Effectiveness of a community-based educational intervention to reduce cardiovascular risk among hypertensive adults in Ecuador: a quasi-experimental study

Effectiveness of a community-based educational intervention to reduce cardiovascular risk among hypertensive adults in Ecuador: a quasi-experimental study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of a community-based educational intervention to reduce cardiovascular risk among hypertensive adults in Ecuador: a quasi-experimental study Verónica Bertha Sarango Varzallo, Rosario Suárez, Tamara Rodríguez Quintana, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6648692/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Arterial hypertension (AH) is a leading risk factor for cardiovascular diseases (CVDs) and plays a key role in determining cardiovascular risk (CVR). Strategies to reduce CVR are fundamental in primary health care. Objective: To evaluate the effectiveness of an educational intervention on improving knowledge about CVDs and reducing CVR levels in hypertensive patients at a health center in Ecuador. Methods: A quasi-experimental before-and-after study was conducted with 55 hypertensive adults. CVR was assessed using the Globorisk scale, and knowledge about CVDs was measured through a validated questionnaire from the EMDADER-CV study. Baseline and six-month post-intervention measurements were compared. Clinical trial number: not applicable. Ethical considerations: The study was approved by the corresponding ethics committees and conducted in accordance with the Declaration of Helsinki and national regulations. Written informed consent was obtained from all participants. Results: The mean participant age was 58.3 years, with women representing 69.1% of the sample. After six months, the mean CVR significantly decreased from 8.8–5.9% (p < 0.05), and the mean knowledge score significantly increased from 5.2 to 9.0 points (p < 0.05). The proportion of individuals with high or very high CVR declined from 36.4–10.9%, while those at low or moderate risk increased from 63.6–89.1%. Conclusion: The educational strategy was effective in both reducing cardiovascular risk and improving knowledge about CVDs among hypertensive patients in a primary care setting. cardiovascular diseases arterial hypertension cardiovascular risk educational intervention Introduction Arterial hypertension (AH) significantly increases the risk of suffering heart diseases, encephalopathies, nephropathies and other diseases. Its frequency increases with age as a consequence of changes in rigidity of the arteries, vascular remodeling and alterations in the renal and hormonal mechanisms (1)(2). At the global level, there are 1,130 million people with hypertension and most of them (nearly two-thirds) live in countries marked by low socioeconomic conditions. In 2015, 1 out of 4 men and 1 out of 5 women had AH, of which, considering both genders, only 1 out of 5 had the disease under control. AH is one of the main causes of premature death in the world (3). Two groups of cardiovascular risk (CVR) factors can be mentioned: non-modifiable, such as age, gender and family history; and modifiable, which include hypercholesterolemia, smoking habit, diabetes, AH, obesity, sedentary lifestyle and stress (4). AH is an independent risk factor for cardiovascular diseases (CVDs) (5). It is thus fundamental to assess CVR in all patients aged over 40 years old attending a Primary Health Care unit. The age up to which a periodic risk assessment should be performed is unknown; however, many of the validated risk calculators only include patients aged up to 79 years old. In addition, the decisions regarding CVR assessment should be individualized (6). CVD prevention is defined as a series of actions at the population or individual levels that seek to eliminate or minimize the impact of these diseases and their related disabilities. Multiple assessment tools with different groups have been designed to assess CVR, although none of them is suitable for all patients (7). The 10-year CVR estimation by means of the Globorisk tool evaluates all the aforementioned risk factors and was applied to a characteristic multiethnic population; it allows estimating CVR for Ecuador since, during its validation, a Latin American population representative of Mexico was included and because it is the scale recommended by the National Clinical Practice Guide for AH Management, of the Public Health Ministry ( Ministerio de Salud Pública , MSP) (8). The Pan American Health Organization (PAHO) has pointed out that, in Ecuador, approximately 20% of the population aged over 19 years old suffers from AH (9). CVDs are an important health problem because they do not only reduce life expectancy but they also cause physical disability in a high percentage of the population. According to the statistical data, it is considered that 30% of those over the age of 40 suffer from some CVD. In addition, according to the Ensanut survey in Ecuador, 20% of men and 21% of women aged between 30 and 69 years old have presented early mortality due to CVDs (10,11). In the Ecuadorian city of Loja, cardiovascular diseases are among the 10 main causes of mortality with 30.4%; in addition, AH is the leading cause of chronic morbidity with 38.6% (12) and the association of age with higher prevalence of high cardiovascular risk has been shown; therefore, there is a need to promote healthy lifestyles in early life stages (13). It is important that people in general, and especially hypertensive individuals, possess adequate knowledge about these risk factors and are aware of the benefits provided by healthy lifestyle practices (14)(15)(16), so that they contribute to reducing CVR. Although educational interventions are considered slow and hardly effective in changing lifestyles related to CVR (17), they constitute the health care team's starting point at the first care level. However, there are few studies in Ecuador about the assessment of programs based on interventions targeted at educating the population and improving AH and CVR control. The objective of this research was to evaluate the effectiveness of an educational intervention about the knowledge level regarding CVDs and CVR levels, fostering healthy lifestyles in a Primary Health Care center from Loja, Ecuador. It is hypothesized that the community-based educational intervention will significantly reduce cardiovascular risk and improve knowledge about cardiovascular diseases among hypertensive patients. Materials and methods A research study of the quasi-experimental type and with a before-and-after design was conducted with a population of 55 hypertensive patients from three sectors of neighborhoods attached to a health center from the city of Loja, Ecuador. It was carried out during 2021. The work was conducted with 100% of the population that met the following inclusion criteria: subjects with an AH diagnosis and aged between 40 and 74 years old, who were willing to participate and signed the informed consent form, excluding those with cognitive deterioration and pregnant women. The study was developed in three stages: in the first stage, a data collection form specifically designed by the authors for this study was employed to collect both sociodemographic data —age, gender, marital status, schooling level, and occupation— and clinical variables —blood pressure, smoking status, diagnosis of type 2 diabetes mellitus, weight, height, body mass index, and total cholesterol. This form is included as a supplementary file (see Appendix 1). In addition, the Questionnaire to assess knowledge about cardiovascular risk factors and diseases used in the study called Effect of the Dáder Pharmacotherapy Follow-Up Method on the cardiovascular risk of patients with cardiovascular risk factors or diseases (EMDADER-CV) (18) was applied, which consists of 10 questions where the score for each question is 1 (if answered correctly) or 0 (if answered incorrectly), generating an ordinal result between 0 and 10, where 0 represents the worst knowledge level and 10, the best. In addition, less than 7 points was defined as inadequate knowledge and 7 points or more, as adequate. This test had been already validated, obtaining a Cronbach's alpha value of 0.88 and, according to the intraclass correlation coefficient, a