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Hypertension in the African American Community: The Root of It

Cherie Grant, MPHc Health Equity Capstone April 26, 2021

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Table of Contents

Abstract 3

Understanding Hypertension in the United States 4

Hypertension in the United States 4

Hypertension Diagnosis and Management 9

Historical Context of Hypertension 11

Hypertension in the African American Community Today 13

Analysis of Causes 14

Social Determinants of Health and Psychosocial Factors 14 The World Health Organization’s Social Determinants of Health Framework 16 Analysis of the Structural Determinants of the Social Determinants of Health 18 Analysis of the Intermediary Determinants of the Social Determinants of Health 20 Overview of Interventions for Hypertension Prevention and Control 24

Lifestyle Change Intervention: The DASH Diet 25

Mind-Body Therapy: Transcendental Meditation 26

Team-Based Approach and Medication Adherence 28

Recommendations and Future Directions 30

Conclusion 34

References 35

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Abstract

This review presents information on the intersecting factors that contribute to the prevalence of hypertension among African Americans. Hypertension is a widespread health condition that affects American adults and is uncontrolled or untreated in many of these individuals. Underrepresented minority communities, namely African American communities, are disproportionately affected by hypertension. The effects of hypertension on minority communities require a multilevel approach to understand how structural and intermediary determinants of the social determinants of health influence hypertension incidence and prevalence within the African American community.

Psychosocial factors as defined by the Centers for Disease Control and Prevention (CDC) are factors that influence an individual’s coping strategies, specifically racism, access to care, socioeconomic status, area of residence, availability of social support, personal attitudes toward one’s specific circumstance, and other factors that threaten the mental health of an individual.

This review will aim to understand how psychosocial factors are related to the incidence and prevalence of hypertension in the African American community, and what role does access to health care play in the disparity. Future recommendations for research, interventions, and policy to improve the health outcomes of the African American community are also discussed.

Furthermore, the information from this review could inform long-term health outcomes

surrounding the COVID-19 pandemic, where chronic stress as a result of multiple psychosocial factors is evident. Most importantly, this information could potentially support other research findings discussing increased stress as a result of social injustice. For the purposes of this review, the terms non-Hispanic black and African American are used interchangeably.

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Understanding Hypertension in the United States

Hypertension in the United States

Heart disease is the leading cause of death in the United States and across the globe, taking about 17.9 million lives each year (Cardiovascular diseases (CVDs), 2021). Common risk factors for heart disease include increased blood pressure (hypertension), glucose, and lipid formation in addition to inability to maintain healthy weight (Cardiovascular diseases (CVDs), 2021). Moreover, hypertension affects nearly one-third of American adults (67 million people) and is uncontrolled or untreated in nearly half of these individuals (Million Hearts®). Of the 67 million people, more than 40% of non-Hispanic black men and women have hypertension (High Blood Pressure and African Americans, 2021). Uncontrolled hypertension affects not only the arteries of the heart, but also affects other blood vessels all over the body which could cause life- threatening blood clots or damages to the brain, kidneys or eyes (High Blood Pressure and African Americans, 2021).

According to the American Heart Association, hypertension rates within African

Americans are among the highest in the world and are usually diagnosed much earlier in life and are more severe (High Blood Pressure and African Americans, 2021). Hypertension is a major risk factor for many chronic diseases such as cardiovascular disease, kidney disease, stroke, dementia, cancer, and diabetes due to its effects to the brain, kidneys, eyes, and other blood vessels (APA, 2017; Kokubo & Iwashima, 2015). As a result, African Americans also suffer from chronic kidney disease, stroke, dementia, cancer, and diabetes at a disproportionate rate (Carey et. al., 2019).

Furthermore, hypertension is more common in adults ages 65 and older; however, a large body of research has shown early diagnosis of hypertension can happen as early as 18 (Million

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Hearts®). Still, 14.1 million American adults are unaware they have hypertension (Million Hearts®). To that end, some individuals living with hypertension may not know they have hypertension or any heart related condition until they experience a heart attack or stroke. Isolated systolic hypertension, which was thought to merely be a side effect of aging, is the most common form of hypertension that affects young adults (McEniery, 2016). Increased diagnoses appear in young African American men between the ages of 14 and 23 (McEniery, 2016).Isolated systolic hypertension is caused by elevated cardiac output, which increases arterial stiffness, thus

increasing individuals’ predisposition to cardiovascular disease (McEniery, 2016). More simply, isolated systolic hypertension relates solely to a systolic blood pressure number above 130 mmHG on a blood pressure reading; this number continues to elevate, while the diastolic number on the blood pressure reading remains normal (McEniery, 2016).

Over the past two decades, trends in hypertension remain consistent in the population at large regardless of age, race, and gender (Products - Data Briefs - Number 289 - October 2017, 2021). This disparity is reflected in Figure 1 which shows the percentage of the United States’

adult population with controlled hypertension from 1999 through 2016 adjusted for age, race, and gender. Along with the consistent rates in hypertension, hypertension control mechanisms have recently started to decline (Products - Data Briefs - Number 289 - October 2017, 2021). The recent decrease in hypertension control has been linked to the increase in hypertension diagnoses and decrease in available resources to manage the burden (Products - Data Briefs - Number 289 - October 2017, 2021). This is especially concerning for African American individuals because hypertension is diagnosed at a higher rate within this community (Products - Data Briefs - Number 289 - October 2017, 2021). Some medical professionals and researchers theorize that

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this recent decline in hypertension control is due to the increase in hypertension diagnoses and decrease in the resources necessary to regulate hypertension (Carey et. al., 2019).

Figure 1: Age-adjusted trends in hypertension and controlled hypertension among adults aged 18 and over. United States, 1999-2016.

