Can a multicomponent, workplace-based intervention strategy that combines workplace health promotion and standardized management of hypertension improve blood pressure control among employees?
In this cluster randomized clinical trial of 4166 employees with hypertension from 60 workplaces, after a 24-month intervention, the intervention group had significantly higher blood pressure control and a net reduction in systolic and diastolic blood pressure of 5.8 and 3.6 mm Hg compared with the control group.
Results of this trial suggest that a multicomponent intervention may represent an effective addition to workplace programs to control hypertension with a community health center intervention accompanied by monthly visits.
A workplace-based intervention could be an effective approach to managing high blood pressure (BP). However, few studies to date have addressed hypertension control among the Chinese working population.
To assess the effect of a workplace-based, multicomponent intervention strategy on improving BP control.
Design, Setting, and Participants
A cluster randomized clinical trial of a hypertension management program was conducted from January 2013 to December 2014 in 60 workplaces across 20 urban regions in China. Workplaces were randomized to either the intervention group (n = 40) or control group (n = 20). Employee participants in each workplace were asked to complete a cross-sectional survey. Data analysis on an evaluable population was conducted from January 2016 to January 2017.
The 2-year intervention included 2 components: (1) a workplace wellness program for improving employees’ cardiovascular health and (2) a guidelines-oriented hypertension management protocol with a community health center intervention accompanied by monthly visits for achieving BP control over a period of 24 months.
Main Outcomes and Measures
The primary outcome was the change in BP control rate from baseline to 24 months among employees with hypertension in the intervention and control groups. The secondary outcomes were the changes in BP level and lifestyle factors by the end of the trial.
Overall, 4166 participants (3178 in the intervention group and 988 in the control group) were included (mean [SD] age, 46.3 [7.6] years; 3451 men [82.8%]). Blood pressure control rate at baseline was 19.5% in the intervention group and 20.1% in the control group. After 24 months of the intervention, the BP control rate for the intervention group compared with the control group was significantly higher (66.2% vs 44.0%; odds ratio, 1.77; 95% CI, 1.58-2.00; P < .001). The intervention effect on systolic BP level was −5.8 mm Hg (95% CI, −6.8 to −4.9 mm Hg; P < .001) and on diastolic BP level was −3.6 mm Hg (95% CI, −4.4 to −2.9 mm Hg; P < .001). The BP control rate showed a gradual increment throughout the whole duration in the intervention group. Moreover, greater reduction was reported in the rates of drinking (−18.4%; 95% CI, −20.6% to −16.2%; P < .001), perceived stress (−22.9%; 95% CI, −24.8% to −21.1%; P < .001), and excessive use of salt (−32.0%; 95% CI, −33.7% to −30.4%; P < .001).
Conclusions and Relevance
This trial found that a workplace-based, multicomponent intervention appeared to be more effective than usual care, leading to measurable benefits such as lower blood pressure, improved hypertension control, and adoption of healthy lifestyle habits. The intervention can therefore be considered for large-scale use or inclusion in hypertension control programs in workplaces in China and other countries.
Chinese Clinical Trial Registry No. ChiCTR-ECS-14004641
Elevated blood pressure (BP) is established as a strong independent risk factor for cardiovascular disease (CVD), accounting for 70% of strokes and 50% of myocardial infarctions in China.1 A national survey showed that elevated BP is common in the Chinese population, but hypertension treatment rates are less than 50% and control rates are less than 20%.2 Appropriate BP control in patients with hypertension has been known to reduce CVD events effectively3; however, a substantial proportion of the population still has uncontrolled BP.
Baseline results of The Standardized Management of Hypertensive Employees Program in China indicated that less than 10% of the participating employees had controlled BP, and BP control varied by individual and workplace factors.4 From the international perspective, a workplace-based intervention could be an effective approach to assisting employees with uncontrolled hypertension to reach their BP goals.5,6 However, few studies to date have been specifically designed to address hypertension control among the Chinese working population. Most of the previous studies were limited by small sample sizes and did not report the effectiveness of the intervention on specific subgroups.5-8 In addition, these studies did not link BP control with individual and workplace factors simultaneously.
