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

Abstract

Background Hypertension 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 Results We 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<0.001). After SDoH, health factor, and modifiable health behavior adjustment, Black women maintained higher odds of uncontrolled BP than White women (odds ratio, 2.31 [95% CI, 1.08-4.92]), whereas Asian and Hispanic women showed no difference. Conclusions We identified racial inequities in uncontrolled BP and food insecurity among women of childbearing age with hypertension. Further exploration beyond the SDoH measured is needed to understand the inequity in hypertension control in Black women.

Keywords: disparity; equity; hypertension; race; reproductive health; women.

Figure 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<0.001) women have a worsening disparity in BP control compared with White women. P‐trend was not calculated for Asian/White disparity ratios given that there were only 2 time points.

Figure 2. Factors associated with uncontrolled blood pressure (BP) in childbearing age women with hypertension.

Multivariable logistic regression evaluating uncontrolled BP associations in National Health and Nutrition Examination Surveys 2011 to 2018 using model 2. Model 2 adjusts for age, education (>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 <5 g/d), alcohol (≤1 and >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.