Relation of socioeconomic status to hypertension occurrence

Lower Socioeconomic Status, Psychological Distress, and Self-reported Hypertension: A Longitudinal Moderated Mediation Analysis

BACKGROUND

Lower socioeconomic status (SES) has been associated with hypertension; however, the mediators and moderators of this association remain understudied. We examined the mediation effect of psychological distress on the link between lower SES and self-reported hypertension and the racial and sex moderation effects.

METHODS

We analyzed the data collected from 2009 to 2019 among adults from the Panel Study of Income Dynamics (PSID). Lower SES was defined as one of 3 indicators: education ≤12 years, unemployed, or individual annual income <$27,800. Psychological distress was assessed using the Kessler K6 scale. Cox proportional hazard regression was conducted. Mediation analyses were performed using the PROCESS macro.

RESULTS

In the sample of heads of family who did not have self-reported hypertension in 2009 (N = 6,214), the mean age was 41 years, 30.6% were female, 32.9% were African American. The cumulative incidence of self-reported hypertension was 29.8% between 2009 and 2019. Cox proportional hazard regression analysis showed that after controlling for covariates, lower SES (score > 0 vs. score = 0) was associated with self-reported hypertension (hazard ratio = 1.27, 95% confidence interval = 1.14-1.42). SES had indirect effect on self-reported hypertension through psychological distress and the indirect effect (0.02 in females, 0.01 in males, P < 0.05) was moderated by sex but not by race.

CONCLUSIONS

The association of SES and self-reported hypertension was mediated by psychological distress and sex moderated the mediation effect. Interventions focused on reducing contributors to SES and psychological stress should be considered to reduce hypertension risk.

Mobile health strategies for blood pressure self-management in urban populations with digital barriers: systematic review and meta-analyses

Mobile health (mHealth) technologies improve hypertension outcomes, but it is unknown if this benefit applies to all populations. This review aimed to describe the impact of mHealth interventions on blood pressure outcomes in populations with disparities in digital health use. We conducted a systematic search to identify studies with systolic blood pressure (SBP) outcomes located in urban settings in high-income countries that included a digital health disparity population, defined as mean age ≥65 years; lower educational attainment (≥60% ≤high school education); and/or racial/ethnic minority (<50% non-Hispanic White for US studies). Interventions were categorized using an established self-management taxonomy. We conducted a narrative synthesis; among randomized clinical trials (RCTs) with a six-month SBP outcome, we conducted random-effects meta-analyses. Twenty-nine articles (representing 25 studies) were included, of which 15 were RCTs. Fifteen studies used text messaging; twelve used mobile applications. Studies were included based on race/ethnicity (14), education (10), and/or age (6). Common intervention components were: lifestyle advice (20); provision of self-monitoring equipment (17); and training on digital device use (15). In the meta-analyses of seven RCTs, SBP reduction at 6-months in the intervention group (mean SBP difference = -4.10, 95% CI: [-6.38, -1.83]) was significant, but there was no significant difference in SBP change between the intervention and control groups (p = 0.48). The use of mHealth tools has shown promise for chronic disease management but few studies have included older, limited educational attainment, or minority populations. Additional robust studies with these populations are needed to determine what interventions work best for diverse hypertensive patients.

Inequalities and risk factors analysis in prevalence and management of hypertension in India and Nepal: a national and subnational study

BACKGROUND

Hypertension is one of the leading risk factors for cardiovascular diseases in India and Nepal. Socio-economic disparity in these two countries has created wide gap in management of hypertension. However, inequalities in prevalence and management (awareness, treatment, and control) of hypertension is poorly assessed. This study analyzes the risk factors associated with prevalence and management of hypertension in India and Nepal and assesses the wealth-and education-based inequalities in them.

METHODS

This study used data from the Demographic and Health Survey; a cross-sectional survey conducted between January 2015 to December 2016 in India and June 2016 to January 2017 in Nepal. A total of 787,713 individuals in India and 14,454 individuals in Nepal aged between 15 and 49 years were included in the study. Respondents were classified as being hypertensive if their systolic blood pressure (SBP) readings were at least 140 mmHg or diastolic blood pressure (DBP) readings were at least 90 mmHg, or if they reported currently taking anti-hypertensive medication. Multilevel logistic regression models with random intercepts at household-and community-levels were used to identify the risk factors associated with prevalence and management of hypertension. For inequality assessment, slope index and relative index of inequalities in prevalence and management of hypertension were estimated.

