Multilevel and spatial-time trend analyses of the prevalence of hypertension in a large urban city in the USA

Association between Cardiovascular Risk and Coronavirus Disease 2019: Findings from 2021 National Health Interview Survey

PURPOSE

To examine the association between pre-existing cardiovascular disorders and the risk of coronavirus disease 2019 (COVID-19) among community-dwelling adults in the United States (US).

METHODS

We analyzed data from the 2021 National Health Interview Survey (NHIS), encompassing 28,848 nationally representative participants aged ≥18. We examined the association by two age groups, younger adults (aged 18-59) and older adults (aged>60). Weighted analyses were conducted to consider the complex sampling design used in the NHIS.

RESULTS

Our results show that 13.9% of younger and 8.2% of older adults were infected with coronavirus, corresponding to a nationwide estimate of 23,701,358 COVID-19 cases in younger adults and 6,310,206 in older adults in 2021. Subjects who lived in the South region of the US had the highest COVID-19 rate (13.4%), followed by the Midwest (12.6%), West (10.9%), and Northeast (10.4%). Pre-existing cardiovascular risk factors (overweight, obesity, hypertension, and diabetes) were significantly associated with increased risk for COVID-19 infection in younger and older adults. Pre-existing cardiovascular diseases (angina, heart attack, and coronary heart disease) were significantly associated with COVID-19 in older adults but not significantly in younger adults. Significant dose-response relationships existed between the increased number of pre-existing cardiovascular risk factors and COVID-19 infection, with the strongest association in non-Hispanic (NH) Black and Hispanic ethnicities compared to NH White.

CONCLUSION

Pre-existing cardiovascular disorders are significantly associated with the risk of COVID-19 infection. The magnitudes of this risk association are stronger among the minority populations than NH White. Further studies are needed to determine the long-term impact of COVID-19 infection and its relationship to pre-existing cardiovascular disorders.

Influence of contextual socioeconomic position on hypertension risk in low- and middle-income countries: disentangling context from composition

Background

Hypertension has emerged as the single most significant modifiable risk factor for cardiovascular disease and death worldwide. Resource-limited settings are currently experiencing the epidemiological transition from infectious diseases to chronic non-communicable diseases, primarily due to modifications in diet and lifestyle behaviour. The objective of this study was to examine the influence of individual-, community- and country-level factors associated with hypertension in low- and middle-income countries (LMICs).

Methods

Multivariable multi-level logistic regression analysis was applied using 12 Demographic and Health Survey (DHS) datasets collected between 2011 and 2018 in LMICs. We included 888,925 respondents (Level 1) nested within 33,883 neighbourhoods (Level 2) from 12 LMICs (Level 3).

Results

The prevalence of hypertension ranged from 10.3% in the Kyrgyz Republic to 52.2% in Haiti. After adjusting for the individual-, neighbourhood- and country-level factors, we found respondents living in the least deprived areas were 14% more likely to have hypertension than those from the most deprived areas (OR = 1.14, 95% CI 1.10 to 1.17). We observed a significant variation in the odds of hypertension across the countries and the neighbourhoods. Approximately 26.3 and 47.6% of the variance in the odds of hypertension could be attributed to country- and neighbourhood-level factors, respectively. We also observed that respondents moving to a different neighbourhood or country with a higher risk of hypertension had an increased chance of developing hypertension, the median increase in their odds of hypertension was 2.83-fold (95% CI 2.62 to 3.07) and 4.04- fold (95% CI 3.98 to 4.08), respectively.

Conclusions

This study revealed that individual compositional and contextual measures of socioeconomic status were independently associated with the risk of developing hypertension. Therefore, prevention strategies should be implemented at the individual level and the socioeconomic and contextual levels to reduce the burden of hypertension.

Examining the Drivers of Racial/Ethnic Disparities in Non-Adherence to Antihypertensive Medications and Mortality Due to Heart Disease and Stroke: A County-Level Analysis