reliability level between acceptable and excellent (18). The CVR level was also calculated using the Globorisk tool (lab form), which includes the following parameters: gender, age, total blood cholesterol levels, smoking/non-smoking or diabetes history, and systolic blood pressure values (mmHg). This tool allows classifying the CVR levels as follows: Low risk: <5%; Moderate risk: ≥5% and < 10%; High risk: ≥10% and < 20%; and Very high risk: ≥20% (8). The anthropometric variables measured were weight in kilograms and height in meters. For weight and height, a Rise Lake® portable mechanical scale with a tallimeter for adults was used, which was placed on a stable and flat floor. The participants' weight and height were measured with them barefooted. An OMRON® digital tensiometer was used to measure blood pressure (BP). Each participant was subjected to three measurements with three-minute intervals, following the STEPwise method recommendations (19), using the mean of the second and third AH readings in the analysis. Arterial hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg, according to the 2019 Clinical Practice Guide for arterial hypertension issued by the Ecuadorian MSP (8) In the second stage, an educational strategy was implemented by means of five individual sessions, conducted once a month within the Health Center facilities or in home visits. Each session consisted in a conversation about the following: Session 1, Risk factors for CVDs, both modifiable and non-modifiable; Session 2, Healthy eating; Session 3, Physical exercise; Session 4, Smoking cessation; and Session 5, Importance and practical advice about pharmacological adherence, lasting 40 minutes each. For the Healthy eating, Physical exercise and Smoking cessation sessions, the 5 As strategy (“ Averiguar, Asesorar, Apreciar, Ayudar y Arreglar ” [“Find out, Advise, Assess, Help and Fix”]) was used based on the HEARTS technical bundle for the management of cardiovascular diseases in Primary Health Care issued by the Pan American Health Organization (PAHO), in addition to handing in educational didactic material to the patients (20). In the third stage, effectiveness of the educational strategy was assessed by means of a new evaluation of CVR and the knowledge level about CVDs, using the same instruments from the pre-intervention assessment. The data were analyzed in SPSS 24®. The quantitative variables were presented as central tendency and dispersion measures and the qualitative variables, as frequencies and percentages. In order to assess the effectiveness of the educational strategy, the means of the CVR values and of the knowledge level score were compared by means of the Student's t test for related samples. In turn, to compare the results of the qualitative variables, the McNemar test was used after verifying normality in data distribution. The values were considered statistically significant when p < 0.05. Clinical trial number: not applicable Results The distribution of the population under study according to its general characteristics is shown in Table 1 . Table 1 Distribution of the participants according to sociodemographic variables. n (55) % Gender Male 17 30.9 Female 38 69.1 Age 40–44 2 3.6 45–49 3 5.4 50–54 16 29.1 55–59 5 9.0 60–64 16 29.1 65–69 7 12.7 70–74 6 10.9 Marital status Single 20 36.4 Married 21 38.2 Consensual union 1 1.8 Divorced 2 3.6 Widowed 7 12.7 Schooling Elementary School 17 30.9 High School 23 41.8 Technical Level 1 1.8 Higher Education 14 25.5 Occupation House chores 26 47.3 Tradesperson 15 27.3 Retiree 6 10.9 Driver 1 1.8 Farmer 1 1.8 None 1 1.8 Other 5 9.1 The mean age in the population under study was 58.3 (SD: 7.66) years old and there was prevalence of women, with 69.1%. In terms of age, there was 29.1% prevalence of subjects aged from 50 to 54 and from 60 to 64 years old in both groups. Regarding marital status, they were mostly married (38.2%), followed by single (36.2%) individuals. In relation to the schooling level, the highest percentage corresponds to High School, with 41.8%. Referring to occupation, the subjects devoted to house chores prevailed with 47.3%. Table 2 Cardiovascular risk and knowledge level about cardiovascular risk and diseases before and after the intervention. Before the intervention After the intervention p n % n % Cardiovascular risk Low 12 21.8 25 45.5 0.000 Moderate 23 41.8 24 43.6 High 16 29.1 5 9.1 Very high 4 7.3 1 1.8 Knowledge level Inadequate Adequate 30 25 54.5 45.5 4 51 7.3 92.7 < 0.001 Table 2 shows that, before the intervention, most of the subjects presented moderate CVR values, which represents 41.8%, followed by the patients with high CVR: 29.1%. However, after the intervention, 45.5% achieved low CVR levels. From the results obtained, it was possible to evidence a significant change in CVR (p < 0.000). Before the intervention, more than half of the population (54.5%) presented inadequate knowledge about cardiovascular risk and CVDs; whereas after the intervention, 92.7% achieved adequate knowledge levels with statistical significance when applying the McNemar test (p < 0.001). In addition, it seems important to note that only four subjects, representing 7.3% of the sample, maintained inadequate knowledge levels after the intervention. Table 3 Comparison between clinical variables and from scales applied before and after the intervention Characteristic Before the intervention Mean (SD) After the intervention Mean (SD) p Cardiovascular risk (%) 8.8 (5.5) 5.9 (3.9) 0.000 Knowledge about cardiovascular risk and CVDs (points) 5.2 (2.1) 9.0 (1.2) Cholesterol (mg/dl) 216.8 (82.4) 187.9 (36.7) Systolic Blood Pressure (mmHg) 130.6 (18.1) 119.4 (9.2) Body Mass Index (kg/m 2 ) 31.5 (5.6) 30.6 (5.5) SD (Standard Deviation) In the current study, it is evidenced (see Table 3 ) that there was a significant CVR reduction (from 8.8–5.9%, p < 0.001); in addition, an increase in the knowledge about cardiovascular risk and CVDs was obtained, from a mean score of 5.2 points to 9.0 points (p < 0.001). Among the risk factors that were able to be modified to reduce CVR, it was observed that the cholesterol level dropped from a mean of 216.8 mg/dl to 187.9 mg/dl (p < 0.001), that systolic blood pressure decreased from 130.6 mmHg to 119.43 mmHg (p < 0.001), and that BMI was reduced from 31.9 kg/m 2 to 30.6 kg/m 2 (p < 0.001). Regarding the smoking habit, 9.1% and 1.8% were smokers before and after the intervention, respectively. Discussion The results found in the current research coincide with the increase in the prevalence of AH as age advances, as the age group most affected by this disease was the one from 50 to 65 years old. In Ecuador, in a study conducted in the city of Esmeraldas about the CVR factors among patients with AH, the age group with the highest prevalence of AH was the one from 41 to 60 years old (21). According to the National Health and Nutrition Survey (NHANES), higher percentages of AH are more frequent in men than in women aged up to 45 years old, the numbers are equaled between 45 and 64 years of age, and there is a higher percentage of women with AH after that age, which is probably related to pathophysiological processes such as 17-β-estradiol reduction and the high cardiac output and might explain the higher number of women with AH. In the current study, the female gender was the most affected by AH (22); however, this can be due to the small sample obtained by convenience, as all the patients diagnosed with hypertension in a health center were selected. Regarding CVR, most of the population (41.8%) included in the current study had moderate risk and 36.4% presented high or very high CVR before the intervention. This is in contrast with a study conducted in Colombia (23), where people with a low CVR level (47.8%) prevailed. Several studies measuring the CVR levels have been conducted in Ecuador, but with scales other than GLOBORISK. One of them reported similar results to those of the current research, although it employed the PROCAM scale for CVR, finding that 37.5% of the patients had moderate CVR values and 23.7% presented high or very high CVRs; in addition, it only included a population comprised by older adults from Quito, Ecuador (24) Another study (25) investigated CVR according to the Framingham scale in patients with AH from a health center in the city of