As recommended by the American Heart Association,9 a workplace wellness program can be an important strategy for preventing major risk factors for CVD. Therefore, we conducted a cluster randomized clinical trial of a hypertension management program to develop a multicomponent intervention strategy that combined workplace health promotion and standardized management of hypertension to improve BP control among employees.
In this cluster randomized clinical trial, the workplace was the unit of randomization. Twenty urban medical institutions were chosen as subcenters (Figure 1), representing various geographic locations in China. Furthermore, 2 to 4 workplaces, comparable in sector, ownership, size, economic level, and medical condition, were included within each subcenter. In each subcenter, 1 workplace was randomized to the control group and the others to the intervention group after completion of a cross-sectional survey. The group randomization was undertaken by our statistician (Z.C.) in the coordinating center, who was not involved in the trial and was blind to the workplaces. Forty workplaces were randomized to the intervention group, and 20 workplaces were randomized to the control group. Participants from each workplace were asked to complete the questionnaire with the help of study staff. Ethics approval for this study was obtained from Fuwai Hospital and each subcenter, and written informed consent was obtained from each participant. This trial followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline, which is provided with the study protocol in Supplement 1.
After randomization, at least 50 potential participants with hypertension were identified and selected from each workplace in the intervention group, and the same was done for at least 50 participants in the control group. The inclusion criteria for individuals included (1) hypertension diagnosis, (2) aged 18 to 60 years, (3) contracted employee, (4) signed consent form, and (5) agreed to participate for 2 years. Exclusion criteria included (1) secondary hypertension; (2) acute myocardial infarction or stroke within 3 months; (3) pregnancy or childbirth within 3 months for women; (4) life expectancy of less than 2 years; (5) psychiatric illness, hearing difficulty, or physical incapacitation; and (6) occupation as a health care practitioner.
The intervention lasted 2 years and included 2 components: (1) a population-based workplace wellness program that covered all participants and (2) a guidelines-based hypertension management protocol that focused on participants with hypertension and included a community health center (CHC) intervention and monthly visits.
A workplace wellness program aimed at improving employees’ cardiovascular health was developed on the basis of recommendations from the American Heart Association9 and the 2010 Chinese hypertension management guidelines,10 which included (1) CVD health education, (2) a reasonable diet, (3) tobacco cessation, (4) physical environment promotion, (5) physical activity, (6) stress management, and (7) health screening. The health education component used lectures, posters, and text messages to educate employees about the knowledge of risk or prevention of CVD. The reasonable diet component included providing nutrition education and/or healthy diet information to the employees. In addition to other foods, affordable, healthy (eg, low-salt, low-fat) foods were easily accessible in the workplace cafeteria, and participants were encouraged to select the healthy options when having lunch in the cafeteria. For the tobacco cessation component, tobacco control regulation was developed to improve tobacco cessation rates among employees, and smoking was prohibited in the workplaces. Improvements of the physical environment included modifying workstations and office layouts to decrease sedentary behavior and increase movement. The physical activity component encouraged participants to increase physical activity with exercise breaks during working hours. Accessible indoor or outdoor sports facilities, including an indoor walking path, were provided to engage employees in regular physical activity. For the stress management component, relaxation techniques were provided monthly by employees who specialized in meditation, tai chi, or deep breathing to help workers deal with stress. The health screening component included annual health checkups and feedback to identify key risk factors.
The hypertension management protocol, based on the 2010 Chinese hypertension guidelines,10 was developed and included the following: classification of hypertension, stratification of global risk, targets for BP control, principles of treatment, lifestyle changes, drug treatment, and follow-up management. For the principles of antihypertensive treatment, low-dose initiation, long-acting medication, combination therapy, and individualization were recommended. Specifically, the initial first-line therapy for stage 1 hypertension consisted of single drugs, and combination therapy was recommended for employees with stage 2 hypertension and a mean BP reading of 20/10 mm Hg above the BP target (eFigure 1 in Supplement 2).
