Social Determinants of Health and Uncontrolled Blood Pressure in a National Cohort of Black and White US Adults: the REGARDS Study
VIEW EDITORIAL:Hypertension—A Social Disease in Need of Social Solutions
Abstract
Background:
Determining the contribution of social determinants of health (SDOH) to the higher proportion of Black adults with uncontrolled blood pressure (BP) could inform interventions to improve BP control and reduce cardiovascular disease.
Methods:
We analyzed data from 7306 White and 7497 Black US adults taking antihypertensive medication from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study (2003–2007). SDOH were defined using the Healthy People 2030 domains of education, economic stability, social context, neighborhood environment, and health care access. Uncontrolled BP was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg.
Results:
Among participants taking antihypertensive medication, 25.4% of White and 33.7% of Black participants had uncontrolled BP. The SDOH included in the current analysis mediated the Black-White difference in uncontrolled BP by 33.0% (95% CI, 22.1%–46.8%). SDOH that contributed to excess uncontrolled BP among Black compared with White adults included low annual household income (percent-mediated 15.8% [95% CI, 10.8%–22.8%]), low education (10.5% [5.6%–15.4%]), living in a health professional shortage area (10.4% [6.5%–14.7%]), disadvantaged neighborhood (11.0% [4.4%–18.0%]), and high-poverty zip code (9.7% [3.8%–15.5%]). Together, the neighborhood-domain accounted for 14.1% (95% CI, 5.9%–22.9%), the health care domain accounted for 12.7% (95% CI, 8.4%–17.3%), and the social-context-domain accounted for 3.8% (95% CI, 1.2%–6.6%) of the excess likelihood of uncontrolled BP among Black compared with White adults, respectively.
Conclusions:
SDOH including low education, low income, living in a health professional shortage area, disadvantaged neighborhood, and high-poverty zip code contributed to the excess likelihood of uncontrolled BP among Black compared with White adults.
Graphical Abstract
Novelty and Relevance
What Is New?
In the United States, Black adults are more likely to have uncontrolled blood pressure (BP) than White adults. Determining the contribution of social determinants of health to the higher proportion of Black adults with uncontrolled BP could inform interventions to improve BP control and reduce cardiovascular disease in the Black population.
What Is Relevant?
Social determinants of health including having a low annual household income, low education, living in a disadvantaged neighborhood, a health professional shortage area and a high-poverty zip code contribute to the higher likelihood of uncontrolled BP among Black adults compared with White adults. The likelihood of uncontrolled BP increased with the number of adverse social determinants of health after adjustment.
Clinical/Pathophysiological Implications
Interventions to improve social determinants of health may reduce racial disparities in BP control and subsequent cardiovascular disease risk among adults taking antihypertensive medication.
See Editorial, pp 1414–1416
The prevalence of hypertension is substantially higher among Black compared with White US adults.1,2 Also, in the United States, Black adults taking antihypertensive medication are less likely to achieve controlled blood pressure (BP) than White adults.3,4 The higher prevalence of uncontrolled BP among Black compared with White US adults has been estimated to contribute to 8000 excess cardiovascular disease deaths annually among Black adults.5 Randomized trials have shown that reducing BP by lifestyle modification, antihypertensive medication use, or both among adults with hypertension decreases the risk of cardiovascular disease and premature mortality in both Black and White adults.6,7
In October 2020, the US Surgeon General published a Call-to-Action for hypertension control that acknowledged that social determinants of health (SDOH) may be associated with uncontrolled BP among US adults.8 Because Black adults experience a heavier burden of adverse SDOH,9,10 and because SDOH are associated with hypertension,11,12 we hypothesized that SDOH could contribute to the excess prevalence of uncontrolled BP among Black adults. The purpose of the current analysis was to determine the association between SDOH and uncontrolled BP among Black compared with White adults taking antihypertensive medication. In addition, we determined the proportion of the excess prevalence of uncontrolled BP among Black compared with White adults taking antihypertensive medication that could be potentially attributed to SDOH. To accomplish these goals, we analyzed data from the national REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study.
Methods
Data Availability
Requests to access the dataset from qualified researchers trained in human subject confidentiality protocols may be sent to the REGARDS executive committee at http://regardsstudy.org. The REGARDS study enrolled a population-based sample of 30,239 Black and White adults aged ≥45 years from the 48 contiguous US states and the District of Columbia between 2003 and 2007.13 The REGARDS study was approved by the institutional review boards of the participating institutions and all participants provided written informed consent.
The current analysis was restricted to participants with complete information on systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the baseline examination and with hypertension defined as SBP ≥140 mm Hg, DBP ≥90 mm Hg, or self-reported taking antihypertensive medication (Figure S1). We excluded participants who were not taking antihypertensive medication determined by self-report and confirmed on a medication inventory. After applying these criteria, a total of 14 803 (7306 White and 7497 Black) participants were included in the current analyses.
