Population effects on individual systolic blood pressure: a multilevel analysis of the World Health Organization MONICA Project

Am J Epidemiol. 2004 Jun 15;159(12):1168-79. doi: 10.1093/aje/kwh160.


Individuals from the same population share a number of contextual circumstances that may condition a common level of blood pressure over and above individual characteristics. Understanding this population effect is relevant for both etiologic research and prevention strategies. Using multilevel regression analyses, the authors quantified the extent to which individual differences in systolic blood pressure (SBP) could be attributed to the population level. They also investigated possible cross-level interactions between the population in which a person lived and pharmacological (antihypertensive medication) and nonpharmacological (body mass index) effects on individual SBP. They analyzed data on 23,796 men and 24,986 women aged 35-64 years from 39 worldwide Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study populations participating in the final survey of this World Health Organization project (1989-1997). SBP was positively associated with low educational achievement, high body mass index, and use of antihypertensive medication and, for women, was negatively associated with smoking. About 7-8% of all SBP differences between subjects were attributed to the population level. However, this population effect was particularly strong (i.e., 20%) in antihypertensive medication users and overweight women. This empirical evidence of a population effect on individual SBP emphasizes the importance of developing population-wide strategies to reduce individual risk of hypertension.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Antihypertensive Agents / therapeutic use*
  • Blood Pressure*
  • Body Mass Index
  • Demography
  • Female
  • Humans
  • Hypertension / epidemiology
  • Hypertension / etiology*
  • Male
  • Middle Aged
  • Reference Values
  • Regression Analysis
  • Reproducibility of Results
  • Risk Factors
  • Sensitivity and Specificity
  • Systole
  • World Health Organization


  • Antihypertensive Agents