Participants with hypertension were treated for at least 2 years by physicians who were oriented to the hypertension management protocol in the designated adjacent CHCs, which were easily accessible to participants to be interviewed. Most CHCs were funded by the Chinese government, and a few were funded by the employing companies. Participants were referred to a higher-level designated hospital when necessary and then returned to the CHCs for follow-up when they were in a stable condition.
In the intervention group, employees were asked to visit the CHCs for monthly visits, during which the physicians evaluated their compliance with medicine therapy, lifestyle changes, BP level, and adverse events. Physicians could modify management as necessary according to the hypertension management protocol. Employees in the control group were seen in the CHCs at baseline and the end of the program, received only routine care for prevention or treatment of diseases, and did not receive any intervention from the program.
Definitions and Measurements
Two BP readings were taken on the right arm of employees in a seated position after at least 5 minutes of rest and a 1-minute interval between readings using an automatic digital BP monitoring device (Omron HBP-1300; Omron). If the difference between the 2 measurements was greater than 5 mm Hg for systolic BP (SBP) or diastolic BP (DBP), a third measurement was obtained. The last 2 measurements were recorded and used for all analyses. Blood pressure control was defined as a mean SBP/DBP lower than 140/90 mm Hg while receiving treatment. Body mass index was calculated as weight in kilograms divided by height in meters squared, and the body mass index cutoff point was 24 to 27.9 for overweight and 28 or higher for obesity.11
Demographic characteristics and lifestyle factors were measured using a standardized questionnaire developed by the coordinating center.12 Per a previous report,4 smoking was defined as the use of at least 1 cigarette per day, current alcohol consumption as consumption of at least 1 drink per week, regular exercise as physical exercise performed for more than 30 minutes at least 3 times a week, and stress perception as perception of high levels of stress. History of CVD was defined as myocardial infarction or stroke that occurred more than 3 months ago. Adverse events, including all-cause death, stroke, acute myocardial infarction, percutaneous transluminal coronary angioplasty, stent placement, coronary artery bypass surgery, and medication adverse effect, were also recorded in every review.
The selected workplaces can be differentiated by the types of ownership,13 including state-owned enterprise, private enterprise (domestic or foreign), or public institution. Regarding hospital affiliation,14 the workplaces were categorized into those with an affiliated hospital, without an affiliated hospital, or with a previously affiliated hospital that is now separated.
The primary outcome was the change in BP control rate, defined as the proportion of participants with well-controlled BP (<140/90 mm Hg), from baseline to 24 months. The secondary outcomes included changes in BP level and prevalence of smoking, drinking, exercise, and overweight or obesity from baseline to 24 months. For continuous outcomes, the intervention effect was defined as the difference between 2 groups, calculated as intervention (values at 24 months minus values at baseline) minus control (values at 24 months minus values at baseline). For dichotomous outcomes, the intervention effect was reported as odds ratio (OR) and 95% CIs compared with the control group.
Program training and employee recruitment took place in October 2012. Baseline assessments were carried out before randomization between November 2012 and December 2012. The intervention program was conducted from January 2013 to December 2014. The follow-up surveys were administered between December 2014 and January 2015.
The study was designed as an effectiveness trial of active interventions compared with the usual care group. Based on previous literature,15 we expected a 20% difference of BP control rate at the 24-month follow-up. Considering the intervention benefits and ethical issues, we recruited employees using a 3:1 ratio. Cluster randomization power analysis was performed for the 2 independent proportions. With a 2.5% type I error and intracluster correlation coefficient of 0.01,16 we estimated that a sample size of 3000 intervention participants (cluster size: 75) and 1000 control participants (cluster size: 50) would provide 90% power to detect an improvement of 25% in BP control between the 2 groups while allowing 20% loss to follow-up in each group. To ensure adequate power, 3600 intervention participants and 1200 control participants were recruited in this study.
All employees who attended follow-up visits at 24 months and had complete data for the primary outcome and other variables were included in the analysis. To examine the differences of baseline data between groups as well as the intervention effect on BP control rate and other outcomes over time, we used mixed-effects models (PROC MIXED [SAS Institute Inc] for continuous dependent variable and PROC GLIMMIX [SAS Institute Inc] for categorical dependent variable) that included a random cluster effect (workplace). Group (intervention or control), all of the baseline covariates, and potential interaction terms were used for adjustment in all models. The hierarchical statistical techniques were used to capture the heterogeneity in the workplace intervention. To evaluate the robustness of the results of the primary analyses, we adopted a multiple-imputation method17 to handle missing data on outcome and covariates in a sensitivity analysis.