Data Collection
At baseline, data were collected by trained research staff during computer-assisted telephone interviews and by trained technicians during a subsequent in-home visit. Pill bottles for medications being taken by study participants in the 2 weeks before their study visit were reviewed as part of a medication inventory. Table S1 shows detailed definitions of covariates included in the current analysis.14–18
Social Determinants of Health
Similar to previous REGARDS studies,19–21 we used the Healthy People 2030 framework of SDOH22 to guide the selection of SDOH for the current analysis (Figure S2). The framework includes 5 domains: education, economic, social context, neighborhood, and health care.22 Table S2 provides details on how these variables were defined. Briefly, the education domain was categorized as <high school (adverse level), high school, some college, and college graduate. The economic domain was categorized as annual household income <$20 000, $20 000 to <$35 000, $35 000 to <$75 000, and ≥$75 000. Low annual household income was defined as <$35 000 (adverse level), consistent with prior REGARDS studies.19,20 The social context domain included 1) the number of friends/relatives seen monthly, categorized as 0 (adverse level), 1 to 5, 6 to 10, and >10 friends/relatives, or (2) having nobody to care for you if ill or disabled (adverse level) versus having someone. The neighborhood domain included (1) a neighborhood socioeconomic score (SES)23 categorized into quartiles (quartile 1 as adverse level), (2) living in a rural area, defined as rural-urban commuting area codes 9 and 1024 (adverse level), or (3) living in a zip code with >25% of residents living below the federal poverty line (adverse level). The health care domain included (1) not having health insurance (adverse level), (2) residing in a county with poor availability of primary care physicians, defined as a health professional shortage area (adverse level),25 or (3) living in the worst ranked states for public health infrastructure, categorized as the bottom 20% (adverse level) versus all others, based on America’s Health Ranking data (Tables S3 and S4).26
BP Measurement and Uncontrolled BP
In the REGARDS study, SBP and DBP were assessed as the average of 2 measurements using an aneroid sphygmomanometer (American Diagnostic Corporation, Hauppauge, NY) following a standardized protocol after participants had a seated rest for 5 minutes with both feet flat on the floor.13 The BP data were monitored for quality control and retraining of technicians took place as necessary. Uncontrolled BP was defined as SBP ≥140 mm Hg or DBP ≥90 mm Hg.
Statistical Analysis
Participant characteristics and distribution of SDOH were calculated overall and by race. The proportion of participants with uncontrolled BP for each level of every SDOH was calculated overall and for Black and White adults, separately. We evaluated collinearity among included SDOH and correlation coefficients were tabulated. Poisson regression with robust variance estimators was used to calculate prevalence ratios and 95% CIs for uncontrolled BP associated with each SDOH, overall and among Black and White adults, separately. The primary model (model 1) included adjustment for age, sex, and race in the overall analysis and for age and sex in the race-stratified analysis. In secondary analyses, we examined a fully adjusted model (model 2), which included adjustment for variables in model 1 and body mass index, current smoking, alcohol use, physical activity, adherence to the dietary approach to stop hypertension diet, perceived stress, history of coronary heart disease, diabetes, chronic kidney disease, and number of classes of antihypertensive medication being taken. We considered model 1 the primary model as some of the covariates in the fully adjusted model could be in the pathway between SDOH and uncontrolled BP. We calculated P value for trend across levels of the SDOH by modeling the SDOH exposures as continuous variables with adjustment for covariates as described above using Poisson regression. We tested if race modified the association between SDOH and uncontrolled BP. Next, the SDOH that were individually positively associated with uncontrolled BP were used to create an SDOH count that ranged from 0 to 6. The prevalence ratio for uncontrolled BP associated with the SDOH count was calculated, overall and among Black and White adults, separately. The P value for trend was calculated across the number of SDOH and we tested for effect modification by race.
A mediation analysis was conducted to determine the proportion of the excess prevalence of uncontrolled BP among Black compared with White adults taking antihypertensive medication that could be attributed to SDOH. The mediation analysis was conducted using the inverse odds weighting method.27,28 This method allows the estimation of single and multiple mediator effects. Our mediators included each adverse SDOH, all SDOH across a domain, and all SDOH included in the current analysis. Details on the mediation analysis are provided in the Supplemental Material.
In a sensitivity analysis, the above analyses were repeated defining hypertension and uncontrolled BP using thresholds (SBP≥130 mm Hg or DBP≥80 mm Hg) in the 2017 American College of Cardiology/American Heart Association BP guideline.29 For all analyses, missing data were imputed with 30 datasets using chained equations. The number and percentage of participants with missing data for each covariate is reported in Table S5. All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC).