Ambato, Ecuador, reporting low CVR in 11.7% of the patients, 29.2% with intermediate risk and 59.1% with high risk. Certain differences are found in a study about CVR conducted in Sucúa, Ecuador (26), based on the Framingham tables and in patients assisted in an outpatient unit, where it was determined that low CVR was present in most of the sample (96.8%), although the population under study included younger people aged between 20 and 62 years old. In relation to the knowledge level about cardiovascular risk and CVDs, 54.5% had inadequate knowledge before the intervention (< 7 points) whereas 92.7% achieved adequate knowledge (≥ 7 points) after the intervention (p < 0.05) (Table 2 ). The association between the knowledge level about CVDs and its relationship with risk factors for such diseases was analyzed in a study conducted in Colombia (23), which found a significant association (p = 0.04) between knowledge levels and the patients performing healthy practices such as periodic physical activity; however, it was a cross-sectional study in which no intervention was conducted. A cross-sectional study about knowledge regarding risk factors for AH was also conducted in Ecuador, finding that 61% of the participants were unaware of such factors, with predominance of sedentary lifestyle as the main risk factor (63.8%) (21). In Ecuador, no studies with before-and-after designs or clinical trials have been reported that analyzed the effectiveness of educational interventions on the knowledge levels and cardiovascular diseases or the risk to suffer from them. Regarding the mean values obtained from the instruments applied, the current study evidenced that there was a significant reduction in CVR after the intervention (from 8.8–5.9%, p < 0.001); in addition, it was possible to observe an increase in the knowledge level about cardiovascular risk and CVDs, which rose from a mean score of 5.2 points to 9.0 points. This is in line with a study conducted in Cuba regarding the effectiveness of an educational intervention to modify the knowledge about lifestyles in hypertensive patients, which found that most of the subjects were unaware of their disease and of lifestyles related to the benefits of antihypertensive medications, education in nutrition, consumption of alcoholic beverages, smoking habit, physical exercise, stress, obesity and coffee consumption. Its effectiveness was evidenced because the knowledge about the diseases and inadequate lifestyle practices were significantly changed in the patients sampled (27). One of the reasons for inadequate practices in cardiovascular prevention among patients is the fact that they are unaware of their disease. In order to empower patients, it is fundamental to provide them with self-care support. Long-term satisfactory arterial hypertension control requires certain skills from the patients, as well as the necessary motivation and confidence to adopt a proper eating, physical exercise and pharmacological treatment regime (28). A study conducted in Colombia as a pilot test to assess the effectiveness of four strategies based on information and communication technologies for reducing five cardiovascular risk factors in working people showed improvements in several risk factors, obtaining a significant difference only for body weight in the group that used the web page (p = 0.032). The sedentary lifestyle level dropped from 80.9–76.1%, although the reduction was relatively brief in time: 8 weeks (29). Other studies outside the Latin American context have shown the effectiveness of interventions for CVD reduction or to modify unhealthy lifestyles. One of these intervention models is the Colorado Heart Healthy Solutions, based on community health workers, which proved to reduce the CVD risk by 0.8% in Framingham's risk score among the general population, in addition to a 2.0% reduction among the people who were at risk before the intervention. In addition, it was profitable in cost-effectiveness terms (30). The HOPE 4 study, a clustered randomized clinical trial conducted in Colombia and Malaysia, applied a community-based intervention led by health care workers (both physicians and not physicians) that substantially improved blood pressure control and the CVR levels as measured by the Framingham scale, when compared to usual management, which is generally only physician-centered (31). In Spain, the PREDIMED-Plus clinical trial has shown its long-term beneficial impact on the classic and emerging cardiovascular risk factors, such as hypertension, dyslipidemia, increased adiposity, Type 2 diabetes, insulin resistance, and oxidative stress, inflammation and endothelial dysfunction markers. It was based on a Mediterranean diet with energy restriction, promotion of physical activity and behavioral support, when compared to the Control Group, which followed a Mediterranean diet with no energy restriction and no advice for physical activity; however, less than 12 months were necessary to see significant changes in the main target variables (32). All these studies, conducted with large samples, reflect that financial resources that allow using specialized digital tools are required for their implementation, in addition to other resources specific to each program, such as people training, additional medications and laboratory inputs available or others, which hinders their application in low- and medium-income countries. This is why the current research might be useful as a pilot study that contributes to gradually assess the local characteristics and conditions that might serve as the basis for broader and more structured programs within clinical trials. Given that this was a quasi-experimental study without randomization, potential external factors cannot be fully ruled out. Nonetheless, measures were taken to ensure comparability between baseline and post-intervention evaluations. It is worth noting the importance of this type of research studies, which allow visualizing the feasibility of applying the Globorisk tool and several questionnaires about knowledge regarding cardiovascular risk and CVDs, so that the patients can recognize the modifiable risk factors and healthy lifestyles are fostered, as well as the effectiveness of an intervention strategy that allows improving the knowledge level about CVDs and reduce CVR in the short term. This is also important because intervening in them can also reduce the risk of Type 2 diabetes mellitus, considering that a number of studies have shown that the cardiovascular profile is not only important in cardiovascular risk stratification and prevention but also to establish blood glucose control, due to the relationship between CVR and deficient insulin secretion (34). The following can be mentioned as study limitations: having worked with a reduced group of patients, and the fact that the intervention was brief. Conclusions Most participants were women aged 50 to 64 years, married, with a high school education and engaged in housework. At baseline, the predominant cardiovascular risk (CVR) level ranged from moderate to high, and knowledge about cardiovascular diseases (CVDs) and associated risk factors was largely inadequate. Six months after implementing the educational intervention, there was a significant reduction in CVR and a marked improvement in participants’ knowledge. These findings support the integration of this intervention model into national primary healthcare programmes as a cost-effective strategy to reduce CVR through community participation and patient empowerment. Declarations Conflict of interests The authors declare no conflict of interests. Ethical considerations The study involved minimal risk to participants and was conducted in full compliance with the ethical standards outlined in the Declaration of Helsinki and the national regulations of Ecuador. Ethical approval was obtained from the Ethics Committee for Research Involving Human Beings of the Private Technical University of Loja (Universidad Técnica Particular de Loja, UTPL) (code: UTPL-CEISH-2021-PP04), as well as from the corresponding Regional Health Coordination Office. All participants provided written informed consent prior to enrollment, and confidentiality of the collected data was strictly maintained throughout the research process. Anonymity and confidentiality of participants' data were strictly maintained. Consent for Publication Not applicable. The manuscript does not contain any individual person’s data in any form (including individual details, images or videos). Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution VS: Conceptualization, formal analysis, methodology, project management, clinical supervision, visualization, writing, original draft preparation, review and editing. RS: Conceptualization, formal analysis, methodology, project management, clinical supervision, visualization, writing, original draft preparation, review and editing. TR: Conceptualization, formal analysis, methodology, writing, original draft preparation, review and editing. JF: Data curation, investigation, writing, review, methodology and editing.SI: Data curation, investigation, writing, methodology, review and editing. AV: Review and editing. Data Availability The datasets generated and/or analyzed during the present study are available upon reasonable request to the corresponding author. References Félix-Redondo FJ, Lozano Mera L, Alvarez-Palacios Arrighi P, Grau Magana M, Ramírez-Romero JM, Fernández-Bergés D. 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Areiza M, Osorio E, Ceballos M, Amariles P. Knowledge and cardiovascular risk factors in ambulatory patients. Revista Colombiana de Cardiologia. 2018 Mar 1;25(2):162–8. Guerrón L, Terán R, Villacrés A. Caracterización del riesgo cardiovascular en el paciente adulto mayor que acude a la consulta externa del Hospital General Dr Enrique Garcés, en el período comprendido entre Junio 2018 a septiembre de 2018 [Thesis]. [Quito]: Pontificia Universidad Católica del Ecuador; 2018. Abril P, Escobar C, Vega V. Riesgo cardiovascular según la escala de Framingham en pacientes hipertensos del centro de salud de la parroquia de San Miguelito de Píllaro, Ecuador [Thesis]. [Ambato]: Universidad Regional Autónoma de Los Andes; 2018. Arboleda Carvajal MS, García Yánez AR. Riesgo cardiovascular: análisis basado en las tablas de Framingham en pacientes asistidos en la unidad ambulatoria 309, IESS – Sucúa. Revista Med. 2017 Jun 25;25(1):20–30. Reyes M, Menéndez L, Obregón J, Nuñez M, García E. 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BMC Public Health [Internet]. 2019 Sep 6 [cited 2023 Feb 22];19(1):1–8. Available from: https://link.springer.com/articles/10.1186/s12889-019-7573-8 Schwalm JD, Mccready T, Lopez-Jaramillo P, Yusoff K, Attaran A, Lamelas P, et al. A community-based comprehensive intervention to reduce cardiovascular risk in hypertension (HOPE 4): a cluster-randomised controlled trial. www.thelancet.com [Internet]. 2019 [cited 2023 Feb 28];394. Available from: http://dx.doi.org/10.1016/ Salas-Salvadó J, Díaz-López A, Ruiz-Canela M, Basora J, Fitó M, Corella D, et al. Effect of a Lifestyle Intervention Program With Energy-Restricted Mediterranean Diet and Exercise on Weight Loss and Cardiovascular Risk Factors: One-Year Results of the PREDIMED-Plus Trial. Diabetes Care [Internet]. 2019 May 1 [cited 2023 Feb 28];42(5):777–88. Available from: https://diabetesjournals.org/care/article/42/5/777/40527/Effect-of-a-Lifestyle-Intervention-Program-With Additional Declarations No competing interests reported. Supplementary Files Appendix1SociodemographicandClinicalDataCollectionForm.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6648692","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":466455223,"identity":"03a72219-e4a0-48a3-980a-b632fa63aafe","order_by":0,"name":"Verónica Bertha Sarango Varzallo","email":"","orcid":"","institution":"Universidad Técnica Particular de Loja","correspondingAuthor":false,"prefix":"","firstName":"Verónica","middleName":"Bertha Sarango","lastName":"Varzallo","suffix":""},{"id":466455224,"identity":"d83e91d8-3533-49cb-8e57-23bd3ac3569f","order_by":1,"name":"Rosario Suárez","email":"","orcid":"","institution":"Universidad Técnica Particular de Loja","correspondingAuthor":false,"prefix":"","firstName":"Rosario","middleName":"","lastName":"Suárez","suffix":""},{"id":466455225,"identity":"ef697836-7218-485f-ad24-8c43f3f361d8","order_by":2,"name":"Tamara Rodríguez Quintana","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYJACCQYDEMV+8AGQlAFiA7zKeRBaeJINGBLAAsRogQAzCaK02EsfPni7oqA2sZ//QFo17487PAzszdskGCrscNvCl5ZsecbgeOLMhoPHbvMkPONh4DlWJsFwJhm3Fh4eM8kGg2OJGw42pAG1HOZhkMgxk2BsO0BYy/7DDGbFYC3yb4Ba/hHUUpO4gY3BjBliCw9QSwMeLWfYki0bDA4YzzjDkyw5J+0ZDxtPWrFFwjHcfmHvYT54s+FPnWx///GDH97Y3JHjZz+88caHGtwhBgWHYYwDDGwgKoGQBgaGOoSWUTAKRsEoGAXoAAC2EEyLb8mGBAAAAABJRU5ErkJggg==","orcid":"","institution":"Universidad Técnica Particular de Loja","correspondingAuthor":true,"prefix":"","firstName":"Tamara","middleName":"Rodríguez","lastName":"Quintana","suffix":""},{"id":466455226,"identity":"8247318f-c172-4b46-8ba7-752511e5ee14","order_by":3,"name":"Justo Reinaldo Fabelo Roche","email":"","orcid":"","institution":"Universidad de Ciencias Médicas de la Habana","correspondingAuthor":false,"prefix":"","firstName":"Justo","middleName":"Reinaldo Fabelo","lastName":"Roche","suffix":""},{"id":466455227,"identity":"8fad70ec-ade3-4ef3-afa2-b041c56a88d9","order_by":4,"name":"Serguei Iglesias Moré","email":"","orcid":"","institution":"Universidad de Ciencias Médicas de la Habana","correspondingAuthor":false,"prefix":"","firstName":"Serguei","middleName":"Iglesias","lastName":"Moré","suffix":""},{"id":466455228,"identity":"58e655e3-ec93-4248-8b53-5be355706efd","order_by":5,"name":"Ana Magdalena Vargas-Martínez","email":"","orcid":"","institution":"University of Castilla-La Mancha","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Magdalena","lastName":"Vargas-Martínez","suffix":""}],"badges":[],"createdAt":"2025-05-12 16:53:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6648692/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6648692/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86763602,"identity":"eb3e3fcb-2a16-43b3-abe5-6a3bdf427e54","added_by":"auto","created_at":"2025-07-15 10:39:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":646411,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6648692/v1/44cc9745-c3e3-4ce6-8d10-35555759c684.pdf"},{"id":84100412,"identity":"bb2d0eb5-288c-46c4-b580-59a4f8330c6e","added_by":"auto","created_at":"2025-06-06 19:04:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":83088,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1SociodemographicandClinicalDataCollectionForm.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6648692/v1/9d861fa4a0855c1c144221c4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of a community-based educational intervention to reduce cardiovascular risk among hypertensive adults in Ecuador: a quasi-experimental study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eArterial hypertension (AH) significantly increases the risk of suffering heart diseases, encephalopathies, nephropathies and other diseases. Its frequency increases with age as a consequence of changes in rigidity of the arteries, vascular remodeling and alterations in the renal and hormonal mechanisms (1)(2). At the global level, there are 1,130\u0026nbsp;million people with hypertension and most of them (nearly two-thirds) live in countries marked by low socioeconomic conditions. In 2015, 1 out of 4 men and 1 out of 5 women had AH, of which, considering both genders, only 1 out of 5 had the disease under control. AH is one of the main causes of premature death in the world (3).\u003c/p\u003e \u003cp\u003eTwo groups of cardiovascular risk (CVR) factors can be mentioned: non-modifiable, such as age, gender and family history; and modifiable, which include hypercholesterolemia, smoking habit, diabetes, AH, obesity, sedentary lifestyle and stress (4). AH is an independent risk factor for cardiovascular diseases (CVDs) (5). It is thus fundamental to assess CVR in all patients aged over 40 years old attending a Primary Health Care unit. The age up to which a periodic risk assessment should be performed is unknown; however, many of the validated risk calculators only include patients aged up to 79 years old. In addition, the decisions regarding CVR assessment should be individualized (6).