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Social Determinants, Blood Pressure Control, and Racial Inequities in Childbearing Age Women With Hypertension, 2001 to 2018

2023; Wiley; Volume: 12; Issue: 5 Linguagem: Inglês

10.1161/jaha.122.027169

2047-9980

Claire V. Meyerovitz, Stephen P. Juraschek, Didem Ayturk, Tiffany A. Moore Simas, Sharina D. Person, Stephenie C. Lemon, David D. McManus, Lara Kovell,

Health disparities and outcomes

HomeJournal of the American Heart AssociationVol. 12, No. 5Social Determinants, Blood Pressure Control, and Racial Inequities in Childbearing Age Women With Hypertension, 2001 to 2018 Open AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialOpen AccessResearch ArticlePDF/EPUBSocial Determinants, Blood Pressure Control, and Racial Inequities in Childbearing Age Women With Hypertension, 2001 to 2018 Claire V. Meyerovitz, BA, Stephen P. Juraschek, MD, PhD, Didem Ayturk, MS, Tiffany A. Moore Simas, MD, MPH, MEd, Sharina D. Person, PhD, Stephenie C. Lemon, PhD, David D. McManus, MD and Lara C. Kovell, MD Claire V. MeyerovitzClaire V. Meyerovitz https://orcid.org/0000-0002-5715-5236 , UMass Chan Medical School, , Worcester, , MA, , Stephen P. JuraschekStephen P. Juraschek https://orcid.org/0000-0003-4168-2696 , Division of General Medicine, , Beth Israel Deaconess Medical Center/Harvard Medical School, , Boston, , MA, , Didem AyturkDidem Ayturk https://orcid.org/0000-0003-1309-8388 , Department of Population and Quantitative Health Sciences, , UMass Chan Medical School, , Worcester, , MA, , Tiffany A. Moore SimasTiffany A. Moore Simas https://orcid.org/0000-0002-8356-6418 , Department of Population and Quantitative Health Sciences, , UMass Chan Medical School, , Worcester, , MA, , Departments of Obstetrics and Gynecology, Pediatrics and Psychiatry, , UMass Chan Medical School, , Worcester, , MA, , Sharina D. PersonSharina D. Person , Department of Population and Quantitative Health Sciences, , UMass Chan Medical School, , Worcester, , MA, , Stephenie C. LemonStephenie C. Lemon https://orcid.org/0000-0003-3321-6070 , Department of Population and Quantitative Health Sciences, , UMass Chan Medical School, , Worcester, , MA, , David D. McManusDavid D. McManus , Division of Cardiovascular Medicine, Department of Medicine, , UMass Chan Medical School, , Worcester, , MA, and Lara C. KovellLara C. Kovell *Correspondence to: Lara C. Kovell, MD, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655. Email: E-mail Address: [email protected] https://orcid.org/0000-0002-7919-2361 , Division of Cardiovascular Medicine, Department of Medicine, , UMass Chan Medical School, , Worcester, , MA, Originally published27 Feb 2023https://doi.org/10.1161/JAHA.122.027169Journal of the American Heart Association. 2023;12:e027169Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 27, 2023: Ahead of Print AbstractBackgroundHypertension is an important modifiable risk factor of serious maternal morbidity and mortality. Social determinants of health (SDoH) influence hypertension outcomes and may contribute to racial and ethnic differences in hypertension control. Our objective was to assess SDoH and blood pressure (BP) control by race and ethnicity in US women of childbearing age with hypertension.Methods and ResultsWe studied women (aged 20–50 years) with hypertension (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg or use of antihypertensive medication) in the National Health and Nutrition Examination Surveys 2001 to 2018. SDoH and BP control (systolic BP <140 mm Hg and diastolic BP <90 mm Hg) were examined by race and ethnicity (White race, Black race, Hispanic ethnicity, and Asian race). Using multivariable logistic regression, odds of uncontrolled BP by race and ethnicity were modeled, adjusting for SDoH, health factors, and modifiable health behaviors. Responses on hunger and affording food determined food insecurity status. Across women of childbearing age with hypertension (N=1293), 59.2% were White race, 23.4% were Black race, 15.8% were Hispanic ethnicity, and 1.7% were Asian race. More Hispanic and Black women experienced food insecurity than White women (32% and 25% versus 13%; both P 1 BP value recorded. Women with systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg who did not self‐report a hypertension diagnosis were classified as "hypertension unaware." Uncontrolled BP was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg. Women who self‐reported they were told to take prescribed medicine because of high BP were included in "BP medication prescribed."Social Determinants of HealthSDoH were chosen from the American Heart Association's Scientific Statement on Social Determinants of Risk and Outcomes for Cardiovascular Disease, which includes socioeconomic position (education, income, food security, and home ownership), language, and health insurance/access to health care.10 Education, health insurance, health care access (including having a usual facility to receive health