Results
Of the 7306 (49.4%) White and 7497 (50.6%) Black participants taking antihypertensive medication that were included in this analysis, 25.4% of White and 33.7% of Black participants had uncontrolled BP (Table 1). Compared with White participants, Black participants were younger, and less likely to be male, heavy alcohol users, or report a history of coronary heart disease but were more likely to be current cigarette smokers, have diabetes, and chronic kidney disease. On average, Black participants had higher body mass index, SBP and DBP and a median higher perceived stress score than White participants. Black participants were also more likely to have <high school education, an annual household income <$20 000, lack health insurance, and live in a poor neighborhood, high-poverty zip code, and health professional shortage area compared with White participants.
| Characteristics | Overall (n=14 803) | White adults (n=7306) | Black adults (n=7497) |
|---|---|---|---|
| Age, y; mean±SD | 66.3±9.0 | 67.4±8.9 | 65.1±8.9 |
| Male, % | 42.9 | 50.5 | 35.5 |
| Current cigarette smoking, % | 13.7 | 11.1 | 16.2 |
| Excessive alcohol use, % | 3.7 | 5.1 | 2.3 |
| No physical activity, % | 38.9 | 37.1 | 40.7 |
| Body mass index, kg/m2, mean±SD | 30.7±6.4 | 29.6±5.9 | 31.7±6.8 |
| DASH diet score, mean±SD | 23.9±4.3 | 24.5±4.3 | 23.2±4.2 |
| Diabetes, % | 31.1 | 23.7 | 38.3 |
| Chronic kidney disease, % | 31.7 | 30.0 | 33.4 |
| History of coronary heart disease, % | 23.7 | 28.0 | 19.4 |
| Number of classes of antihypertensive medication, median (IQR) | 2.0 (1.0–3.0) | 2.0 (1.0–3.0) | 2.0 (1.0–3.0) |
| Perceived stress, median (IQR) | 3.0 (0.0–5.0) | 2.0 (0.0–5.0) | 3.0 (1.0–6.0) |
| SBP, mm Hg, mean±SD | 131.4±16.7 | 129.7±15.8 | 133.0±17.3 |
| DBP, mm Hg, mean±SD | 77.6±9.9 | 76.2±9.3 | 78.9±10.2 |
| % with uncontrolled BP, % | 29.6 | 25.4 | 33.7 |
| Social determinants of health | |||
| Education, % | |||
| <High school | 15.6 | 9.1 | 21.9 |
| High school graduate | 27.5 | 26.5 | 28.5 |
| Some college | 26.6 | 27.5 | 25.7 |
| College graduate | 30.3 | 36.8 | 23.9 |
| Annual household income, % | |||
| <$20,000 | 24.7 | 16.2 | 33.1 |
| $20,000 to <$35,000 | 29.8 | 28.7 | 30.9 |
| $35,000 to <$75,000 | 31.8 | 36.5 | 27.3 |
| ≥$75,000 | 13.7 | 18.7 | 8.7 |
| Social support, % | |||
| 0 close friend or relatives | 3.9 | 3.7 | 4.1 |
| 1–5 close friend or relatives | 50.3 | 46.6 | 53.9 |
| 6–10 close friend or relatives | 27.2 | 28.4 | 26.1 |
| >10 close friend or relatives | 18.7 | 21.4 | 16.0 |
| Having someone to care for you if ill or disabled, % | |||
| No | 14.3 | 14.2 | 14.5 |
| Yes | 85.7 | 85.8 | 85.5 |
| Neighborhood socioeconomic status score, % | |||
| Quartile 1 (poor) | 25.0 | 11.0 | 38.2 |
| Quartile 2 | 25.0 | 21.2 | 28.6 |
| Quartile 3 | 25.0 | 28.5 | 21.8 |
| Quartile 4 | 25.0 | 39.4 | 11.5 |
| Living in a high-poverty zip code, % | |||
| Yes | 22.9 | 10.8 | 34.6 |
| No | 77.1 | 89.2 | 65.4 |
| Residing in rural area, % | |||
| Yes | 2.6 | 4.1 | 1.3 |
| No | 97.4 | 95.9 | 98.7 |
| Health insurance, % | |||
| Yes | 94.1 | 96.5 | 91.8 |
| No | 5.9 | 3.5 | 8.2 |
| Resident in health professional shortage area, % | |||
| Yes | 42.7 | 36.2 | 49.0 |
| No | 57.3 | 63.8 | 51.0 |
| Resident in worst ranked states for public health infrastructure, % | |||
| Yes | 63.9 | 39.0 | 33.3 |
| No | 36.1 | 61.1 | 66.7 |
Numbers in the table are mean±SD, median (interquartile range [IQR]) or percentages where specified. BP indicates blood pressure; DASH, Dietary Approach To Stop Hypertension; DBP, diastolic blood pressure; REGARDS, Reasons for Geographic and Racial Differences in Stroke; and SBP, systolic blood pressure.