RESULTS

Overall prevalence of hypertension in India and Nepal were 11.4% (95% confidence interval (CI), 11.4-11.5) and 19.6% (95% CI, 18.9-20.2), respectively. Less than one-third of the hypertensive population received treatment and below 20% among them had their blood pressure controlled. In both countries, wealth-and education-based inequalities in awareness, treatment, and control of hypertension were significantly high in urban and rural areas.

CONCLUSION

Wealth- and education-based inequalities in prevalence and management of hypertension were high among different socio-economic groups at national and sub-national levels. Tailored strategies are required to effectively manage hypertension in different regions by considering socio-economic and demographic factors.

Urbanization and Socioeconomic Disparities in Hypertension among Older Adult Women in Sudan

Background:

Evidence from the developed world associates higher prevalence of hypertension with lower socioeconomic status (SES). However, patterns of association are not as clear in Africa and other developing countries, with varying levels of socioeconomic development and epidemiological transition. Using wealth and education as indicators, we investigated association between SES and hypertension among older adult women in Sudan and examined whether urbanicity mediates the relationship.

Methods:

The sample included women aged 50 years and over participating in the nationally representative population-based second Sudan Health Household Survey (SHHS) conducted in 2010. Principal components analysis was used to assign each household with a wealth score based on assets owned. The score was categorized into quintiles from lowest (poorest) to highest (richest).

Findings:

The sample included a total of 5218 women, median and mean age 55 and 59 years, respectively, with the majority not have any schooling (81.6%). The overall prevalence of reported hypertension was found to be 10.5%. After adjustment for age, marital status, work status and urban/rural location, better wealth and higher education were independently and positively associated with hypertension prevalence rates. However, when stratified by urbanicity, the relationship between wealth and hypertension lost its significance for women in urban areas but maintained it in rural areas, increasing significantly and consistently with each increase in quintile index (adjusted odds ratio, aOR₁ = 1.95 95% CI = 1.08–3.52; aOR₂ = 5.25, 95% CI = 3.01–9.15; aOR₃ = 8.27, 95% CI = 4.78–14.3; and aOR₄ = and 11.4, 95% CI = 6.45–20.0; respectively). By contrast, education played a greater role in increasing the odds of hypertension among women in urban locations but not in rural locations (aOR = 2.14, 95% CI = 1.25–7.90 vs. aOR = 0.79, 95% CI = 0.27–2.30, respectively).

Conclusions:

Our findings of a socioeconomic gradient in the prevalence of hypertension among women, mediated by urbanization, call for targeted interventions from early stages of economic development in Sudan and similar settings of transitioning countries.

The Current Situation of Hypertension among Rural Minimal Assurance Family Participants in Liaoning (China): A Cross-Sectional Study

In China, the prevalence of hypertension is increasing and is showing an epidemic accelerating trend. However, there is a lack of studies reporting the hypertension status of rural residents with minimum living allowances. We performed a cross-sectional study including 11,435 (5285 men and 6150 women) from the general population aged ≥35 years in the Liaoning Province of China from 2012 to 2013, of which 1258 (11.0%) participants came from minimal assurance families. Anthropometric measurements, laboratory examinations and self-reported lifestyle factor information were collected by trained personnel. Multivariate logistic regression was used to detect the association between socioeconomic status (SES) and the risk of hypertension. We found that the prevalence of hypertension was as high as 61.9% in participants from minimal assurance families and the odd ratio for hypertension was 1.32 (95% CI: 1.15–1.52). The awareness, treatment, and control rates among treated hypertensive participants did not increase with higher level of income and education. In the total sample, the lower income levels increased the risk for hypertension, but education didn’t show a significant association with hypertension. Thus, there is a severe hypertension situation in the Liaoning rural population of minimal assurance families, which need more attention and prevention and control measures for hypertension.