care and health care visits in the past year), and home ownership were self‐reported. For language, women who reported using no amount of English at home were included in the non‐English only group. Poverty/income ratio was calculated by dividing self‐reported family income by the federal poverty guidelines.20 Food security was categorized by NHANES from answers to 10 questions centering around ability to afford food and hunger. Food insecurity questions in 2001 to 2002 and 2003 to 2004 were not asked of high‐income households.18 Responses for those individuals were marked as "missing," which NHANES notes should be counted as negative for food insecurity. Individuals who answered affirmatively to ≥3 questions were designated as food insecure. Food insecurity included low (3–5 affirmative responses) and very low food security (6–10 affirmative responses).18Other CovariatesWomen who reported not smoking at least 100 cigarettes in their lifetime were included as never smokers. Current alcohol use and quantity of daily alcohol consumption were obtained from the dietary questionnaire. Diabetes and hyperlipidemia were defined by a self‐report of diabetes or high cholesterol, respectively. Gravidity was based on number of prior pregnancies. Body mass index was calculated from measured height and weight. Self‐reported health was based on participants' description of their general health as excellent, very good, fair, or poor.Statistical AnalysisAll analyses were performed using the sample weights, primary sampling units, and strata recommended by the National Center for Health Statistics to account for the NHANES complex sampling design. Standard errors were determined for all metrics using the Taylor series (linearization) method. Demographics, hypertension control, and SDoH were compared between White women (reference) and Black, Hispanic, and Asian women. Multivariable logistic regression was used to model the odds of uncontrolled BP by race and ethnicity, in both all women with hypertension and women aware of their hypertension diagnosis. Model 1 was adjusted for age, education, race, poverty/income ratio, insurance, routine place to go for health care, language, home ownership, food security, and non‐US birth. Model 2 was adjusted for model 1 plus health factors and modifiable health behaviors, including diabetes, body mass index, smoking, physical activity, and sodium, fiber, and alcohol intake. Model fitting was checked using c‐statistic, and degrees of freedom were controlled so as not to overfit. Temporal trends in uncontrolled BP were reported over 6‐year periods using disparity ratios. Disparity ratios were created using the method described by Hunt et al.21 The percentages of Black, Hispanic, and Asian women with uncontrolled BP were each divided by the percentage of White women with uncontrolled BP (reference). A ratio equal to 1 indicated no disparity. A ratio >1 indicated greater disparity in the non‐White group compared with White women. P‐trend over the pooled years was calculated by χ2 test comparing the disparity ratios. P‐trend was determined for Black/White and Hispanic/White disparity ratios, but was not calculated for Asian/White disparity ratios given that there were only 2 time points.Analyses were performed with Statistical Analysis System software (v.9.4; SAS Institute, Cary, NC). The significance level was set at P<0.05, and all test hypotheses were 2 sided. Several authors had full access to all data in this study and accept responsibility for the data integrity and analysis.RESULTSDemographic Characteristics, Comorbidities, and BPAcross women of childbearing age with hypertension (N=1293), the mean (SE) age was 36.4 (0.25) years, 59.2% were White women, 23.4% were Black women, 15.8% were Hispanic women, and 1.7% were Asian women (Table 1). Black and Hispanic women had higher prevalence of obesity than White women (P<0.001 and P<0.05, respectively), and Hispanic women had higher prevalence of diabetes (P<0.05). A total of 1 in 5 women (20%) had never been pregnant; Black and Hispanic women were less likely to have never been pregnant than White women (P<0.001 and P<0.05, respectively). Black, Hispanic, and Asian women had higher mean gravidity than White women (all P<0.05). Of White women, 21% rated their health as fair or poor, which was less than Black (33%), Hispanic (45%), and Asian (31%) women (all P<0.001). Asian women were more likely to be unaware of their hypertension (26% versus 14% of White women; P<0.001). White, Black, and Hispanic women had similar hypertension awareness. More Black women reported being prescribed antihypertensive medication than White women (75% versus 61%; P<0.001). Black and Asian women had higher mean BP and were more likely to have uncontrolled BP than White women (38% and 36% versus 25%; both P<0.001) (Table 1).Table 1. Demographics, Comorbidities, and BP Control in Childbearing Aged Women With HypertensionAll (N=1293)White women (N=467)Black women (N=468)Hispanic