Individual SDOH and Uncontrolled BP
The included SDOH were not highly correlated (all correlation coefficients <0.5, Table S6). The proportion of participants with uncontrolled BP by each SDOH overall, and among Black and White adults, separately, is presented in Figure 1 and Table S7, respectively. Among White adults, after age and sex adjustment, uncontrolled BP was more common among those with <high school education and high school graduates versus college graduates, those with annual household income <$20 000, $20 000 to <$35 000, and $35 000 to <$75 000 versus ≥$75 000, those living in a neighborhood with a SES score in quartiles 1, 2, and 3, versus quartile 4, high-poverty zip code, health professional shortage area and those lacking health insurance (Table 2). Among Black adults, after age and sex adjustment, uncontrolled BP was more common among those with <high school education, high school graduates, and some college, versus college graduates, those with annual household income <$20 000 and $20 000 to <$35 000 versus ≥$75 000, those living in a neighborhood with a SES score in quartile 1 versus quartile 4, a high-poverty zip code, health professional shortage area, and without health insurance. There was no evidence of effect modification between each SDOH and uncontrolled BP by race. Table 2 shows the association of each SDOH with uncontrolled BP overall, and among White and Black adults, separately after multivariable adjustment (model 2).
| Categories of social determinants of health | Overall | White adults | Black adults | |||
|---|---|---|---|---|---|---|
| Model 1 | Model 2 | Model 1 | Model 2 | Model 1 | Model 2 | |
| Education | ||||||
| College graduate | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) |
| Some college | 1.03 (0.96–1.11) | 1.00 (0.93–1.07) | 0.99 (0.89–1.09) | 0.95 (0.85–1.05) | 1.08 (0.98–1.19) | 1.05 (0.95–1.15) |
| High school graduate | 1.17 (1.10–1.26) | 1.12 (1.05–1.20) | 1.15 (1.04–1.27) | 1.10 (1.00–1.22) | 1.20 (1.10–1.32) | 1.15 (1.05–1.26) |
| <high school | 1.24 (1.15–1.33) | 1.14 (1.06–1.24) | 1.19 (1.04–1.37) | 1.10 (0.96–1.27) | 1.29 (1.18–1.42) | 1.19 (1.08–1.32) |
| P-trend | <0.001 | <0.001 | 0.001 | 0.03 | <0.001 | <0.001 |
| P-interaction* | 0.62 | 0.55 | ||||
| Annual household income | ||||||
| ≥$75 000 | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) |
| $35 000 to <$75 000 | 1.17 (1.06–1.29) | 1.14 (1.03–1.26) | 1.27 (1.11–1.45) | 1.25 (1.09–1.43) | 1.03 (0.89–1.20) | 0.98 (0.85–1.14) |
| $20 000 to <$35 000 | 1.40 (1.26–1.54) | 1.32 (1.19–1.46) | 1.48 (1.29–1.70) | 1.43 (1.24–1.64) | 1.25 (1.09–1.45) | 1.16 (1.00–1.34) |
| <$20 000 | 1.50 (1.36–1.66) | 1.38 (1.24–1.53) | 1.63 (1.41–1.90) | 1.55 (1.32–1.81) | 1.34 (1.17–1.55) | 1.20 (1.03–1.38) |
| P-trend | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 |
| P-interaction* | 0.22 | 0.09 | ||||
| Social isolation | ||||||
| Number of friends or relatives seen monthly | ||||||
| >10 friends or relatives | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) |
| 6–10 friends or relatives | 0.90 (0.83–0.97) | 0.90 (0.84–0.97) | 0.83 (0.74–0.93) | 0.84 (0.75–0.94) | 0.95 (0.86–1.05) | 0.96 (0.87–1.06) |
| 1–5 friends or relatives | 0.91 (0.85–0.97) | 0.91 (0.85–0.97) | 0.92 (0.84–1.02) | 0.92 (0.83–1.01) | 0.91 (0.83–0.99) | 0.90 (0.83–0.99) |
| 0 friends or relatives | 0.87 (0.75–1.00) | 0.83 (0.73–0.96) | 0.87 (0.70–1.09) | 0.84 (0.67–1.06) | 0.86 (0.72–1.04) | 0.83 (0.69–0.99) |