Background: Prior research has identified disparities in anti-hypertensive medication (AHM) non-adherence between Black/African Americans (BAAs) and non-Hispanic Whites (nHWs) but the role of determinants of health in these gaps is unclear. Non-adherence to AHM may be associated with increased mortality (due to heart disease and stroke) and the extent to which such associations are modified by contextual determinants of health may inform future interventions. Methods: We linked the Centers for Disease Control and Prevention (CDC) Atlas of Heart Disease and Stroke (2014-2016) and the 2016 County Health Ranking (CHR) dataset to investigate the associations between AHM non-adherence, mortality, and determinants of health. A proportion of days covered (PDC) with AHM < 80%, was considered as non-adherence. We computed the prevalence rate ratio (PRR)-the ratio of the prevalence among BAAs to that among nHWs-as an index of BAA-nHW disparity. Hierarchical linear models (HLM) were used to assess the role of four pre-defined determinants of health domains-health behaviors, clinical care, social and economic and physical environment-as contributors to BAA-nHW disparities in AHM non-adherence. A Bayesian paradigm framework was used to quantify the associations between AHM non-adherence and mortality (heart disease and stroke) and to assess whether the determinants of health factors moderated these associations. Results: Overall, BAAs were significantly more likely to be non-adherent: PRR = 1.37, 95% Confidence Interval (CI):1.36, 1.37. The four county-level constructs of determinants of health accounted for 24% of the BAA-nHW variation in AHM non-adherence. The clinical care (β = -0.21, p < 0.001) and social and economic (β = -0.11, p < 0.01) domains were significantly inversely associated with the observed BAA-nHW disparity. AHM non-adherence was associated with both heart disease and stroke mortality among both BAAs and nHWs. We observed that the determinants of health, specifically clinical care and physical environment domains, moderated the effects of AHM non-adherence on heart disease mortality among BAAs but not among nHWs. For the AHM non-adherence-stroke mortality association, the determinants of health did not moderate this association among BAAs; the social and economic domain did moderate this association among nHWs. Conclusions: The socioeconomic, clinical care and physical environmental attributes of the places that patients live are significant contributors to BAA-nHW disparities in AHM non-adherence and mortality due to heart diseases and stroke.

Mapping the Burden of Hypertension in South Africa: A Comparative Analysis of the National 2012 SANHANES and the 2016 Demographic and Health Survey

This study investigates the provincial variation in hypertension prevalence in South Africa in 2012 and 2016, adjusting for individual level demographic, behavioural and socio-economic variables, while allowing for spatial autocorrelation and adjusting simultaneously for the hierarchical data structure and risk factors. Data were analysed from participants aged ≥15 years from the South African National Health and Nutrition Examination Survey (SANHANES) 2012 and the South African Demographic and Health Survey (DHS) 2016. Hypertension was defined as blood pressure ≥ 140/90 mmHg or self-reported health professional diagnosis or on antihypertensive medication. Bayesian geo-additive regression modelling investigated the association of various socio-economic factors on the prevalence of hypertension across South Africa’s nine provinces while controlling for the latent effects of geographical location. Hypertension prevalence was 38.4% in the SANHANES in 2012 and 48.2% in the DHS in 2016. The risk of hypertension was significantly high in KwaZulu-Natal and Mpumalanga in the 2016 DHS, despite being previously nonsignificant in the SANHANES 2012. In both survey years, hypertension was significantly higher among males, the coloured population group, urban participants and those with self-reported high blood cholesterol. The odds of hypertension increased non-linearly with age, body mass index (BMI), waist circumference. The findings can inform decision making regarding the allocation of public resources to the most affected areas of the population.

Neighbourhood socioeconomic characteristics and blood pressure among Jamaican youth: a pooled analysis of data from observational studies

Introduction

Neighbourhood characteristics are associated with several diseases, but few studies have investigated the association between neighbourhood and health in Jamaica. We evaluated the relationship between neighbourhood socioeconomic status (SES) and blood pressure (BP) among youth, 15-24 years old, in Jamaica.

Methods

A pooled analysis was conducted using data from three studies (two national surveys and a birth cohort), conducted between 2005-2008, with individual level BP, anthropometric and demographic data, and household SES. Data on neighbourhood SES were obtained from the Mona Geo-Informatics Institute. Neighbourhood was defined using community boundaries from the Social Development Commission in Jamaica. Community characteristics (poverty, unemployment, dependency ratio, population density, house size, and proportion with tertiary education) were combined into SES scores using principal component analysis (PCA). Multivariable analyses were computed using mixed effects multilevel models.

Results

Analyses included 2,556 participants (1,446 females; 1,110 males; mean age 17.9 years) from 306 communities. PCA yielded two neighbourhood SES variables; the first, PCA-SES1, loaded highly positive for tertiary education and larger house size (higher value = higher SES); while the second, PCA-SES2, loaded highly positive for unemployment and population density (higher value = lower SES). Among males, PCA-SES1 was inversely associated with systolic BP (β-1.48 [95%CI -2.11, -0.84] mmHg, p < 0.001, for each standard deviation unit increase in PCA-SES1 score) in multivariable model accounting for age, household SES, study, BMI, fasting glucose, physical activity and diet. PCA-SES1 was not significantly associated with systolic BP among females (β -0.48 [-1.62, 0.66], p = 0.410) in a similar model. Associations for PCA-SES2 was assessed using linear splines to account for non-linear effects. The were no significant associations between systolic BP and PCA-SES2 among males. Among females, higher PCA-SES2 (i.e. lower SES) was associated with higher systolic BP at spline 2 [z-score -1 to 0] (β4.09 [1.49, 6.69], p = 0.002), but with lower systolic BP at spline 3 [z-core 0 to 1] (β-2.81 [-5.04, -0.59], p = 0.013). There were no significant associations between diastolic BP and PCA-SES1, but PCA-SES2 showed non-linear associations with diastolic BP particularly among males.