women (N=314)Asian women (N=44)US population*6 997 8134 139 2431 638 1271 103 411117 032Age, y36.4 (0.25)36.8 (0.34)36.2 (0.30)35.4 (0.24)†36.6 (0.59)Born in the United States, %879793‡50‡13‡Current alcohol use, %1315158†6Never smoker, %554866‡65‡86‡BMI, kg/m233.0 (0.25)32.3 (0.4)35.3 (0.4)‡33.0 (0.3)28.2 (0.27)‡Obesity (BMI ≥30.0 kg/m2), %585568‡60†43Hyperlipidemia, %§302341‡56‡—Diabetes, %87912†4Never been pregnant, %202312‡15†33‡Gravidity3.1 (0.07)2.9 (0.09)3.4 (0.09)†3.4 (0.08)†3.3 (0.07)†Self‐reported health fair/poor, %282133‡45‡31‡Hypertension unaware, %1414141426‡BP medication prescribed, %636175‡5762Systolic BP, mm Hg126.0 (0.5)123.9 (0.6)130.5 (0.8)‡126.2 (0.7)131.1 (1.4)‡Diastolic BP, mm Hg77.4 (0.4)77.0 (0.5)79.1 (0.6)†76.0 (0.5)82.1 (0.9)‡Uncontrolled BP, %≥140 or ≥90 mm Hg292538‡2736‡≥130 or ≥80 mm Hg‖494559‡4467‡Data from National Health and Nutrition Examination Survey (NHANES) sample 2001 to 2018, reported as mean percentage of subjects or mean (SE) number of indicated units and weighted on the basis of the complex NHANES sampling strategy. White women with hypertension used as comparison reference group. BMI indicates body mass index; and BP, blood pressure.*On the basis of NHANES complex sampling.†Indicates P<0.05.‡Indicates P 25% of data.‖American College of Cardiology/American Heart Association 2017 guidelines updated the threshold for hypertension and considered <130/80 mm Hg a reasonable treatment target.19Social Determinants of HealthBlack and Hispanic women with hypertension reported less education, with 19% and 39% earning less than a high school degree versus 12% of White women (both P<0.001). Asian women were more likely to have higher education, with 77% attaining at least some college compared with 63% of White women (P<0.001). More Hispanic and Asian women spoke no English at home than Black women (34% and 32% versus 2%; both P<0.001). Black and Hispanic women were less likely to have private insurance and more likely to experience poverty, with 59% of Black and 65% of Hispanic women at a poverty/income ratio ≤1.85 versus 34% of White women (all P<0.001). Hispanic and Asian women were more likely to have no place to go for health care (16.2% and 14.6%, respectively) than White women (8.8%; both P<0.05). Hispanic women were also more likely to have seen no health care provider in the past year (18%) compared with White women (7.9%; P<0.001). Food insecurity was more prevalent among Black (25%) and Hispanic (32%) women than White women (13%; both P<0.001) (Table 2).Table 2. SDoH in Women of Childbearing Age With HypertensionAll (N=1293)White women (N=467)Black women (N=468)Hispanic women (N=314)Asian women (N=44)US population*6 997 8134 139 2431 638 1271 103 411117 032Education level, %<High school degree181219†39†9†High school degree2425222614≥Some college5863593577Non‐English language only, %‡71234†32†PIR ≤1.85, %453459†65†34Private insurance, %778364†66†84No place to go for health care, %9.88.87.816.2§14.6§Not seen by health care provider in past year, %9.47.97.518.0†9.2Home owned, %556538†45†56*Food insecurity, %‖191325†32†11†Data from National Health and Nutrition Examination Survey (NHANES) sample 2001 to 2018, reported as mean percentage of subjects and weighted on the basis of the complex NHANES sampling strategy. White women with hypertension used as comparison reference group. PIR indicates poverty/income ratio; and SDoH, social determinants of health.*On the basis of NHANES complex sampling.†Indicates P<0.001.‡Language spoken at home. Black women with hypertension used as reference comparison group because of low prevalence of White women speaking non‐English language only.§Indicates P 1 throughout all pooled years, indicating higher rates of uncontrolled BP in Black women (Figure 1). Moreover, this increased from years 2007 to 2012 (1.19 [95% CI, 0.75–1.63]) to 2013 to 2018 (2.28 [1.29–3.28]; P‐trend<0.001). The Asian/White disparity ratio was 1.62 (95% CI, 0.74–2.50) in 2011 to 2012 and 1.78 (0.93–2.63) in 2013 to 2018. The Hispanic/White disparity ratio in years 2001 to 2006 and 2007 to 2012 started around 1, then increased in 2013 to 2018 to 1.44 (95% CI, 0.78–2.10; P‐trend<0.001).Download figureDownload PowerPointFigure 1. Trends in uncontrolled blood pressure (BP) disparities in childbearing age women.From weighted National Health and Nutrition Examination Surveys (NHANES) 2001 to 2018, disparity ratios were calculated on the basis of unadjusted prevalence of uncontrolled BP (N=1241; 52 excluded for missing BP values) in each racial and ethnic group, pooled in 6‐year increments. Asian was first included as a separate category in 2011. Disparity ratios (reported with 95% CIs) compare prevalence in Black (blue), Hispanic (red), and Asian (green) women with White women. A ratio of <1 indicates higher prevalence of uncontrolled BP in White women. Black and Hispanic (both P‐trend 1.85 and private insurance were associated with higher odds of uncontrolled BP, whereas lower sodium