Pre- and undiagnosed-hypertension in urban Chinese adults: a population-based cross-sectional study

Hypertension is common in adults and often undiagnosed, and the prevalence of pre- and undiagnosed-hypertension remains unclear. We aimed to investigate the prevalence of pre- and undiagnosed-hypertension and their correlates among urban Chinese adults. A total of 7435 participants aged 20-79 were included in this study. Data on demographics, lifestyle and medical history were collected through a structured interview. Pre- and undiagnosed-hypertension was defined as systolic blood pressure/ diastolic blood pressure (SBP/DBP) of 120-139/80-89 mm Hg and SBP⩾140 mm Hg and/or DBP⩾90 mm Hg, respectively, in participants without a history of hypertension and use of antihypertensive medication. Prevalence rates were calculated and standardized using local age- and gender-specific census data. Data were analysed using multinomial logistic regression with adjustment for potential confounders. Of all the participants, 2726 (36.7%) were diagnosed with pre-hypertension and 919 (12.3%) with undiagnosed-hypertension. Undiagnosed-hypertension accounted for 37.3% of all participants with hypertension. The prevalence of pre-hypertension gradually decreased with age, while undiagnosed-hypertension increased, although presenting different changing patterns among men and women. In a fully adjusted multinomial logistic regression, age, male sex, low socio-economic status (SES), abdominal obesity, alcohol drinking, physical inactivity and type 2 diabetes mellitus (T2DM) were significantly associated with increased odds of pre- and undiagnosed-hypertension. In conclusions, the prevalence of pre- and undiagnosed-hypertension was ~50% among urban Chinese adults. Abdominal obesity, low SES, alcohol drinking, physical inactivity and T2DM may be indicators for pre- and undiagnosed-hypertension.

Income Related Inequality of Health Care Access in Japan: A Retrospective Cohort Study

The purpose of this retrospective cohort study was to analyze the association between income level and health care access in Japan. Data from a total of 222,259 subjects (age range, 0–74 years) who submitted National Health Insurance claims in Chiba City from April 2012 to March 2014 and who declared income for the tax period from January 1 to December 31, 2012 were integrated and analyzed. The generalized estimating equation, in which household was defined as a cluster, was used to evaluate the association between equivalent income and utilization and duration of hospitalization and outpatient care services. A significant positive linear association was observed between income level and outpatient visit rates among all age groups of both sexes; however, a significantly higher rate and longer period of hospitalization, and longer outpatient care, were observed among certain lower income subgroups. To control for decreased income due to hospitalization, subjects hospitalized during the previous year were excluded, and the data was then reanalyzed. Significant inverse associations remained in the hospitalization rate among 40–59-year-old men and 60–69-year-old women, and in duration of hospitalization among 40–59 and 60–69-year-olds of both sexes and 70–74-year-old women. These results suggest that low-income individuals in Japan have poorer access to outpatient care and more serious health conditions than their higher income counterparts.

The Relationship Between Socioeconomic Status and CV Risk Factors: The CRONICAS Cohort Study of Peruvian Adults

BACKGROUND

Variations in the distribution of cardiovascular disease and risk factors by socioeconomic status (SES) have been described in affluent societies, yet a better understanding of these patterns is needed for most low- and middle-income countries.

OBJECTIVE

This study sought to describe the relationship between cardiovascular risk factors and SES using monthly family income, educational attainment, and assets index, in 4 Peruvian sites.

METHODS

Baseline data from an age- and sex-stratified random sample of participants, ages ≥35 years, from 4 Peruvian sites (CRONICAS Cohort Study, 2010) were used. The SES indicators considered were monthly family income (n = 3,220), educational attainment (n = 3,598), and assets index (n = 3,601). Behavioral risk factors included current tobacco use, alcohol drinking, physical activity, daily intake of fruits and vegetables, and no control of salt intake. Cardiometabolic risk factors included obesity, elevated waist circumference, hypertension, insulin resistance, diabetes mellitus, low high-density lipoprotein cholesterol, and high triglyceride levels.

RESULTS

In the overall population, 41.6% reported a monthly family income

CONCLUSIONS

The association between SES and cardiometabolic risk factors varies depending on the SES indicator used. These results highlight the need to contextualize risk factors by socioeconomic groups in Latin American settings.