| P-trend | 0.01 | 0.004 | 0.28 | 0.19 | 0.02 | 0.01 |
| P-interaction* | 0.11 | 0.10 | ||||
| Do not have anyone to care for you if ill or disabled | 1.07 (0.99–1.14) | 1.04 (0.97–1.12) | 1.08 (0.96–1.21) | 1.05 (0.93–1.18) | 1.06 (0.97–1.15) | 1.03 (0.94–1.13) |
| P-interaction* | 0.75 | 0.80 | ||||
| Neighborhood and built environment | ||||||
| Neighborhood socioeconomic score | ||||||
| Quartile 4 | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) | 1 (ref) |
| Quartile 3 | 1.11 (1.03–1.20) | 1.09 (1.00–1.17) | 1.16 (1.05–1.28) | 1.14 (1.03–1.26) | 1.03 (0.91–1.17) | 1.00 (0.89–1.14) |
| Quartile 2 | 1.14 (1.05–1.23) | 1.08 (1.00–1.17) | 1.20 (1.07–1.34) | 1.15 (1.03–1.28) | 1.05 (0.94–1.18) | 1.00 (0.89–1.13) |
| Quartile 1 (poor) | 1.20 (1.11–1.30) | 1.13 (1.04–1.22) | 1.25 (1.10–1.43) | 1.18 (1.03–1.35) | 1.12 (1.00–1.25) | 1.05 (0.94–1.18) |
| P-trend | <0.001 | 0.01 | <0.001 | 0.003 | 0.02 | 0.25 |
| P-interaction* | 0.39 | 0.35 | ||||
| Living in a high-poverty zip code | 1.10 (1.04–1.17) | 1.08 (1.02–1.14) | 1.12 (0.99–1.26) | 1.08 (0.96–1.22) | 1.10 (1.03–1.18) | 1.08 (1.01–1.15) |
| P-interaction* | 0.89 | 0.93 | ||||
| Rural residence | 1.04 (0.88–1.23) | 1.03 (0.87–1.23) | 1.07 (0.88–1.32) | 1.08 (0.88–1.32) | 0.96 (0.70–1.31) | 0.97 (0.71–1.32) |
| P-interaction* | 0.56 | 0.58 | ||||
| Health and health care | ||||||
| Lack of health insurance | 1.15 (1.04–1.28) | 1.12 (1.01–1.24) | 1.22 (0.99–1.50) | 1.14 (0.92–1.40) | 1.12 (1.00–1.26) | 1.10 (0.98–1.23) |
| P-interaction* | 0.49 | 0.79 | ||||
| Resident in health professional shortage area | 1.14 (1.08–1.19) | 1.13 (1.07–1.19) | 1.09 (1.00–1.18) | 1.07 (0.99–1.16) | 1.17 (1.10–1.25) | 1.17 (1.10–1.25) |
| P-interaction* | 0.13 | 0.09 | ||||
| Resident in worst ranked states for public health infrastructure | 0.97 (0.92–1.02) | 0.96 (0.91–1.01) | 0.99 (0.92–1.08) | 0.99 (0.91–1.07) | 0.95 (0.89–1.01) | 0.94 (0.87–1.00) |
| P-interaction* | 0.39 | 0.34 | ||||
Numbers in the table are prevalence ratio (95% CI) except for the P value or P interaction. Model 1: adjusted for age, sex and race for the overall analysis and for age and sex for the stratified analysis. Model 2: adjusted for variables in model 1 and body mass index, current smoking, excessive alcohol use, no physical activity, adherence to the dietary approach to stop hypertension diet, perceived stress, history of coronary heart disease, diabetes, chronic kidney disease, and number of classes of antihypertensive medication. Uncontrolled blood pressure was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. REGARDS indicates Reasons for Geographic and Racial Differences in Stroke; and SDOH, social determinants of health.
*
P-interaction is the P value for interaction between the SDOH factor and race on uncontrolled blood pressure.
Number of SDOH and Uncontrolled BP
The proportion of participants with uncontrolled BP increased with each adverse SDOH (Figure 2A). When stratified by race, Black adults had a higher proportion of uncontrolled BP than White adults across the number of adverse SDOH (Figure 2B). After age and sex adjustment, the prevalence of uncontrolled BP was higher with more adverse SDOH among White and Black adults (Table 3). There was no evidence of an effect modification between number of adverse SDOH and race on uncontrolled BP. After multivariable adjustment, having more adverse SDOH was associated with higher prevalence of uncontrolled BP.