\u003c/p\u003e \u003cp\u003eCVD prevention is defined as a series of actions at the population or individual levels that seek to eliminate or minimize the impact of these diseases and their related disabilities. Multiple assessment tools with different groups have been designed to assess CVR, although none of them is suitable for all patients (7). The 10-year CVR estimation by means of the Globorisk tool evaluates all the aforementioned risk factors and was applied to a characteristic multiethnic population; it allows estimating CVR for Ecuador since, during its validation, a Latin American population representative of Mexico was included and because it is the scale recommended by the National Clinical Practice Guide for AH Management, of the Public Health Ministry (\u003cem\u003eMinisterio de Salud P\u0026uacute;blica\u003c/em\u003e, MSP) (8).\u003c/p\u003e \u003cp\u003eThe Pan American Health Organization (PAHO) has pointed out that, in Ecuador, approximately 20% of the population aged over 19 years old suffers from AH (9). CVDs are an important health problem because they do not only reduce life expectancy but they also cause physical disability in a high percentage of the population. According to the statistical data, it is considered that 30% of those over the age of 40 suffer from some CVD. In addition, according to the Ensanut survey in Ecuador, 20% of men and 21% of women aged between 30 and 69 years old have presented early mortality due to CVDs (10,11). In the Ecuadorian city of Loja, cardiovascular diseases are among the 10 main causes of mortality with 30.4%; in addition, AH is the leading cause of chronic morbidity with 38.6% (12) and the association of age with higher prevalence of high cardiovascular risk has been shown; therefore, there is a need to promote healthy lifestyles in early life stages (13).\u003c/p\u003e \u003cp\u003eIt is important that people in general, and especially hypertensive individuals, possess adequate knowledge about these risk factors and are aware of the benefits provided by healthy lifestyle practices (14)(15)(16), so that they contribute to reducing CVR. Although educational interventions are considered slow and hardly effective in changing lifestyles related to CVR (17), they constitute the health care team's starting point at the first care level. However, there are few studies in Ecuador about the assessment of programs based on interventions targeted at educating the population and improving AH and CVR control.\u003c/p\u003e \u003cp\u003eThe objective of this research was to evaluate the effectiveness of an educational intervention about the knowledge level regarding CVDs and CVR levels, fostering healthy lifestyles in a Primary Health Care center from Loja, Ecuador.\u003c/p\u003e \u003cp\u003eIt is hypothesized that the community-based educational intervention will significantly reduce cardiovascular risk and improve knowledge about cardiovascular diseases among hypertensive patients.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eA research study of the quasi-experimental type and with a before-and-after design was conducted with a population of 55 hypertensive patients from three sectors of neighborhoods attached to a health center from the city of Loja, Ecuador. It was carried out during 2021. The work was conducted with 100% of the population that met the following inclusion criteria: subjects with an AH diagnosis and aged between 40 and 74 years old, who were willing to participate and signed the informed consent form, excluding those with cognitive deterioration and pregnant women.\u003c/p\u003e \u003cp\u003eThe study was developed in three stages: in the first stage, a data collection form specifically designed by the authors for this study was employed to collect both sociodemographic data \u0026mdash;age, gender, marital status, schooling level, and occupation\u0026mdash; and clinical variables \u0026mdash;blood pressure, smoking status, diagnosis of type 2 diabetes mellitus, weight, height, body mass index, and total cholesterol. This form is included as a supplementary file (see Appendix 1).\u003c/p\u003e \u003cp\u003eIn addition, the Questionnaire to assess knowledge about cardiovascular risk factors and diseases used in the study called Effect of the D\u0026aacute;der Pharmacotherapy Follow-Up Method on the cardiovascular risk of patients with cardiovascular risk factors or diseases (EMDADER-CV) (18) was applied, which consists of 10 questions where the score for each question is 1 (if answered correctly) or 0 (if answered incorrectly), generating an ordinal result between 0 and 10, where 0 represents the worst knowledge level and 10, the best. In addition, less than 7 points was defined as inadequate knowledge and 7 points or more, as adequate. This test had been already validated, obtaining a Cronbach's alpha value of 0.88 and, according to the intraclass correlation coefficient, a reliability level between acceptable and excellent (18). The CVR level was also calculated using the Globorisk tool (lab form), which includes the following parameters: gender, age, total blood cholesterol levels, smoking/non-smoking or diabetes history, and systolic blood pressure values (mmHg). This tool allows classifying the CVR levels as follows: Low risk: \u0026lt;5%; Moderate risk: \u0026ge;5% and \u0026lt;\u0026thinsp;10%; High risk: \u0026ge;10% and \u0026lt;\u0026thinsp;20%; and Very high risk: \u0026ge;20% (8). The anthropometric variables measured were weight in kilograms and height in meters. For weight and height, a Rise Lake\u0026reg; portable mechanical scale with a tallimeter for adults was used, which was placed on a stable and flat floor. The participants' weight and height were measured with them barefooted. An OMRON\u0026reg; digital tensiometer was used to measure blood pressure (BP). Each participant was subjected to three measurements with three-minute intervals, following the STEPwise method recommendations (19), using the mean of the second and third AH readings in the analysis. Arterial hypertension was defined as systolic blood pressure (SBP)\u0026thinsp;\u0026ge;\u0026thinsp;140 mmHg and/or diastolic blood pressure (DBP)\u0026thinsp;\u0026ge;\u0026thinsp;90 mmHg, according to the 2019 Clinical Practice Guide for arterial hypertension issued by the Ecuadorian MSP (8)\u003c/p\u003e \u003cp\u003eIn the second stage, an educational strategy was implemented by means of five individual sessions, conducted once a month within the Health Center facilities or in home visits. Each session consisted in a conversation about the following: Session 1, Risk factors for CVDs, both modifiable and non-modifiable; Session 2, Healthy eating; Session 3, Physical exercise; Session 4, Smoking cessation; and Session 5, Importance and practical advice about pharmacological adherence, lasting 40 minutes each. For the Healthy eating, Physical exercise and Smoking cessation sessions, the 5 As strategy (\u0026ldquo;\u003cem\u003eAveriguar, Asesorar, Apreciar, Ayudar y Arreglar\u003c/em\u003e\u0026rdquo; [\u0026ldquo;Find out, Advise, Assess, Help and Fix\u0026rdquo;]) was used based on the HEARTS technical bundle for the management of cardiovascular diseases in Primary Health Care issued by the Pan American Health Organization (PAHO), in addition to handing in educational didactic material to the patients (20).\u003c/p\u003e \u003cp\u003eIn the third stage, effectiveness of the educational strategy was assessed by means of a new evaluation of CVR and the knowledge level about CVDs, using the same instruments from the pre-intervention assessment.\u003c/p\u003e \u003cp\u003eThe data were analyzed in SPSS 24\u0026reg;. The quantitative variables were presented as central tendency and dispersion measures and the qualitative variables, as frequencies and percentages. In order to assess the effectiveness of the educational strategy, the means of the CVR values and of the knowledge level score were compared by means of the Student's t test for related samples. In turn, to compare the results of the qualitative variables, the McNemar test was used after verifying normality in data distribution. The values were considered statistically significant when p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eClinical trial number: not applicable\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe distribution of the population under study according to its general characteristics is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of the participants according to sociodemographic variables.