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Key Words Collapse

MESH Headings

• Adult
• Aged
• Alcohol Drinking/epidemiology
• Cardiovascular Diseases/epidemiology
• Cholesterol, HDL
• Cohort Studies
• Diabetes Mellitus/epidemiology
• Diet/statistics & numerical data
• Dyslipidemias/epidemiology
• Educational Status
• Exercise
• Female
• Humans
• Hypertension/epidemiology
• Hypertriglyceridemia/epidemiology
• Income/statistics & numerical data
• Insulin Resistance
• Male
• Middle Aged
• Obesity/epidemiology
• Peru/epidemiology
• Poverty/statistics & numerical data
• Risk Factors
• Smoking/epidemiology
• Social Class
• Waist Circumference

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Grants

• 098504/Z/12/Z Wellcome Trust
• MR/K006584/1 Medical Research Council
• R21 TW009982 FIC NIH HHS
• R21TW009982 FIC NIH HHS
• U19 MH098780 NIMH NIH HHS
• R00HL096955 NHLBI NIH HHS
• R00 HL096955 NHLBI NIH HHS
• MR/K007467/1 Medical Research Council
• U01HL114180 NHLBI NIH HHS
• U19MH098780 NIMH NIH HHS
• 103994/Z/14/Z Wellcome Trust
• HHSN268200900033C NHLBI NIH HHS
• U01 HL114180 NHLBI NIH HHS
• M007405 Medical Research Council
• MR/M020894/1 Medical Research Council
• Wellcome Trust
• MC_UU_12013/5 Medical Research Council

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Affiliation(s)

Renato Quispe CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
Catherine P Benziger CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; Division of Cardiology, University of Washington, Seattle, WA, USA
Juan Carlos Bazo-Alvarez CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
Laura D Howe MRC Integrative Epidemiology Unit at the University of Bristol, School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
William Checkley Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary and Critical Care, School of Medicine Johns Hopkins University, Baltimore, MD, USA
Robert H Gilman Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Asociación Benéfica PRISMA, Lima, Peru
Liam Smeeth Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
Antonio Bernabé-Ortiz CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
J Jaime Miranda CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.

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Hypertension unawareness among Chinese patients with first-ever stroke

Background

The low rates of hypertension treatment and control, partly due to its unawareness, are the main causes of the high stroke incidence in China. The purpose of this study was to evaluate hypertension unawareness amongst patients with first-ever stroke and to detect factors associated with its unawareness.

Methods

We selected those diagnosed with hypertension from patients with first-ever stroke registered in the Nanjing Stroke Registry Program between 2004 and 2014. These hypertensives were divided as being aware or unaware of their hypertension by using a brief questionnaire conducted shortly after the stroke. Multivariate logistic regression analysis was performed to identify potential factors associated with hypertension unawareness.

Results

Of the 5309 patients with first-ever stroke, 3732 (70.3 %) were diagnosed with hypertension. Among which, 593 (15.9 %) were unaware of their hypertension at the time of stroke onset. Lower-level of education (primary school or illiteracy) and smoking were associated positively with hypertension unawareness; while advanced age, overweight, diabetes mellitus, heart diseases and family history of stroke were associated negatively with hypertension unawareness. Annual data analyzed indicated that the rate of hypertension awareness increased during the past 11 years (r = 0.613, P = 0.045 for trends).

Conclusions

A substantial proportion (15.9 %) of Chinese patients with hypertension had not been aware of this covert risk until an overt stroke occurred. Hypertension unawareness was associated with lower educational levels and smoking, which address the importance of health education especially in these individuals.

Primary Care Providers Perceptions of Racial/Ethnic and Socioeconomic Disparities in Hypertension Control

OBJECTIVE

To evaluate the attitudes and perceptions of primary care providers (PCPs) regarding the presence and underlying sources of racial/ethnic and socioeconomic disparities in hypertension control.

METHODS

We conducted a survey of 115 PCPs from 2 large academic centers in Colorado. We included physicians, nurse practitioners, and physician assistants. The survey assessed provider recognition and perceived contributors of disparities in hypertension control.

RESULTS

Respondents were primarily female (66%), non-Hispanic White (84%), and physicians (80%). Among respondents, 67% and 73% supported the collection of data on the patients' race/ethnicity and socioeconomic status (SES), respectively. Eighty-six percent and 89% agreed that disparities in race/ethnicity and SES existed in hypertension care within the US health system. However, only 33% and 44% thought racial/ethnic and socioeconomic disparities existed in the care of their own patients. Providers were more likely to perceive patient factors rather than provider or health system factors as mediators of disparities. However, most supported interventions such as improving provider communication skills (87%) and cultural competency training (89%) to reduce disparities in hypertension control.

CONCLUSIONS

Most providers acknowledged that racial/ethnic and socioeconomic disparities in hypertension control exist in the US health system, but only a minority reported disparities in care among patients they personally treat. Our study highlights the need for testing an intervention aimed at increasing provider awareness of disparities within the local health setting to improve hypertension control for minority patients.