| Race | Number of adverse SDOH* | P-trend | P-interaction | ||||
|---|---|---|---|---|---|---|---|
| 0 | 1 | 2 | 3 | ≥4 | |||
| Overall population | |||||||
| N cases/N in the sample | |||||||
| All | 688/3047 | 1273/4591 | 1087/3446 | 688/2043 | 644/1676 | … | … |
| % with uncontrolled BP | |||||||
| All | 22.6 | 27.7 | 31.5 | 33.7 | 38.4 | … | … |
| Prevalence ratio (95% CI)-Model 1 | |||||||
| All | 1 (ref) | 1.21 (1.11–1.31) | 1.33 (1.22–1.45) | 1.37 (1.25–1.51) | 1.54 (1.40–1.70) | <0.001 | … |
| Prevalence ratio (95% CI)-Model 2 | |||||||
| All | 1 (ref) | 1.18 (1.09–1.29) | 1.26 (1.16–1.38) | 1.28 (1.17–1.41) | 1.43 (1.29–1.57) | <0.001 | … |
| By race | |||||||
| N cases/N in the sample | |||||||
| White adults | 463/2171 | 720/2854 | 439/1493 | 155/556 | 75/232 | … | … |
| Black adults | 225/876 | 553/1737 | 648/1953 | 533/1487 | 569/1444 | … | … |
| % with uncontrolled BP | |||||||
| White adults | 21.3 | 25.2 | 29.4 | 27.9 | 32.3 | … | … |
| Black adults | 25.7 | 31.8 | 33.2 | 35.8 | 39.4 | … | … |
| Prevalence ratio (95% CI)-Model 1 | |||||||
| White adults | 1 (ref) | 1.17 (1.06–1.31) | 1.37 (1.22–1.54) | 1.31 (1.12–1.54) | 1.55 (1.26–1.91) | <0.001 | 0.64 |
| Black adults | 1 (ref) | 1.25 (1.09–1.43) | 1.31 (1.15–1.50) | 1.41 (1.23–1.61) | 1.56 (1.37–1.79) | <0.001 | |
| Prevalence ratio (95% CI)-Model 2 | |||||||
| White adults | 1 (ref) | 1.15 (1.03–1.28) | 1.30 (1.15–1.47) | 1.23 (1.05–1.45) | 1.45 (1.17–1.79) | <0.001 | 0.61 |
| Black adults | 1 (ref) | 1.23 (1.08–1.41) | 1.25 (1.10–1.43) | 1.33 (1.16–1.52) | 1.45 (1.27–1.66) | <0.001 | |
Model 1: adjusted for age, sex and race for the overall analysis and for age and sex for the stratified analysis. Model 2: adjusted for variables in model 1 and body mass index, current smoking, excessive alcohol use, no physical activity, adherence to the dietary approach to stop hypertension diet, perceived stress, history of coronary heart disease, diabetes, chronic kidney disease, and number of classes of antihypertensive medication. BP indicates blood pressure; REGARDS, Reasons for Geographic and Racial Differences in Stroke; and SDOH, social determinants of health.
*
Adverse social determinants of health included having <high school education, annual household income <$35 000, residing in a disadvantaged neighborhood (neighborhood socioeconomic score in the first quartile), living in a high-poverty zip code, not having health insurance, and living in a health professional shortage area.
Uncontrolled blood pressure was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg.
Mediation Analysis
After age and sex adjustment, collectively the 10 SDOHs included in the current analysis explained 33.0% (95% CI, 22.1%–46.8%) of the excess prevalence of uncontrolled BP among Black compared with White adults (Table 4). Low annual household income accounted for 15.8% (95% CI, 10.8%–22.8%), living in a disadvantage neighborhood accounted for 11.0% (95% CI, 4.4%–18.0%), <high school education accounted for 10.5% (95% CI, 5.6%–15.4%), living in a health professional shortage area accounted for 10.4% (95% CI, 6.5%–14.7%), and living in a high-poverty zip code accounted for 9.7% (95% CI, 3.8%–15.5%) of the excess prevalence of uncontrolled BP among Black compared with White adults, respectively. Other factors mediating the excess prevalence of uncontrolled BP among Black compared with White adults included seeing no friends or family in the past month (4.0%), having no-one to care for you if ill (4.0%), living in a rural area (4.8%), living in a state with the least public health infrastructure (5.1%), and lack of health insurance (5.1%). Together, the neighborhood domain, health care domain, and social context domain accounted for 14.1%, 12.7%, and 3.8% of the excess prevalence of uncontrolled BP among Black compared with White adults, respectively. Table S8 shows the mediation analysis results after multivariable adjustment.
| Healthy people 2030 domain | SDOH | Natural direct effect PR (95% CI) | Natural indirect effect PR (95% CI) | Total effect PR (95% CI) | % mediated (95% CI) |
|---|---|---|---|---|---|
| Education | Low education (<high school) | 1.35 (1.29–1.42) | 1.04 (1.02–1.05) | 1.40 (1.33–1.47) | 10.5 (5.6–15.4) |
| Economic | Annual household income <$35 000 | 1.33 (1.26–1.40) | 1.05 (1.04–1.08) | 1.40 (1.33–1.47) | 15.8 (10.8–22.8) |
| Social context | Social isolation: saw no friend/family in the past month | 1.38 (1.32–1.46) | 1.01 (1.00–1.02) | 1.40 (1.33–1.47) | 4.0 (1.1–6.7) |
| Social isolation: nobody to care if seriously ill | 1.38 (1.32–1.46) | 1.01 (1.01–1.02) | 1.40 (1.33–1.47) | 4.0 (1.6–6.9) | |
| Neighborhood | Neighborhood disadvantage | 1.35 (1.28–1.43) | 1.04 (1.02–1.06) | 1.40 (1.33–1.47) | 11.0 (4.4–18.0) |
| Rural area | 1.38 (1.31–1.45) | 1.02 (1.00–1.03) | 1.40 (1.33–1.47) | 4.8 (1.0–8.6) | |
| High-poverty zip code | 1.35 (1.29–1.43) | 1.03 (1.01–1.05) | 1.40 (1.33–1.47) | 9.7 (3.8–15.5) | |
| Health care | Lack of health insurance | 1.37 (1.32–1.45) | 1.02 (1.01–1.03) | 1.40 (1.33–1.47) | 5.1 (2.1–8.1) |
| Health professional shortage area | 1.35 (1.29–1.43) | 1.04 (1.02–1.05) | 1.40 (1.33–1.47) | 10.4 (6.5–14.7) | |