The results were reported as rate (%), mean, SD, SE, and 95% CI when appropriate. All data analyses were conducted using SAS, version 9.4 (SAS Institute Inc), and a 2-sided P < .05 was considered statistically significant. Data analysis on an evaluable population was conducted from January 2016 to January 2017.
Participants at the Workplaces
A total of 4548 employees from 60 workplaces were recruited (Figure 1). The baseline characteristics for all employees who completed follow-up as well as the missed visit rate and referral rate of those in the intervention group are shown in eTable 1 and eTable 2 in Supplement 2. No significant difference was found between the individuals who were included and those not included in sex, BP, and body mass index except for age and educational attainment (eTable 3 in Supplement 2).
Overall, of the 4205 participants who completed follow-up, 4166 with complete data (3178 in the intervention group and 988 in the control group) were included in the analyses. These participants had a mean (SD) age of 46.3 (7.6) years and were predominantly male (3451 [82.8%]) (eTable 4 in Supplement 2). At baseline, 1721 participants (41.3%) had obtained a high school education, 2479 (59.5%) were manual labor workers, 2606 (62.6%) were from state-owned enterprise, and 2745 (65.9%) were from a workplace with an affiliated hospital. The mean SBP/DBP was 145.0/91.9 mm Hg in the entire sample. Blood pressure control rate at baseline was 19.5% in the intervention group and 20.1% in the control group.
Trends of Control Rate and Blood Pressure Level
For the intervention group, the BP control rate showed a significant increase within the first 3 months of the intervention (from 21.6% to 46.3%) and then a gradual increase throughout the whole duration (to 65.6%) (Figure 2A). The mean level of BP showed a significant decrease over time (SBP: from 145.2 mm Hg to 134.7 mm Hg; DBP: from 91.9 mm Hg to 84.6 mm Hg) (Figure 2B).
Compared with the BP control rate of 44.0% in the control group, in the intervention group, the BP control rate reached 66.2% (Table 1), and the overall intervention effect was higher (OR, 1.77; 95% CI, 1.58-2.00; P < .001). The interaction effect between subpopulation indicator and the intervention group was significant (F = 3.94; P < .05) only for the category of workplace ownership (eTable 5 in Supplement 2). The intervention effect was significantly different for the variables except for the other occupation status (OR, 2.01; 95% CI, 0.76-5.27; P = .16) and research institute ownership (OR, 0.54; 95% CI, 0.29-1.01; P = .06) between the 2 groups (Table 1). Significant heterogeneity was observed among subcenters (F = 38.21; P < .001) (eFigure 2 in Supplement 2). The random cluster effect was significant (intraclass correlation coefficient, 0.112; P < .001), indicating the hierarchical nature of hypertension control rate and corresponding data from subcenters. Meanwhile, in the intervention group, more employees with uncontrolled hypertension at baseline were able to get their BP under control at the 24-month survey (1583 [49.8%]) compared with their counterparts in the control group (269 [27.2%]) (eTable 6 in Supplement 2).
Overall, SBP changed by −10.5 mm Hg (95% CI, −10.9 to −10.0 mm Hg) from baseline to 24 months in the intervention group and by −4.7 mm Hg (95% CI, −5.5 to −3.9 mm Hg) in the control group. For DBP, we observed changes of −7.3 mm Hg (95% CI, −7.6 to −6.9 mm Hg) in the intervention group and −3.6 mm Hg (95% CI, −4.3 to −3.0 mm Hg) in the control group. The intervention effect was −5.8 mm Hg (95% CI, −6.8 to −4.9 mm Hg; P < .001) for SBP level and −3.6 mm Hg (95% CI, −4.4 to −2.9 mm Hg; P < .001) for DBP level. The OR for the intervention effect of stage 1 hypertension was 0.82 (95% CI, 0.74-0.91), stage 2 was 0.99 (95% CI, 0.89-1.11), and stage 3 was 0.54 (95% CI, 0.39-0.76) (Table 2).