intake ( high school vs ≤high school), race, income (poverty/income ratio [PIR] >1.85 vs ≤1.85), insurance (private vs public), routine place for health care (yes vs no), language (English vs no English), home ownership (yes vs no), food security (yes vs no), diabetes (yes vs no), body mass index (BMI) (25–29.9 and ≥30 vs <25 kg/m2), smoking status (current/former vs never), physical activity (<150 and ≥150 min/wk vs none), sodium (<2000 vs ≥2000 mg/d), fiber (≥5 vs 1 servings/day vs none), and non‐US birth (yes vs no). Exposures (y‐axis) are compared with nonexposure (eg, no physical activity). Black race, PIR >1.85, and private insurance are associated with higher odds of controlled BP, whereas lower sodium intake is associated with lower odds.DISCUSSIONIn this US population of women of childbearing age with hypertension, we found that compared with White women, Black women had higher odds of uncontrolled BP that persisted after adjusting for SDoH, health factors, and modifiable health behaviors, whereas Asian women had higher odds of uncontrolled BP that was no longer significant after adjusting for SDoH. Racial and ethnic inequities in individual SDoH, including health care access and food security, were also identified. Although SDoH have been shown to impact maternal mortality, minimal research has explored factors beyond socioeconomic status.22 Our findings are informative for strategies aimed at addressing inequities in adverse pregnancy and cardiovascular disease outcomes throughout the life course.Asian women were more often unaware of their hypertension and twice as likely to have uncontrolled BP than White women, although the latter finding was no longer significant after adjusting for SDoH. Although higher income and private insurance were independently associated with uncontrolled BP, there was no significant difference in these factors between Asian and White women. Prior research has shown dietary sodium intake, which was associated with uncontrolled BP, is higher among Asian adults than other racial and ethnic groups.23 The lack of significance after full adjustment for SDoH may be attributable to low power, resulting from the smaller sample size of Asian women (N=44) included in this study. Further research including a larger number of Asian women may help to better illuminate BP control in this population.On the other hand, the higher prevalence of uncontrolled BP among Black women persisted after adjustment for SDoH and modifiable health behaviors, aligning with prior research.14, 24 This uncontrolled BP inequity is likely not explained by underprescription of antihypertensive medications, as more Black women reported antihypertensive prescriptions than White women. Despite being prescribed antihypertensive agents, barriers to medication adherence, including cost, complex regimens, and lack of shared decision‐making, may contribute to inequities in BP control.25 Addressing clinical inertia, or the failure of clinicians to escalate therapy, may improve BP, although studies have shown conflicting results on whether clinical inertia is more, less, or similarly prevalent among Black patients.26, 27, 28, 29, 30Our findings suggest factors not explored in this analysis, such as experienced racism, social supports, or stress, may drive inequities in BP control. As discussed by the Black Maternal Heart Health Roundtable, SDoH alone do not explain racial inequity in maternal outcomes and addressing structural racism is necessary to achieve health equity.31 The consequences of structural racism have been associated with cardiovascular risk; residential segregation is associated with increased risk of cardiovascular disease, whereas perceived neighborhood safety is associated with lower BP, especially among women.32, 33 Powell‐Wiley et al suggest a health‐equity driven framework for investigating SDoH, including both structural and daily lived experiences of racism and discrimination.34 In addition, the concepts of weathering and allostatic load suggest cumulative stress and social disadvantage over time lead to decreased health.35, 36 Measurements of stress biomarkers and effects, including BP, used to quantify allostatic load have shown Black women are the most affected racial subgroup.37, 38 Incorporating measures of racism and discrimination in questionnaire‐based health studies as well as collection of biologic markers of allostatic load may help further our understanding of these factors' impact on disease. Furthermore, inequities in BP control for Black women compared with White women have become more disparate and concerning over this 18‐year period. A similar trend is seen in maternal mortality rates; Black women have 3 to 4 times the maternal mortality rates of White women, and this disparity has persisted over years.22, 39, 40 These findings underscore the urgency in identifying and addressing factors contributing to higher BP in Black women.Aside from Black race, private insurance and income above t