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (55)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e69.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u0026ndash;64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsensual union\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eSchooling\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElementary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTechnical Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigher Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHouse chores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTradesperson\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetiree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDriver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean age in the population under study was 58.3 (SD: 7.66) years old and there was prevalence of women, with 69.1%. In terms of age, there was 29.1% prevalence of subjects aged from 50 to 54 and from 60 to 64 years old in both groups. Regarding marital status, they were mostly married (38.2%), followed by single (36.2%) individuals. In relation to the schooling level, the highest percentage corresponds to High School, with 41.8%. Referring to occupation, the subjects devoted to house chores prevailed with 47.3%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCardiovascular risk and knowledge level about cardiovascular risk and diseases before and after the intervention.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eBefore the intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003eAfter the intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCardiovascular risk\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e45.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cem\u003e0.000\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e43.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery high\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eKnowledge level\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate\u003c/p\u003e \u003cp\u003eAdequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e54.5\u003c/p\u003e \u003cp\u003e45.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003cp\u003e92.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that, before the intervention, most of the subjects presented moderate CVR values, which represents 41.8%, followed by the patients with high CVR: 29.1%. However, after the intervention, 45.5% achieved low CVR levels. From the results obtained, it was possible to evidence a significant change in CVR (p\u0026thinsp;\u0026lt;\u0026thinsp;0.000).\u003c/p\u003e \u003cp\u003eBefore the intervention, more than half of the population (54.5%) presented inadequate knowledge about cardiovascular risk and CVDs; whereas after the intervention, 92.7% achieved adequate knowledge levels with statistical significance when applying the McNemar test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In addition, it seems important to note that only four subjects, representing 7.3% of the sample, maintained inadequate knowledge levels after the intervention.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison between clinical variables and from scales applied before and after the intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore the intervention\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter the intervention\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular risk (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.8 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.9 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge about cardiovascular risk\u0026nbsp;and CVDs (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.2 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.0 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCholesterol (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e216.8 (82.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e187.9 (36.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic Blood Pressure (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130.6 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e119.4 (9.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody Mass Index (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.5 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.6 (5.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD (Standard Deviation)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the current study, it is evidenced (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) that there was a significant CVR reduction (from 8.8\u0026ndash;5.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); in addition, an increase in the knowledge about cardiovascular risk and CVDs was obtained, from a mean score of 5.2 points to 9.0 points (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among the risk factors that were able to be modified to reduce CVR, it was observed that the cholesterol level dropped from a mean of 216.8 mg/dl to 187.9 mg/dl (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), that systolic blood pressure decreased from 130.6 mmHg to 119.43 mmHg (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and that BMI was reduced from 31.9 kg/m\u003csup\u003e2\u003c/sup\u003e to 30.6 kg/m\u003csup\u003e2\u003c/sup\u003e (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Regarding the smoking habit, 9.1% and 1.8% were smokers before and after the intervention, respectively.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results found in the current research coincide with the increase in the prevalence of AH as age advances, as the age group most affected by this disease was the one from 50 to 65 years old. In Ecuador, in a study conducted in the city of Esmeraldas about the CVR factors among patients with AH, the age group with the highest prevalence of AH was the one from 41 to 60 years old (21). According to the National Health and Nutrition Survey (NHANES), higher percentages of AH are more frequent in men than in women aged up to 45 years old, the numbers are equaled between 45 and 64 years of age, and there is a higher percentage of women with AH after that age, which is probably related to pathophysiological processes such as 17-β-estradiol reduction and the high cardiac output and might explain the higher number of women with AH. In the current study, the female gender was the most affected by AH (22); however, this can be due to the small sample obtained by convenience, as all the patients diagnosed with hypertension in a health center were selected.\u003c/p\u003e \u003cp\u003eRegarding CVR, most of the population (41.8%) included in the current study had moderate risk and 36.4% presented high or very high CVR before the intervention. This is in contrast with a study conducted in Colombia (23), where people with a low CVR level (47.8%) prevailed. Several studies measuring the CVR levels have been conducted in Ecuador, but with scales other than GLOBORISK. One of them reported similar results to those of the current research, although it employed the PROCAM scale for CVR, finding that 37.5% of the patients had moderate CVR values and 23.7% presented high or very high CVRs; in addition, it only included a population comprised by older adults from Quito, Ecuador (24)\u003c/p\u003e \u003cp\u003eAnother study (25) investigated CVR according to the Framingham scale in patients with AH from a health center in the city of Ambato, Ecuador, reporting low CVR in 11.7% of the patients, 29.2% with intermediate risk and 59.1% with high risk. Certain differences are found in a study about CVR conducted in Suc\u0026uacute;a, Ecuador (26), based on the Framingham tables and in patients assisted in an outpatient unit, where it was determined that low CVR was present in most of the sample (96.8%), although the population under study included younger people aged between 20 and 62 years old.