Participants in the intervention group reported greater reductions in the prevalence of drinking (−18.4%; 95% CI, −20.6% to −16.2%; P < .001), perceived stress (−22.9%; 95% CI, −24.8% to −21.1%; P < .001), and excessive use of salt (−32.0%; 95% CI, −33.7% to −30.4%; P < .001) as well as a substantial improvement in regular exercise (34.0%; 95% CI, 32.3%-35.6%; P < .001) from baseline. Compared with those in the control group, the proportion of participants in the intervention group with smoking (−8.4%; 95% CI, −10.7% to −6.1%; P = .14), fatty food intake (−55.5%; 95% CI, −57.3% to −53.8%; P = .59), and overweight or obesity (−6.7%; 95% CI, −8.4% to −5.0%; P = .84) also decreased, but the intervention effect was insignificant (Table 2).
A higher net effect was seen when treatment involved lifestyle changes and prescription drugs (OR, 1.5; 95%, 1.2-1.8; P < .001) (eTable 7 in Supplement 2). In the sensitivity analysis, multiple-imputation analyses yielded similar results for blood pressure control (OR, 1.80; 95% CI, 1.60-2.03; P < .001) (eTable 8 in Supplement 2). Compliance with medication use increased during the follow-up period, reaching 93% at 24 months (eFigure 3 in Supplement 2).
No treatment-related serious adverse events occurred in either group. In the intervention group, 128 employees (4.0%) experienced drug-related adverse effects, and 47 (1.5%) experienced CVD events in the intervention group. In the control group, 10 employees (1.0%) had medication-related adverse effects, and 23 (2.3%) had CVD events. Twelve all-cause deaths occurred in the intervention group (Table 3).
The results of this trial suggest that a multicomponent intervention strategy that combined workplace health promotion and management of hypertension with a CHC intervention and monthly visits was more effective in improving BP control than usual care. Moreover, the absolute reduction in BP was equivalent to a more than 20% decrease in stroke and a more than 10% decrease in coronary heart disease.18
Although several studies have found that participation in workplace health promotion has led to improved BP control,5-7 the intervention effects in the present study were greater. A possible explanation for this difference may be the socioecological model of health behaviors and health outcomes,19 which emphasizes the multiple levels of influence on an individual’s health. As shown in previous studies,20,21 guideline-oriented standardized BP management significantly improved hypertension control in Chinese communities. Our intervention extended this work within workplaces. In the current usual care model,22 patients with hypertension might receive feedback on their BP once every 3 months during a checkup visit. In our model, more data were collected from study participants during the 2-year intervention. It appears that repeated exposure to BP measurements may have reinforced self-management behaviors and promoted positive lifestyle changes.23 In addition, regular follow-up and modification for drug treatment resulted in a larger improvement in BP control rate compared with BP monitoring and patient education alone.24
Employees with a college-level education or higher presented a more prominent increase in BP control. It has been proposed that individuals with more educational attainment have higher health literacy, which was independently associated with better BP control in this study; therefore, we believe that improving health literacy should be part of a hypertension management program in the workplace.25
Findings of this study suggested that private enterprise employees had significantly greater improvement in control rates. Possible explanations were that private companies had limited economical and human resources and lacked knowledge about how to conduct a workplace-based intervention.26,27 Accordingly, a comprehensive multicomponent intervention strategy was more likely to be an effective strategy for private enterprises. Furthermore, employees from a workplace with a previously affiliated hospital that is now separated indicated greater improvement than those from a workplace with an affiliated hospital. This finding was likely associated with the serious problems faced by hospital-affiliated workplaces in China, such as lack of health care professionals and poor quality of medical services.28 In past decades, Chinese enterprises normally had their own hospitals. However, with the deepening reform of state-owned enterprises in China, enterprise-affiliated hospitals began to separate gradually and to push toward the market economy; therefore, a workplace with a previously affiliated hospital that is now separated needed to improve its economic condition on its own and tended to perform better in managing hypertension. Because physical environment promotion, including modifying workstations and office layouts, requires some capital investment, it may not be affordable for certain enterprises or companies; this expense needs to be considered in the generalizability of this intervention.
