyslipidemia
 Yes2,582 (42.1)2,309 (51.8)0.94 [0.87–1.03]0.240
CKD
 Yes27 (0.4)58 (1.3)0.33 [0.19–0.53]<0.0001
Pre-existing CVD
 Yes150 (2.4)212 (4.8)0.60 [0.48–0.76]<0.0001

Abbreviations: BMI, body mass index; CI, confidence interval; CKD, chronic kidney disease; CVD, cardiovascular disease; ORa, adjusted odds ratio.

*Multivariate logistic regression model including all variables in the table.

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Figure 1.
Awareness of hypertension in the CONSTANCES cohort according to age and sex.
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Awareness of hypertension in the CONSTANCES cohort according to age and sex.

In men, multivariate logistic regression model has shown that unawareness of HTN was inversely associated with age (ORa = 0.14; 95% CI = 0.12–0.17; P < 0.0001), presence of CKD (ORa = 0.29; 95% CI = 0.19–0.44; P <0.0001), presence of DM (ORa = 0.55; 95% CI = 0.49–0.62; P < 0.0001), history of preexisting CVD (ORa = 0.62; 95% CI = 0.54–0.70; P < 0.0001), presence of dyslipidemia (ORa = 0.76; 95% CI = 0.70–0.82; P < 0.0001), higher level of education (ORa = 0.89; 95% CI = 0.81–0.97; P = 0.014), and being obese or overweight (ORa = 0.91; 95% CI = 0.90–0.92; P < 0.0001), but neither DASH score, alcohol consumption nor smoking status significantly entered the model.

In women, multivariate logistic regression model has shown that unawareness of HTN was inversely associated with age (ORa = 0.26; 95% CI = 0.21–0.32; P < 0.0001), presence of CKD (ORa = 0.32; 95% CI = 0.19–0.53; P < 0.0001), presence of DM (ORa = 0.52; 95% CI = 0.44–0.62; P < 0.0001), history of preexisting CVD (ORa = 0.60; 95% CI = 0.48–0.76; P < 0.0001), and being obese or overweight (ORa = 0.94; 95% CI = 0.94–0.95; P < 0.0001). Unawareness of HTN was significantly associated with a higher level of education (ORa = 1.23; 95% CI = 1.09–1.40; P = 0.001), a higher alcohol consumption (ORa = 1.19; 95% CI = 1.01–1.40; P = 0.035) and a more intense physical activity (ORa = 1.39; 95% CI = 1.17–1.64; P < 0.0001) but neither household income, smoking status nor dyslipidemia showed a significant association with unawareness of HTN in women.

Interestingly enough, the unawareness among participants without cardiometabolic factors (CMF, i.e., CVD, DM, CKD) was higher than participants with CMF (67% vs. 41% respectively, P < 0.001) (Table 4).

Table 4.

Unawareness of HTN in the population with and without cardiometabolic factors

At least 1 CMFNo CMFP
Unawareness, n (%) Men and Women1,660 (41.2)15,274 (66.7)<0.001
Unawareness, n (%) Men only1,252 (43.0)9,560 (70.7)<0.001
Unawareness, n (%) Women only408 (36.5)5,714 (61.0)<0.001
At least 1 CMFNo CMFP
Unawareness, n (%) Men and Women1,660 (41.2)15,274 (66.7)<0.001
Unawareness, n (%) Men only1,252 (43.0)9,560 (70.7)<0.001
Unawareness, n (%) Women only408 (36.5)5,714 (61.0)<0.001

Abbreviation: CMF, cardiometabolic factors (i.e., CKD, DM, CVD).

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Table 4.

Unawareness of HTN in the population with and without cardiometabolic factors

At least 1 CMFNo CMFP
Unawareness, n (%) Men and Women1,660 (41.2)15,274 (66.7)<0.001
Unawareness, n (%) Men only1,252 (43.0)9,560 (70.7)<0.001
Unawareness, n (%) Women only408 (36.5)5,714 (61.0)<0.001
At least 1 CMFNo CMFP
Unawareness, n (%) Men and Women1,660 (41.2)15,274 (66.7)<0.001
Unawareness, n (%) Men only1,252 (43.0)9,560 (70.7)<0.001
Unawareness, n (%) Women only408 (36.5)5,714 (61.0)<0.001

Abbreviation: CMF, cardiometabolic factors (i.e., CKD, DM, CVD).