Conclusion

Higher neighbourhood SES was inversely associated with systolic BP among male Jamaican youth; there were non-linear associations between neighbourhood SES and systolic BP among females and for diastolic BP for both males and females.

Geographic Variation in Heart Failure Mortality and Its Association With Hypertension, Diabetes, and Behavioral-Related Risk Factors in 1,723 Counties of the United States

Background and objectives

Studies that examined geographic variation in heart failure (HF) and its association with risk factors at county and state levels were limited. This study aimed to test a hypothesis that HF mortality is disproportionately distributed across the United States, and this variation is significantly associated with the county- and state-level prevalence of high blood pressure (HBP), diabetes, obesity and physical inactivity.

Methods

Data from 1,723 counties in 51 states (including District of Columbia as a state) on the age-adjusted prevalence of obesity, physical inactivity, HBP and diabetes in 2010, and age-adjusted HF mortality in 2013–2015 are examined. Geographic variations in risk factors and HF mortality are analyzed using spatial autocorrelation analysis and mapped using Geographic Information System techniques. The associations between county-level HF mortality and risk factors (level 1) are examined using multilevel hierarchical regression models, taking into consideration of their variations accounted for by states (level 2).

Results

There are significant variations in HF mortality, ranging from the lowest 11.7 (the state of Vermont) to highest 85.0 (Mississippi) per 100,000 population among the 51 states. Age-adjusted prevalence of obesity, physical inactivity, HBP, and diabetes are positively and significantly associated with HF mortality. Multilevel analysis indicates that county-level HF mortality rates remain significantly associated with diabetes (β = 2.7, 95% CI: 1.7–3.7, p < 0.0001), HBP (β = 3.6, 2.1–5.0, p < 0.0001), obesity (β = 0.9, 0.6–1.3, p < 0.0001), and physical inactivity (β = 1.2, 0.8–1.5, p < 0.0001) after controlling for gender, race/ethnicity, and poverty index. After further controlling obesity and physical inactivity in diabetes and HBP models, the effects of diabetes (β = 1.0, −0.3 to 2.3, p = 0.12) and HBP (β = 2.4, 0.9–3.9, p = 0.003) on HF mortality had a considerable reduction.

Conclusion

HF mortality disproportionately affects the counties and states across the nation. The geographic variations in HF morality are significantly explained by the variations in the prevalence of obesity, physical inactivity, diabetes, and HBP.

A cross-sectional and spatial analysis of the prevalence of multimorbidity and its association with socioeconomic disadvantage in South Africa: A comparison between 2008 and 2012

This study utilised data from the National Income Dynamics Study, a longitudinal study with a sample of approximately 28 000 people, to investigate the cross-sectional and spatial distribution of multimorbidity and the association with socioeconomic disadvantage in South Africa for 2008 and 2012. Multimorbidity increased in prevalence from 2.73% to 2.84% in adults between 2008 and 2012 and was associated with age, socioeconomic deprivation, obesity and urban areas. Hypertension was found frequently coexisting with diabetes. Spatial analysis showed clusters (hot spots) of higher multimorbidity prevalence in parts of KwaZulu-Natal and the Eastern Cape, which compared with the socioeconomic disadvantage spatial pattern. Although these results were limited to a district level analysis, this study has provided a platform for future local level research and has provided insight into the socioeconomic determinants of disease multimorbidity within a developing country.

Small-area Variation in Hypertension Prevalence among Black and White Medicaid Enrollees

OBJECTIVES

To examine within-state geographic heterogeneity in hypertension prevalence and evaluate associations between hypertension prevalence and small-area contextual characteristics for Black and White South Carolina Medicaid enrollees in urban vs rural areas.

DESIGN

Ecological.

SETTING

South Carolina, United States.

MAIN OUTCOME MEASURES

Hypertension prevalence.