The current strategies enabled the achievement of significant changes in BP classification and lifestyle behaviors except those associated with smoking and overweight or obesity. Systematic reviews of workplace interventions have shown that a multicomponent intervention would result in significant and positive changes in behaviors,29 and this study confirmed these findings. In turn, behavioral changes have led to lower BP and better control of hypertension.30 However, the greatest effect on hypertension control typically occurred within the first 3 months and then plateaued, which paralleled the results of some weight loss studies in which the enthusiasm for lifestyle changes waned over time.20,24,31 This finding may explain the insignificant effect on the prevalence of overweight or obesity in this study given that weight loss ultimately depends on long-term lifestyle changes,32 a key component of keeping weight loss sustainable at the workplace. Even the control group experienced an SBP/DBP reduction of 4.7/3.6 mm Hg, which may suggest the benefit of having basic public health services coverage across China, which launched in 2009.33
The recently published guidelines34,35 reemphasize the dangers of high BP and the importance of lifestyle-based management combined with medication when necessary. Therefore, exploring and popularizing feasible models are critical to improving BP control and CVD. As this study indicated, implementation of a workplace intervention strategy that combines health promotion and management of hypertension along with CHC intervention and monthly visits may significantly improve BP control. Generalizing this intervention to other countries or less structured workplace environments may help to improve BP control and reduce CVD-related events and deaths among employees.
This study has several limitations. First, because we did not collect data on the employers’ financial investment in the intervention, we could not evaluate the effect of money on the changes in BP control in the intervention and control groups. Second, because the primary end point of the study was to evaluate the change in control rate of BP, the sample size was not large enough to provide sufficient power to test the difference in events between 2 groups during 2 years. As shown in Table 3, the percentage of CVD events was higher in the control group than in the intervention group with the exception of deaths. Meanwhile, participants in the intervention group were followed up every month; however, only 2 interviews were completed in the control group. As a result, recall bias about drug adverse effects was unavoidable. Third, the sample was composed of predominantly men, as a previous study showed that employed men were more likely than women to have hypertension.4 This composition limited the analyses by sex. Fourth, the extent to which the workplaces adopted the recommended changes in the physical environment was not evaluated, even though the conditions had been improved based on the positive lifestyle changes. Fifth, this trial was designed as open label, with the participants, clinicians, and other study investigators aware of treatment randomization. Therefore, the methods of blinded assessment may not be feasible in this trial. In this case, we applied the outcome definition and method of assessment (the measurement of BP and definition of BP control) to minimize the subjective elements and ensure that results were as robust as possible despite the lack of blinding. Sixth, as participants in the intervention group were followed up monthly according to the protocol, all of the effects were potentially the result of the monthly visits, and workplace changes may not have contributed meaningfully.
Findings of this trial suggested that the multicomponent intervention strategy of integrating workplace-based health promotion and guidelines-based hypertension management with monthly visits was effective. This intervention strategy may be considered for application in other types of workplaces in China and other countries. A workplace hypertension management program can potentially have far greater reach and better accessibility among employees and should be considered for inclusion in hypertension control programs.
Accepted for Publication: December 18, 2019.
Corresponding Authors: Zengwu Wang, MD, PhD, Division of Prevention and Community Health, National Center for Cardiovascular Disease, The State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, 167 Beilishi Rd, Xicheng District, Beijing 100037, China (firstname.lastname@example.org); Chun Chang, MD, PhD, School of Public Health, Department of Social Medicine and Health Education, Peking University, 38 Xueyuan Rd, Haidian District, Beijing 100191, China (email@example.com).
Published Online: March 4, 2020. doi:10.1001/jamacardio.2019.6161
Author Contributions: Dr Z. Wang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Z. Wang, Chang.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Z. Wang, Shen, Li, Kang, Jiang.
Critical revision of the manuscript for important intellectual content: Z. Wang, X. Wang, Chen, Zheng, Hao, Chang, Gao.