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Furthermore, in a multivariate logistic regression model with unawareness as the outcome and the explanatory variables identified as potentially pertinent by the univariate analyses (P < 0.05) in men and women, there is a significant interaction between “sex” and “education level” (P = 0.0037).

DISCUSSION

In this large population-based study, 37.5% of participants (men 34.6%, women 42.1%) were aware of their HTN status. Our findings suggest that HTN awareness is associated with age, female gender, history of preexisting CVD, presence of DM, presence of CKD, level of education, and being obese or overweight. The awareness of HTN was higher among participants with CMF compared with participants without CMF. Some differences appeared in both genders in the association between awareness of HTN and sociodemographic, health, and lifestyle factors.

French awareness proportions reported in this article are worse than high15 and low-income3 countries (United States 79% vs. 86%, Canada 84% vs. 72%, United Kingdom 67% vs. 70%, Germany 82% vs. 87%, low-income countries 36% vs. 44%, respectively, in men and women). Moreover, our data revealed that current awareness of HTN in France has decreased substantially in both gender (51.8% vs. 69.8% in the 1990s,7 49.4% vs. 73.1% in 1997–1998,8 54% vs. 66% in 2005–2007,9 respectively, in men and women) whereas studies reported an increase in awareness in neighboring European countries.15 One potential explanation could be the recent worsening of distrust towards physicians’ motivation in France mainly due to the Mediator scandal16 and the recurrent negative messages in the media concerning statins, vaccines, and so on.17 Some “unaware” patients might be suspicious of their HTN diagnosis because they believe that their providers had made mistakes or had financial motivations. Another possible explanation could be physician inertia especially in diagnosis inertia for screening or confirming the diagnosis of HTN.18 Furthermore, the trend of HTN awareness in France highlights the importance to determine what can be learned from experience in other countries. Conversely to the European and North American countries mentioned above, France does not have national screening or hypertension education programs. However, it has shown an improvement in HTN awareness, notably in Canada where the Canadian Hypertension Education Program (CHEP) was associated with large increase in HTN awareness.19 The CHEP is a group of experts in HTN sponsored by multiples governmental and medical organizations. It targets various healthcare professionals, provides, disseminates, and evaluates annually updated recommendations. On the contrary, the French guidelines can take up to 8 years20–22to be updated, sometimes published and passively disseminated by the French Society of Hypertension only, without the collaboration of the French Public health Agency or any other organizations.22 This may explain their suboptimal implementation in clinical practice and the subsequent trend down of HTN awareness when these guidelines were developed with the objective of allowing a greater number of patients with HTN to be detected. As a matter of fact, the physicians do not spend enough time to repeat the BP measurements. Although home BP monitoring (HBPM) is recommended to overcome these issues,23 neither French nor European guidelines on HBPM have been implemented properly by French physicians.24 Meanwhile, the French Society of Hypertension has recently mentioned the urgent need for organizational changes of HTN management in France25 including a working group on HTN screening.26 Our findings may provide useful information that can be used for planning interventions aimed at improving hypertension awareness in France.

Sociodemographic factors

As reported in other studies in France7,9 and elsewhere,27,28 the CONSTANCES study revealed a higher rate of HTN awareness among women compared with men. As previously suggested by others, this may be due to men use health care services at a much lower rate than women.29 Other explanation is that women regularly interact with health care professionals to access birth control, gynecological health, maternal, and childcare-oriented programs30 and therefore they may be more likely to have their BP measured than men.