\u003c/p\u003e \u003cp\u003eIn relation to the knowledge level about cardiovascular risk and CVDs, 54.5% had inadequate knowledge before the intervention (\u0026lt;\u0026thinsp;7 points) whereas 92.7% achieved adequate knowledge (\u0026ge;\u0026thinsp;7 points) after the intervention (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The association between the knowledge level about CVDs and its relationship with risk factors for such diseases was analyzed in a study conducted in Colombia (23), which found a significant association (p\u0026thinsp;=\u0026thinsp;0.04) between knowledge levels and the patients performing healthy practices such as periodic physical activity; however, it was a cross-sectional study in which no intervention was conducted. A cross-sectional study about knowledge regarding risk factors for AH was also conducted in Ecuador, finding that 61% of the participants were unaware of such factors, with predominance of sedentary lifestyle as the main risk factor (63.8%) (21). In Ecuador, no studies with before-and-after designs or clinical trials have been reported that analyzed the effectiveness of educational interventions on the knowledge levels and cardiovascular diseases or the risk to suffer from them.\u003c/p\u003e \u003cp\u003eRegarding the mean values obtained from the instruments applied, the current study evidenced that there was a significant reduction in CVR after the intervention (from 8.8\u0026ndash;5.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); in addition, it was possible to observe an increase in the knowledge level about cardiovascular risk and CVDs, which rose from a mean score of 5.2 points to 9.0 points. This is in line with a study conducted in Cuba regarding the effectiveness of an educational intervention to modify the knowledge about lifestyles in hypertensive patients, which found that most of the subjects were unaware of their disease and of lifestyles related to the benefits of antihypertensive medications, education in nutrition, consumption of alcoholic beverages, smoking habit, physical exercise, stress, obesity and coffee consumption. Its effectiveness was evidenced because the knowledge about the diseases and inadequate lifestyle practices were significantly changed in the patients sampled (27).\u003c/p\u003e \u003cp\u003eOne of the reasons for inadequate practices in cardiovascular prevention among patients is the fact that they are unaware of their disease. In order to empower patients, it is fundamental to provide them with self-care support. Long-term satisfactory arterial hypertension control requires certain skills from the patients, as well as the necessary motivation and confidence to adopt a proper eating, physical exercise and pharmacological treatment regime (28).\u003c/p\u003e \u003cp\u003eA study conducted in Colombia as a pilot test to assess the effectiveness of four strategies based on information and communication technologies for reducing five cardiovascular risk factors in working people showed improvements in several risk factors, obtaining a significant difference only for body weight in the group that used the web page (p\u0026thinsp;=\u0026thinsp;0.032). The sedentary lifestyle level dropped from 80.9\u0026ndash;76.1%, although the reduction was relatively brief in time: 8 weeks (29).\u003c/p\u003e \u003cp\u003eOther studies outside the Latin American context have shown the effectiveness of interventions for CVD reduction or to modify unhealthy lifestyles. One of these intervention models is the Colorado Heart Healthy Solutions, based on community health workers, which proved to reduce the CVD risk by 0.8% in Framingham's risk score among the general population, in addition to a 2.0% reduction among the people who were at risk before the intervention. In addition, it was profitable in cost-effectiveness terms (30). The HOPE 4 study, a clustered randomized clinical trial conducted in Colombia and Malaysia, applied a community-based intervention led by health care workers (both physicians and not physicians) that substantially improved blood pressure control and the CVR levels as measured by the Framingham scale, when compared to usual management, which is generally only physician-centered (31). In Spain, the PREDIMED-Plus clinical trial has shown its long-term beneficial impact on the classic and emerging cardiovascular risk factors, such as hypertension, dyslipidemia, increased adiposity, Type 2 diabetes, insulin resistance, and oxidative stress, inflammation and endothelial dysfunction markers. It was based on a Mediterranean diet with energy restriction, promotion of physical activity and behavioral support, when compared to the Control Group, which followed a Mediterranean diet with no energy restriction and no advice for physical activity; however, less than 12 months were necessary to see significant changes in the main target variables (32). All these studies, conducted with large samples, reflect that financial resources that allow using specialized digital tools are required for their implementation, in addition to other resources specific to each program, such as people training, additional medications and laboratory inputs available or others, which hinders their application in low- and medium-income countries. This is why the current research might be useful as a pilot study that contributes to gradually assess the local characteristics and conditions that might serve as the basis for broader and more structured programs within clinical trials. Given that this was a quasi-experimental study without randomization, potential external factors cannot be fully ruled out. Nonetheless, measures were taken to ensure comparability between baseline and post-intervention evaluations.\u003c/p\u003e \u003cp\u003eIt is worth noting the importance of this type of research studies, which allow visualizing the feasibility of applying the Globorisk tool and several questionnaires about knowledge regarding cardiovascular risk and CVDs, so that the patients can recognize the modifiable risk factors and healthy lifestyles are fostered, as well as the effectiveness of an intervention strategy that allows improving the knowledge level about CVDs and reduce CVR in the short term. This is also important because intervening in them can also reduce the risk of Type 2 diabetes mellitus, considering that a number of studies have shown that the cardiovascular profile is not only important in cardiovascular risk stratification and prevention but also to establish blood glucose control, due to the relationship between CVR and deficient insulin secretion (34). The following can be mentioned as study limitations: having worked with a reduced group of patients, and the fact that the intervention was brief.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eMost participants were women aged 50 to 64 years, married, with a high school education and engaged in housework. At baseline, the predominant cardiovascular risk (CVR) level ranged from moderate to high, and knowledge about cardiovascular diseases (CVDs) and associated risk factors was largely inadequate. Six months after implementing the educational intervention, there was a significant reduction in CVR and a marked improvement in participants\u0026rsquo; knowledge. These findings support the integration of this intervention model into national primary healthcare programmes as a cost-effective strategy to reduce CVR through community participation and patient empowerment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of interests\u003c/h2\u003e \u003cp\u003eThe authors declare no conflict of interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e The study involved minimal risk to participants and was conducted in full compliance with the ethical standards outlined in the Declaration of Helsinki and the national regulations of Ecuador. Ethical approval was obtained from the Ethics Committee for Research Involving Human Beings of the Private Technical University of Loja (Universidad T\u0026eacute;cnica Particular de Loja, UTPL) (code: UTPL-CEISH-2021-PP04), as well as from the corresponding Regional Health Coordination Office. All participants provided written informed consent prior to enrollment, and confidentiality of the collected data was strictly maintained throughout the research process. Anonymity and confidentiality of participants' data were strictly maintained.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for Publication\u003c/h2\u003e \u003cp\u003eNot applicable. The manuscript does not contain any individual person\u0026rsquo;s data in any form (including individual details, images or videos).