| Residing in states with least public health infrastructure | 1.37 (1.31–1.45) | 1.02 (1.01–1.03) | 1.40 (1.33–1.47) | 5.1 (2.6–8.1) | |
| Social context | Social isolation: saw no friend/family in the past month, nobody to care if seriously ill | 1.38 (1.32–1.46) | 1.01 (1.00–1.02) | 1.40 (1.33–1.47) | 3.8 (1.2–6.6) |
| Neighborhood | Neighborhood disadvantage, rural area, high-poverty zip code | 1.33 (1.26–1.41) | 1.05 (1.02–1.08) | 1.40 (1.33–1.47) | 14.1 (5.9–22.9) |
| Health care | Lack of health insurance, health professional shortage area, residing in states with least public health infrastructure | 1.34 (1.28–1.41) | 1.04 (1.03–1.06) | 1.40 (1.33–1.47) | 12.7 (8.4–17.3) |
| All SDOH | All SDOH | 1.25 (1.18–1.33) | 1.12 (1.08–1.17) | 1.40 (1.33–1.47) | 33.0 (22.1–46.8) |
Uncontrolled blood pressure was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. Total effect was estimated as the β-coefficients of the association of Black vs White race with uncontrolled blood pressure in a Poisson regression model adjusting for age and sex. Natural direct effect was estimated as the β-coefficients of the association of Black vs White race with uncontrolled blood pressure in a Poisson regression model adjusting for age and sex, with weights applied. Weights were estimated as the predicted probability of the exposure (Black race) on the mediator (SDOH) adjusting for age and sex in a logistic regression model. Natural indirect effect was estimated by subtracting the total effect from the direct effect. Proportion mediated was estimated by the ratio of the indirect effect by the total effect. The 95% CIs for the total, direct, indirect effects and proportion mediated were calculated using the bias correction and acceleration method from 500 bootstrapped samples. PR indicates prevalence ratio; REGARDS, Reasons for Geographic and Racial Differences in Stroke; and SDOH, social determinants of health.
SDOH and Uncontrolled BP Defined Using the 2017 American College of Cardiology/American Heart Association BP Guideline
When defined according to the 2017 American College of Cardiology/American Heart Association BP guideline, 68.0% of Black and 59.0% of White participants had uncontrolled BP. The proportion of participants with uncontrolled BP by each SDOH overall, and among Black and White adults, separately, is presented in Table S9. Table S10 shows the prevalence ratios for uncontrolled BP associated with each SDOH overall and among Black and White adults, separately. After multivariable adjustment, the likelihood of uncontrolled BP increased progressively with higher number of adverse SDOH, overall and among both White and Black adults (Table S11). All SDOH collectively explained 19.1% (7.8%–31.2%) of the excess prevalence of uncontrolled BP among Black compared with White adults after age and sex adjustment (Table S12). The mediation results after multivariable adjustment are shown in Table S13.
Discussion
In this analysis of adults taking antihypertensive medication, the proportion with uncontrolled BP was higher among Black compared with White adults. Among both White and Black adults, SDOH including education, annual household income, neighborhood SES, high-poverty zip code, lack of health insurance, and living in a health professional shortage area were each associated with uncontrolled BP. The proportion with uncontrolled BP was higher among participants with more adverse SDOH among both White and Black adults. Collectively, all SDOH included in the current analysis explained one-third (33.0%) of the excess likelihood of uncontrolled BP among Black compared with White adults.
Many SDOH can be traced to laws and policies, some of which perpetuate long-standing structural racism that limits opportunities for educational, social, and financial advancement.30 In this study, the larger proportion of Black participants compared with White participants exposed to adverse SDOH reflects the downstream consequences of these policies, including racial segregation and fewer opportunities for Black Americans to accumulate wealth. Individuals with low education are more likely to have poor employment opportunities and low-paying jobs characterized by high levels of stress and difficulty paying for basic needs, which may in turn increase BP levels.31,32 While the American Heart Association has recognized structural racism as the root cause for disparities in health and cardiovascular disease,30 addressing structural racism requires interventions at the individual, interpersonal and institutional levels.33
In the current analysis, living in a health care professional shortage area, poor SES, rural, or high-poverty neighborhood mediated the excess likelihood of uncontrolled BP among Black compared with White adults taking antihypertensive medication. Residential segregation, a product of institutionalized racism, has historically led to Black adults being constrained to living in disadvantaged neighborhoods associated with limited health clinics, few grocery stores, limited recreational facilities, poverty, and high crime rates.34–36 Neighborhoods with high rates of crime and low walkability could contribute to low physical activity and higher body mass index,37 which could result in increased BP.