Similar to previous studies,27,28 older adults were much more aware of hypertension than younger individuals in both men and women. These may be the expected findings, as older individuals usually suffer from more comorbidities and they may have hypertension longer than young adults, which may increase use of healthcare and the opportunity of HTN diagnosis. Conversely younger individuals tend to be healthier, they are less likely to see doctors, decreasing the probability of awareness of HTN.31 Therefore, school or worksite-based health screening may reach young adults more successfully.32

The associations between socioeconomic status and HTN awareness are inconsistent. Some reports showed no association between education level and HTN awareness33 and others have reported that greater education was associated with greater awareness.3 Previous findings that being married was associated with higher awareness34 and being single or divorced was associated with higher unawareness35 were not replicated here. In the present study, we found a gender difference in the relationships between awareness and education level. A higher level of education is positively associated with awareness in men and negatively associated in women. It is unexpected that the higher educated women were more likely unaware but we found some evidence to corroborate our results. Liu et al.28 found that the better educated people were more likely to be unaware of their hypertension but reasons remained unclear. There was no significant association between awareness and household incomes. This may be related to the French health care system particularities, as in France, access to medical care is almost universal. Several studies have shown that HTN awareness was higher in urban communities compared with rural areas, however previous findings suggest that HTN awareness is similar in urban and rural setting in high-income countries.3 The difference between urban and rural communities was not analyzed in our study, but should be explored in future research.5

Comorbidities

As reported in other studies,27,36 we found that the presence of CKD, DM, preexisting CVD, and being overweight or obese were positively associated with awareness of HTN. Furthermore, we observed that people without CMF had comparatively lower level of awareness. These results might suggest that those who have these comorbidities are subject to more intense screening for HTN, and often pay close attention to their health.37 Interestingly enough, in our study the presence of CKD and diabetes have both a strong association with awareness of hypertension. Previous European guidelines38 recommended a lower BP target for these high risk patients which might contribute to higher rates of awareness in these specific subgroups.

Strengths and limitations

The main strength of our study is the design of CONSTANCES, which ensure sufficient statistical power and socioeconomic diversity; we adopted a population-based approach using a large nationwide randomly selected sample of participants. To our knowledge, in contrast to the previous studies who appraised the awareness of HTN in French populations,7–9 CONSTANCES is currently the largest study, including persons aged 18–69, living and working in diverse settings, from large cities to small villages in different regions of France, with a broad range of socioeconomic status and trades. On the other hand, several limitations should also be addressed. As in many epidemiologic cohorts, BP was measured in a single visit (although three measurements were taken after rest at that visit); which might have overestimated the proportion of hypertensive patients and consequently might have underestimated awareness of hypertension.8 Furthermore, white coat effect and masked hypertension could possibly impact HTN awareness. Unfortunately, home blood pressure self-measurement was not assessed in the CONSTANCES cohort study. Thus, we cannot estimate the percentage of white coat effect and masked hypertension in our study. However, some data from France suggest that these percentages are similar and therefore the single BP measurement does not actually overestimate HTN prevalence and underestimate awareness.39 Moreover, due to the voluntary participation of cohort members, there was probably an underrepresentation of hard-to-reach subjects, such as heavy drinkers or socially excluded persons,5 which might contribute to a selective bias. Also, HTN awareness, social, demographic, health information, and lifestyle behaviors were based on self-report and potentially subject to recall bias. Finally, because our study was a cross-sectional survey, we could not establish cause-and-effect relationships between awareness of hypertension and sociodemographic, health, and lifestyle factors.

In conclusion, our results suggest that HTN awareness is low. Therefore, our findings have important public health implications and highlight the need for targeting and reviewing the communication strategies for specific population groups (mainly, men < 60 without comorbidities) for more effective hypertension awareness programs in France.

ACKNOWLEDGMENTS

The Constances Cohort Study was supported and funded by the National Health Insurance Administration. The Constances Cohort Study is an “Infrastructure nationale en Biologie et Santé” and benefits from a grant from Agence National de la Recherche (ANR) (ANR-11-INBS-0002) and the Ministère de l’Enseignement Supérieur et de la Recherche. Constances is also partly funded by Merck Sharp and Dohme (MSD), AstraZeneca and H. Lundbeck A/S.

DISCLOSURE

The authors declared no conflict of interest.

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