\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eVS: Conceptualization, formal analysis, methodology, project management, clinical supervision, visualization, writing, original draft preparation, review and editing. RS: Conceptualization, formal analysis, methodology, project management, clinical supervision, visualization, writing, original draft preparation, review and editing. TR: Conceptualization, formal analysis, methodology, writing, original draft preparation, review and editing. JF: Data curation, investigation, writing, review, methodology and editing.SI: Data curation, investigation, writing, methodology, review and editing. AV: Review and editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the present study are available upon reasonable request to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eF\u0026eacute;lix-Redondo FJ, Lozano Mera L, Alvarez-Palacios Arrighi P, Grau Magana M, Ram\u0026iacute;rez-Romero JM, Fern\u0026aacute;ndez-Berg\u0026eacute;s D. 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Available from: www.who.int/chp/steps\u003c/li\u003e\n\u003cli\u003eOrganizaci\u0026oacute;n Panamericana de la Salud. Paquete t\u0026eacute;cnico para el manejo de las enfermedades cardiovasculares en la atenci\u0026oacute;n primaria de salud. H\u0026aacute;bitos y estilos de vida saludables: asesoramiento para los pacientes. Washington, D.C. 2019. ; 2019.\u003c/li\u003e\n\u003cli\u003ede la Rosa J, Acosta M. Possible cardiovascular risk factors in patients with arterial hypertension in three neighborhoods from Esmeraldas, Ecuador. Rev Arch Med Camag\u0026uuml;ey. 2017;21(3).\u003c/li\u003e\n\u003cli\u003eUrrea JK. Hipertensi\u0026oacute;n arterial en la mujer. Revista Colombiana de Cardiolog\u0026iacute;a. 2018 Jan 1;25:13\u0026ndash;20.\u003c/li\u003e\n\u003cli\u003eAreiza M, Osorio E, Ceballos M, Amariles P. Knowledge and cardiovascular risk factors in ambulatory patients. Revista Colombiana de Cardiologia. 2018 Mar 1;25(2):162\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eGuerr\u0026oacute;n L, Ter\u0026aacute;n R, Villacr\u0026eacute;s A. Caracterizaci\u0026oacute;n del riesgo cardiovascular en el paciente adulto mayor que acude a la consulta externa del Hospital General Dr Enrique Garc\u0026eacute;s, en el per\u0026iacute;odo comprendido entre Junio 2018 a septiembre de 2018 [Thesis]. [Quito]: Pontificia Universidad Cat\u0026oacute;lica del Ecuador; 2018.\u003c/li\u003e\n\u003cli\u003eAbril P, Escobar C, Vega V. Riesgo cardiovascular seg\u0026uacute;n la escala de Framingham en pacientes hipertensos del centro de salud de la parroquia de San Miguelito de P\u0026iacute;llaro, Ecuador [Thesis]. [Ambato]: Universidad Regional Aut\u0026oacute;noma de Los Andes; 2018.\u003c/li\u003e\n\u003cli\u003eArboleda Carvajal MS, Garc\u0026iacute;a Y\u0026aacute;nez AR. Riesgo cardiovascular: an\u0026aacute;lisis basado en las tablas de Framingham en pacientes asistidos en la unidad ambulatoria 309, IESS \u0026ndash; Suc\u0026uacute;a. Revista Med. 2017 Jun 25;25(1):20\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eReyes M, Men\u0026eacute;ndez L, Obreg\u0026oacute;n J, Nu\u0026ntilde;ez M, Garc\u0026iacute;a E. Effectiveness of an educational intervention to modify knowledge about lifestyles in hypertensive patients. EDUMECENTRO [Internet]. 2021 [cited 2023 Feb 22];13(1):149\u0026ndash;66. Available from: https://www.medigraphic.com/cgi-bin/new/resumenI.cgi?IDARTICULO=104179\u003c/li\u003e\n\u003cli\u003ePatel P, Ordunez P, DiPette D, Escobar MC, Hassell T, Wyss F, et al. Improved Blood Pressure Control to Reduce Cardiovascular Disease Morbidity and Mortality: The Standardized Hypertension Treatment and Prevention Project. J Clin Hypertens. 2016 Dec 1;18(12):1284\u0026ndash;94.\u003c/li\u003e\n\u003cli\u003eCer\u0026oacute;n JD, L\u0026oacute;pez DM, Urbano L, \u0026Aacute;lvarez-Rosero RE, Mu\u0026ntilde;oz-Ben\u0026iacute;tez S. Estrategias basadas en tecnolog\u0026iacute;as de la informaci\u0026oacute;n y la comunicaci\u0026oacute;n para la reducci\u0026oacute;n de factores de riesgo cardiovascular en personas laboralmente activas. Rev Colomb Cardiol. 2018;25(1):92\u0026ndash;100.\u003c/li\u003e\n\u003cli\u003eSmith L, Atherly A, Campbell J, Flattery N, Coronel S, Krantz M. Cost-effectiveness of a statewide public health intervention to reduce cardiovascular disease risk. BMC Public Health [Internet]. 2019 Sep 6 [cited 2023 Feb 22];19(1):1\u0026ndash;8. Available from: https://link.springer.com/articles/10.1186/s12889-019-7573-8\u003c/li\u003e\n\u003cli\u003eSchwalm JD, Mccready T, Lopez-Jaramillo P, Yusoff K, Attaran A, Lamelas P, et al. A community-based comprehensive intervention to reduce cardiovascular risk in hypertension (HOPE 4): a cluster-randomised controlled trial. www.thelancet.com [Internet]. 2019 [cited 2023 Feb 28];394. Available from: http://dx.doi.org/10.1016/\u003c/li\u003e\n\u003cli\u003eSalas-Salvad\u0026oacute; J, D\u0026iacute;az-L\u0026oacute;pez A, Ruiz-Canela M, Basora J, Fit\u0026oacute; M, Corella D, et al. Effect of a Lifestyle Intervention Program With Energy-Restricted Mediterranean Diet and Exercise on Weight Loss and Cardiovascular Risk Factors: One-Year Results of the PREDIMED-Plus Trial. Diabetes Care [Internet]. 2019 May 1 [cited 2023 Feb 28];42(5):777\u0026ndash;88. Available from: https://diabetesjournals.org/care/article/42/5/777/40527/Effect-of-a-Lifestyle-Intervention-Program-With\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cardiovascular diseases, arterial hypertension, cardiovascular risk, educational intervention","lastPublishedDoi":"10.21203/rs.3.rs-6648692/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6648692/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eArterial hypertension (AH) is a leading risk factor for cardiovascular diseases (CVDs) and plays a key role in determining cardiovascular risk (CVR). Strategies to reduce CVR are fundamental in primary health care.\u003c/p\u003e\u003ch2\u003eObjective:\u003c/h2\u003e \u003cp\u003eTo evaluate the effectiveness of an educational intervention on improving knowledge about CVDs and reducing CVR levels in hypertensive patients at a health center in Ecuador.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA quasi-experimental before-and-after study was conducted with 55 hypertensive adults. CVR was assessed using the Globorisk scale, and knowledge about CVDs was measured through a validated questionnaire from the EMDADER-CV study. Baseline and six-month post-intervention measurements were compared. Clinical trial number: not applicable.\u003c/p\u003e\u003ch2\u003eEthical considerations:\u003c/h2\u003e \u003cp\u003e The study was approved by the corresponding ethics committees and conducted in accordance with the Declaration of Helsinki and national regulations. Written informed consent was obtained from all participants.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe mean participant age was 58.3 years, with women representing 69.1% of the sample. After six months, the mean CVR significantly decreased from 8.8\u0026ndash;5.9% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and the mean knowledge score significantly increased from 5.2 to 9.0 points (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The proportion of individuals with high or very high CVR declined from 36.4\u0026ndash;10.9%, while those at low or moderate risk increased from 63.6\u0026ndash;89.1%.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThe educational strategy was effective in both reducing cardiovascular risk and improving knowledge about CVDs among hypertensive patients in a primary care setting.\u003c/p\u003e","manuscriptTitle":"Effectiveness of a community-based educational intervention to reduce cardiovascular risk among hypertensive adults in Ecuador: a quasi-experimental study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-06 19:04:14","doi":"10.21203/rs.3.rs-6648692/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5d8ec9ec-b38a-4cbf-84a8-2bde6bed2976","owner":[],"postedDate":"June 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-15T10:39:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-06 19:04:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6648692","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6648692","identity":"rs-6648692","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}