Statistical analysis: Z. Wang, Shen, Chen, Kang, Chang.
Obtained funding: Z. Wang.
Administrative, technical, or material support: Chen.
Supervision: Z. Wang, Gao.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by grant 2011BAI11B01 from the Projects in the Chinese National Science and Technology Pillar Program during the 12th Five-year Plan Period and by grant 2017-I2M-1-004 from the Chinese Academy of Medical Science Innovation Fund for Medical Sciences.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
China Hypertension Survey Group: The Standardized Management of Hypertensive Employees Program: The following principal investigators and subcenters in China contributed to this study: National Center for Cardiovascular Diseases and Fuwai Hospital, Beijing: Zengwu Wang, MD, PhD; Xin Wang, MD; Zuo Chen, PhD; Linfeng Zhang, PhD; Lan Shao, BS; Ye Tian, BS; Manlu Zhu, BS; Runlin Gao, MD. West China Hospital of Sichuan University, Sichuan: Xiaoyang Liao, MD; Yu He, BS; Tianhu Liu, BS. The First Affiliated Hospital of Xi'an Jiao Tong University, Shaanxi: Gang Tian, MD; Min Li, BS; Shaowu Song, BS. The Third Xiangya Hospital of Central South University, Hunan: Hong Yuan, MD; Pinting Yang, BS; Nianzu Lan, BS. Jiangsu Provincial Center for Disease Control and Prevention, Jiangsu: Quanyong Xiang, PhD, Peipei Xu, MD; Yumei Shen, BS. Zhejiang Hospital, Zhejiang: Xinhua Tang, MD; Xiaoling Shou, MD; Li Yang, PhD. Datong Coal Mine Group General Hospital, Shanxi: Chengbao Lei, MD; Chunxiang Li, BS. Beijing Anzhen Hospital, Beijing: Xiaohui Yang, BS; Xiaopeng Chen, BS; Haiyan Liu, BS. The First Hospital of Harbin Medical University, Heilongjiang: Xinhua Yin, MD; Xiaohui Zhang, MD; Zhiyu Shi, MD. Suzhou Center for Disease Control and Prevention, Jiangsu: Yihe Hu, BS; Zhengji Zhang, PhD. Wuhan University, Hubei: Xiuping Guan, BS; Mingli Li, BS. Shenzhen Sun Yat-sen Cardiovascular Hospital, Shenzhen: Xiaoling Peng, MD; Zepeng Lin, MD. Xuanwu Hospital Capital Medical University, Beijing: Qi Hua, MD; Peng Hao, MD; Lihua Liu, BS. Institute of Basic Medicine, Shandong Academy of Medical Science, Shandong: Fanghong Lu, MD; Zhendong Liu, BS; Hua Zhang, PhD. Hebei General Hospital, Hebei: Shuping Ma, MD; Mingning ZhuGe, MD; Yanan Wang, BS. Hanzhong General Hospital, Shaanxi: Ruihai Yang, MD; Yong Reng, BS; Shaomei Pan, BS. Yunnan Provincial Center for Disease Control and Prevention, Yunnan: Yize Xiao, BS; Qingping Shi, BS; Shulan Zhang, BS. Guangdong General Hospital, Guangdong: Yingqing Feng, MD; Shiying Chen, MD; Songtao Tang, BS; Man Lu, BS. The First Hospital of Anhui Medical University, Anhui: Haiqing Tang, MD; Xing Liu, BS; Jie Zhang, BS. China Huaneng Group General Hospital, Inner Mongolia: Jingzhong Wang, BS; Hongyue Hou, BS; Kun Xiao, BS. Yuxian General Hospital, Shanxi: Dongshuang Guo, BS; Ruitian Zhang, BS; Shengying Liang, BS. Beijing Hypertension League Institute, Beijing: Hongye Zhang, BS; Weiwei Li, BS; Xiuhong Jia, BS.
Data Sharing Statement: See Supplement 3.
Additional Contributions: This study was accomplished through the fine work of the China Hypertension Survey Group staff at the national level. Zugui Zhang, PhD, Thomas Jefferson University, provided editing assistance and received no compensation for this contribution.
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