Gender differences in the association of individual and contextual socioeconomic status with hypertension in 230 Latin American cities from the SALURBAL study: a multilevel analysis

Abstract

Background: Despite global interest in gender disparities and social determinants of hypertension, research in urban areas and regions with a high prevalence of hypertension, such as Latin America, is very limited. The objective of this study was to examine associations of individual- and area-level socioeconomic status with hypertension in adults living in 230 cities in eight Latin America countries.

Methods: In this cross-sectional study, we used harmonized data from 109,184 adults (aged 18-97 years) from the SALURBAL (Salud Urbana en America Latina/Urban Health in Latin America) project. Hypertension was assessed by self-report. Individual-, sub-city- and city-level education were used as proxies of socioeconomic status. All models were stratified by gender.

Results: Higher individual-level education was associated with lower odds of hypertension among women (university education or higher versus lower than primary: odds ratio [OR] = 0.67, 95% confidence interval [CI] = 0.61-0.74) but higher odds among men (OR = 1.65; 95%CI 1.47-1.86), although in men an inverse association emerged when measured blood pressure was used (OR = 0.86; 95%CI 0.76-0.97). For both genders, living in sub-city areas with higher educational achievement was associated with higher odds of hypertension (OR per standard deviation [SD] = 1.07, 95%CI = 1.02-1.12; OR = 1.11 per SD, 95%CI = 1.05-1.18, for women and men, respectively). The association of city-level education with hypertension varied across countries. In Peru, there was an inverse association (higher city level education was associated with lower odds of hypertension) in women and men, but in other countries no association was observed. In addition, the inverse association of individual-level education with hypertension became stronger (in women) or emerged (in men) as city or sub-city education increased.

Conclusion: The social patterning of hypertension differs by gender and by the level of analysis highlighting the importance of context- and gender-sensitive approaches and policies to reduce the prevalence of hypertension in Latin America.

Keywords: Education; Hypertension; Latin America; Multilevel analysis; Socioeconomic status; Urban health.

Fig. 1

Predicted probabilities of hypertension based on the regression models to assess the effect modification of individual-level education by area-level education. The p-value presented refers to the global interaction test. Education level: 1 = less than primary; 2 = primary; 3 = secondary; 4 = university or higher. Sub-city- and city-educational attainment score values are based on the standardized variable used in the model so the range of values differs from the one presented in Table 1