Some culturally tailored interventions addressing SDOH, including poor access to care, have been shown to improve hypertension control among Black adults. A faith-based lifestyle intervention delivered by community health workers compared with health education alone was found to decrease SBP by 5 mm Hg after 9 months of follow-up.38 Also, team-based care provided in barbershops with predominantly low-income Black male patrons was associated with a 27 mm Hg decrease in SBP among the intervention group compared with their control counterparts.39 Additional social intervention programs that address SDOH and racial disparities among disadvantaged populations are needed.
Although Black adults and other socioeconomically disadvantaged minority populations experience worse health outcomes than White adults, populations of all races with low socioeconomic status experience worse health outcomes.40 In a retrospective study of 3305 patients with uncontrolled BP at baseline who enrolled in a hypertension digital medicine program, there was no difference in controlled BP at 1 year of follow-up between Black and White adults once 2 or more SDOH barriers to health care were present.41
Prior National Health and Nutrition Examination Survey analyses showed evidence of a decrease in BP control among US adults with hypertension from 2013 to 2014 to 2017 to 2018, with persisting racial/ethnic disparities.42 Although racial and ethnic disparities persist in SDOH factors,9,10 there is a paucity of information on how the adverse effects of SDOH on racial/ethnic disparities in BP control have changed over the past 10 years. Future studies that use contemporary data, and assess a wider range of SDOH, including other individual level measures of access to care, would be needed to build on the current findings.
The current analysis has a number of strengths, which include the use of a large, national, population-based sample of Black and White adults. BP and other measures were collected following standardized protocols. We included 10 SDOH measures in the current analysis. However, the results of the current analysis should be considered in the context of certain limitations. BP was measured at a single visit. Guidelines recommend estimating BP as the average of measurements obtained at 2 or more visits.29,43 The BP control status for some participants may be different if data from 2 visits were used. Future studies may consider examining the association of SDOH with BP measured at multiple time points. Despite the availability of a wide variety of SDOH variables, some potentially important SDOH including racialized policing and systemic racism in our justice system were not available limiting our ability to explore the contribution of these SDOH to the excess likelihood of uncontrolled BP. Also, data on food deserts, pharmacy deserts, green spaces and other components of the built environment were not included in the current analysis. Therefore, this analysis could be underestimating the contribution of SDOH to the racial/ethnic disparity in uncontrolled BP. We were unable to determine if the mediation effects varied by levels of age or sex due to study sample size. The data for the current analysis were collected between 2003 and 2007.
Perspectives
The current study suggests that among adults taking antihypertensive medication, SDOH, including having a low annual household income, low education, living in a disadvantaged neighborhood, a health professional shortage area and a high-poverty zip code largely contribute to the higher likelihood of uncontrolled BP among Black compared with White adults. The likelihood of uncontrolled BP increased with the number of SDOH. Interventions addressing SDOH at the public policy, environmental, organizational, and individual levels may improve BP control and reduce Black:White disparities in cardiovascular disease mortality.
Article Information
Author Contributions
All listed authors have made substantial contributions to the conceptualization, data collection/analysis and/or writing of this manuscript.
Supplemental Material
Supplemental Methods
Tables S1–S13
Figures S1 and S2
Acknowledgments
The authors wish to thank the other investigators, the staff, and the participants of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study for their valuable contributions. A full list of participating REGARDS investigators and institutions can be found at: https://www.uab.edu/soph/regardsstudy/.
Footnote
Nonstandard Abbreviations and Acronyms
- BP
- blood pressure
- DBP
- diastolic blood pressure
- REGARDS
- Reasons for Geographic and Racial Differences in Stroke
- SBP
- systolic blood pressure
- SDOH
- social determinants of health
- SES
- socioeconomic status
Supplemental Material
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© 2023 American Heart Association, Inc.
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Received: 23 August 2022
Accepted: 29 March 2023
Published online: 21 April 2023
Published in print: July 2023
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Disclosures
Disclosures Dr Akinyelure received a predoctoral grant award from the American Heart Association (828562) for the current work. Dr Hardy is supported by a career development award (K01HL164763) from the National Heart, Lung, and Blood Institute.
Sources of Funding
REGARDS (Reasons for Geographic and Racial Differences in Stroke) is supported by cooperative agreement U01 NS041588 co-funded by the National Institute of Neurological Disorders and Stroke (NINDS) and the National Institute on Aging (NIA), National Institutes of Health, Department of Health and Human Service. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NINDS or the NIA. Representatives of the NINDS were involved in the review of the article but were not directly involved in the collection, management, analysis, or interpretation of the data. The funders did not play a role in conceptualizing the present study, conducting analyses, or developing the article.
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