METHODS

Data representing adult South Carolina Medicaid recipients enrolled in fiscal year 2013 (N=409,907) and ZIP Code Tabulation Area (ZCTA)-level contextual measures (racial segregation, rurality, poverty, educational attainment, unemployment and primary care physician adequacy) were linked in a spatially referenced database. Optimized Getis-Ord hotspot mapping was used to visualize geographic clustering of hypertension prevalence. Spatial regression was performed to examine the association between hypertension prevalence and small-area contextual indicators.

RESULTS

Significant (alpha=.05) hotspot spatial clustering patterns were similar for Blacks and Whites. Black isolation was significantly associated with hypertension among Blacks and Whites in both urban (Black, b=1.34, P<.01; White, b=.66, P<.01) and rural settings (Black, b=.71, P=.02; White, b=.70, P<.01). Primary care physician adequacy was associated with hypertension among urban Blacks (b=-2.14, P<.01) and Whites (b=-1.74, P<.01).

CONCLUSIONS

The significant geographic overlap of hypertension prevalence hotspots for Black and White Medicaid enrollees provides an opportunity for targeted health intervention. Provider adequacy findings suggest the value of ACA network adequacy standards for Medicaid managed care plans in ensuring health care accessibility for persons with hypertension and related chronic conditions.

Community Characteristics are Associated with Blood Pressure Levels in a Racially Integrated Community

Community problems have been associated with higher, and community resources and social cohesion with lower, blood pressure. However, prior studies have not accounted for potential confounding by residential racial segregation. This study tested associations between community characteristics and blood pressure levels and prevalent hypertension in a racially integrated community. The Exploring Health Disparities in Integrated Communities Study measured blood pressure in residents of two contiguous racially integrated and low-income US Census Tracts. Community characteristics included a standardized community problem score and binary indicators for community social cohesion, having a community leader available, and having at least one community resource observed on the participant's block. In adjusted models, greater community problems and proximity to resources were associated with lower systolic (β = -2.020, p = 0.028; β = -4.132, p = 0.010) and diastolic (β = -1.261, p = 0.038; β = -2.290, 0.031) blood pressure, respectively, among whites (n = 548). Social cohesion was associated with higher systolic (β = 4.905, p = 0.009) and diastolic blood pressure (β = 3.379, p = 0.008) among African Americans (n = 777). In one racially integrated low-income community, community characteristics were associated with blood pressure levels, and associations differed by race. Directions of associations for two findings differed from prior studies; greater community problem was associated with lower blood pressure in whites and community social cohesion was associated with higher blood pressure in African Americans. These findings may be due to exposure to adverse environmental conditions and hypertensive risk factors in this low-income community.

Burden of Cardiovascular Disease among Multi-Racial and Ethnic Populations in the United States: an Update from the National Health Interview Surveys

PURPOSE

The study aimed to provide new evidence of health disparities in cardiovascular disease (CVD) and diabetes mellitus (DM), and to examine their associations with lifestyle-related risk factors across the U.S. multi-racial and ethnic groups.

METHODS

The analysis included a randomized population sample of 68,321 subjects aged ≥18 years old who participated in the U.S. 2012 and 2013 National Health Interview Surveys. Hypertension, coronary heart disease (CHD), stroke, and DM were classified according to participants' self-report of physician diagnosis. Assessments of risk factors were measured using standard survey instruments. Associations of risk factors with hypertension, CHD, stroke, and DM were analyzed using univariable and multivariable analysis methods.

RESULTS

Non-Hispanic (NH)-Blacks had significantly higher odds of hypertension, while Hispanics had significantly lower odds of hypertension, and NH-Asians and Hispanics had significantly lower odds of stroke than NH-Whites (p < 0.001). All minority groups, NH-Blacks, NH-Asians, and Hispanics had significantly higher odds of DM, but they had significantly lower odds of CHD than NH-Whites (p < 0.001). Increased body weight, cigarette smoking, and physical inactivity were significantly associated with increased odds of hypertension, CHD, stroke, and DM (p < 0.001). However, the strengths of associations between lifestyle-related factors and the study outcomes were different across racial and ethnic groups. NH-Asians with BMI ≥30 kg/m(2) had the highest odds ratios (OR, 95% CI) for hypertension (5.37, 4.01-7.18), CHD (2.93, 1.90-4.52), and stroke (2.23, 1.08-4.61), and had the second highest odd ratios for DM (3.78, 2.68-5.35) than NH-Whites, NH-Blacks, and Hispanics.

CONCLUSION

CVD and DM disproportionately affect the U.S. multi-racial and ethnic population. Although lifestyle-related risk factors are significantly associated with increased odds of CVD and DM, the magnitudes of these associations are different by race and ethnicity.