title: Challenges in standardization of blood pressure measurement at the population level.
abstract: BACKGROUND
  Accurate blood pressure measurements are needed in clinical practice, intervention studies and health examination surveys. Blood pressure measurements are sensitive: their accuracy can be affected by measurement environment, behaviour of the subject, measurement procedures, devices used for the measurement and the observer. To minimize errors in blood pressure measurement, a standardized measurement protocol is needed.
  
  
  METHODS
  The European Health Examination Survey (EHES) Pilot project was conducted in 2009-2012. A pilot health examination survey was conducted in 12 countries using a standardized protocol. The measurement protocols used in each survey, training provided for the measurers, measurement data, and observations during site visits were collected and evaluated to assess the level of standardization.
  
  
  RESULTS
  The EHES measurement protocol for blood pressure was followed accurately in all 12 pilot surveys. Most of the surveys succeeded in organizing a quiet and comfortable measurement environment, and staff instructed survey participants appropriately before examination visits. In all surveys, blood pressure was measured three times, from the right arm in a sitting posture. The biggest variation was in the device used for the blood pressure measurement.
  
  
  CONCLUSIONS
  It is possible to reach a high level of standardization for blood pressure measurements across countries and over time. A detailed, standardized measurement protocol, and adequate training and monitoring during the fieldwork and centrally organized quality assessment of the data are needed. The recent EU regulation banning the sale of mercury sphygmomanometer in European Union Member States has set new challenges for the standardization of measurement devices since the validity of oscillometric measurements is device-specific and performance of aneroid devices depends very much on calibration.
authors.affiliation: Department of Health, National Institute for Health and Welfare, Helsinki, Finland. hanna.tolonen@thl.fi.
authors.forename: Hanna
authors.initials: H
authors.lastname: Tolonen
authors.affiliation: Department of Health, National Institute for Health and Welfare, Helsinki, Finland. paivikki.koponen@thl.fi.
authors.forename: Päivikki
authors.initials: P
authors.lastname: Koponen
authors.affiliation: Hellenic Health Foundation, Athens, Greece and Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens, Greece. anaska@nut.uoa.gr.
authors.forename: Androniki
authors.initials: A
authors.lastname: Naska
authors.affiliation: Department of Health, National Institute for Health and Welfare, Helsinki, Finland. satu.mannisto@thl.fi.
authors.forename: Satu
authors.initials: S
authors.lastname: Männistö
authors.affiliation: The Cardinal Stefan Wyszynski Institute of Cardiology, Warsaw, Poland. hanna.tolonen@thl.fi.
authors.forename: Grazyna
authors.initials: G
authors.lastname: Broda
authors.affiliation: Department of Health, National Institute for Health and Welfare, Helsinki, Finland. tarja.palosaari@thl.fi.
authors.forename: Tarja
authors.initials: T
authors.lastname: Palosaari
authors.affiliation: Department of Health, National Institute for Health and Welfare, Helsinki, Finland. kari.kuulasmaa@thl.fi.
authors.forename: Kari
authors.initials: K
authors.lastname: Kuulasmaa
mesh_terms: D001794:Blood Pressure / Q000502:physiology*; D001795:Blood Pressure Determination / Q000295:instrumentation / Q000379:methods* / Q000592:standards*; D005060:Europe; D006306:Health Surveys / Q000379:methods / Q000706:statistics & numerical data; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000503:physiopathology*; D009991:Oscillometry / Q000379:methods / Q000592:standards; D010865:Pilot Projects; D012015:Reference Standards; D012189:Retrospective Studies