Social Determinants of Health and Disparities in Hypertension and Cardiovascular Diseases

Abstract

High blood pressure causes over 10 million preventable deaths annually globally. Populations in low- and middle-income countries suffer the most, experiencing increased uncontrolled blood pressure and cardiovascular disease (CVD) deaths. Despite improvements in high-income countries, disparities persist, notably in the United States, where Black individuals face up to 4× higher CVD mortality than White individuals. Social determinants of health encompass complex, multidimensional factors linked to an individual's birthplace, upbringing, activities, residence, workplaces, socioeconomic and environmental structures, and significantly affect health outcomes, including hypertension and CVD. This review explored how social determinants of health drive disparities in hypertension and related CVD morbidity from a socioecological and life course perspective. We present evidence-based strategies, emphasizing interventions tailored to specific community needs and cross-sector collaboration to address health inequalities rooted in social factors, which are key elements toward achieving the United Nations' Sustainable Development Goal 3.4 for reducing premature CVD mortality by 30% by 2030.

Keywords: blood pressure; cardiovascular diseases; health equity; hypertension; social determinants of health.

Figure 1.

Socioecological and life course approaches of social determinants of health leading to hypertension and cardiovascular disease (CVD). Social determinants of health (SDOHs) encompass socioeconomic, political, and environmental contexts, including neighborhood poverty and poor housing conditions, social policies and built environment, public health policies and legislation, climate change and pollution, and crisis events. These SDOHs contribute to an increased risk of premature CVD and major adverse cardiac events (MACE) through health care system and psychosocial stress pathway, such as sympathetic-adreno-medullar and hypothalamic-pituitary-adrenal axis activation. BP indicates blood pressure; CKD, chronic kidney disease; CRP, C-reactive protein; and UPF, ultra-processed food.

Figure 2.

Trends in the number of people with hypertension who reported a diagnosis, who used treatment, and whose blood pressure was effectively controlled, globally and by region, 1990 to 2019. Data derived from Zhou et al.

Figure 3.

Estimated age-adjusted mortality rates for cardiovascular disease in the United States, 2000 to 2019, by year and racial group. This figure displays age-adjusted mortality rates (AAMRs) for cardiovascular disease in the United States from 2000 to 2019, delineated by racial groups. Shaded areas indicate 95% uncertainty intervals. Data source: the Institute for Health Metrics and Evaluation, 2023.

Figure 4.

Forest plot of multivariable analysis for all-cause mortality and major cardiovascular disease (CVD) by level of education and wealth across country income strata. This forest plot presents the results of multivariable models adjusting for education, wealth, age, sex, urban vs rural settings, baseline CVD, and INTERHEART risk score in low-income, middle-income, and high-income countries. Hazard ratios (HRs) and 95% CIs are displayed for total mortality and major CVD, with the participants with the highest level of education (trade school, college, or university) and the richest third of the participants serving as the reference group. HIC indicates high-income country; LIC, low-income country; and MIC, middle-income country. *Adjusted HR. ** Secondary/High school/ Higher secondary. Note: P for interaction is for testing the interaction between country income and education or wealth. Data derived from Rosengren et al.