Regardless of age and racial/ethnic background, the inverse relationship between hypertension rates and hypertension control is often overlooked in the African American

community. According to the Centers for Disease Control and Prevention (CDC), non-Hispanic whites have a higher percentage of hypertension control compared to non-Hispanic blacks (Products - Data Briefs - Number 289 - October 2017, 2021). Many would associate high

prevalence of hypertension within a community with increased health care resources allocated to that community, but many systemic and social barriers inhibit proper dissemination of resources.

This creates a supply and demand effect on health. The specific barriers to health care that create the supply and demand effect will be discussed in section two of this review.

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Based on the information provided within Figure 2, with no other confounders considered, hypertension appears to be more prevalent in older women than older men.

According to the National Institute on Aging, older people are much more likely to suffer from heart attack, stroke, coronary heart disease, and heart failure (Heart Health and Aging, 2021). As individuals age, the ability for the heart to pump fast during physical activity or during times of high stress decreases (Heart Health and Aging, 2021).

Figure 2: Prevalence of hypertension among adults aged 18 and over, by gender and age. United States, 2015-2016

The estimates in Figure 2 show that hypertension prevalence increases about 20% approximately every 20 years of life in both men and women. Overall, men between the ages of 40 and 59 tend to have a greater prevalence of hypertension; on the contrary, women over the age of 60 have a greater prevalence of hypertension. It is possible that this rate is the result of the increased occupational stress experienced by middle-aged men between ages 40 and 59 as a result of increased conflict, high demand, and extrinsic time pressure (Djindjic et. al., 2012). Additionally,

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it appears that hypertension rates in women over the age of 60 are more than men over the age of 60 (Wegner et. al., 2018). The onset of pregnancy related hypertension in women who conceive in unfavorable social conditions and/or later in life also contribute to this disparity (Garovic, 2013; Seely et. al., 2015; Wegner et. al., 2018).

Furthermore, when adjusted for age and divided by gender, race, and Hispanic origin it appears that non-Hispanic blacks have a higher prevalence of hypertension among men and women (Figure 3).

Figure 3: Age-adjusted prevalence of hypertension among adults aged 18 and over, by gender, race, and Hispanic origin. United States, 2015-2016

When considering gender and race, both black men and women have about the same prevalence of hypertension, compared to other races and minority groups no matter their age (Figure 3). Race plays a greater role in hypertension prevalence than gender (Lackland, 2014).

The potential root causes for this disparity will be analyzed in section two of this review. Racial

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and ethnic disparities in hypertension rates continue to be a cause for concern in the United States. With this in mind, it is important to consider the trends of hypertension to formulate a clear understanding of how disparities in hypertension rates emerge. In a recent national survey, African Americans aged 20 and older had the highest percentage of hypertension diagnosis (APA, 2017). Moreover, the CDC analyzed trends in hypertension diagnosis among those over the age of 18 from year 2015 through 2016 and found that African American women have had the most consistent rates of hypertension diagnoses (Products - Data Briefs - Number 289 - October 2017, 2021).

Hypertension Diagnosis and Management

For decades hypertension, or high blood pressure, has been defined as increased activity of the heart and its tissues caused by increased plaque formation in the blood vessels in the heart (What is High Blood Pressure, 2021). Proper function of the heart and blood vessels are vital to ensuring all tissues of the body receive adequate oxygen and nutrition to stay alive (What is High Blood Pressure, 2021). In an individual with normal blood pressure, defined as less than or equal to 120/80mmHg, blood is flowing free with no resistance within the blood vessels

(Understanding Blood Pressure Readings, 2021). The number above the line represents the systolic blood pressure or the pushing force of the blood through the blood vessels out of the heart; whereas the bottom number represents the diastolic blood pressure which is created when the heart rests (What is High Blood Pressure, 2021). Medical professionals categorize

hypertension into five different categories: normal, elevated, hypertension stage 1, hypertension stage 2, and hypertensive crisis (Understanding Blood Pressure Readings, 2021). It is important to note medical doctors classify individuals within a specific category only after they have

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consistent blood pressure readings that fall within a category (Understanding Blood Pressure Readings, 2021). Table 1 displays these values and ranges in more detail.

Table 1: The American Heart Association’s Blood Pressure Categories

In the case of individuals with hypertension, both the systolic and diastolic numbers change. This change is due to consistent overexertion of the blood vessels within the heart which causes damage to the tissues; in turn, low-density lipoprotein (LDL) cholesterol binds to the damaged tissues forming plaque (What is High Blood Pressure, 2021). This process is also known as atherosclerosis (What is High Blood Pressure, 2021). For this reason, LDL cholesterol is often times referred to as “bad cholesterol” because of its ability to build up in blood vessels. It is important to note that atherosclerosis is not typically an outcome of aging but is the result of the stiffening of the walls of the arteries over time due to stress (Heart Health and Aging, 2021).

Over time, increased plaque formation causes narrowing of the space within the blood vessels which later progresses into various diseases including heart attack, stroke, chronic kidney disease or failure, sexual dysfunction, heart failure, or vision loss (What is High Blood Pressure, 2021).

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There are no outward facing symptoms of hypertension, making consistent blood pressure readings necessary for patients to receive adequate care (What is High Blood Pressure, 2021).

Though national rates of hypertension have remained consistent, hypertension diagnosis rates within the African American community have increased (Lackland, 2014). The origins of hypertension and the increased rate of diagnoses within the African American community is rooted in its historical context.

Historical Context of Hypertension

There have been reports that individuals who live in the United States who are of African descent, have had consistently higher blood pressures since the 1930s (Cooper, 2015).Therefore, taking a holistic approach at understanding why hypertension continues to plague the African American community, warrants one to consider their perceived social environment, psychosocial stressors, and structural factors in society. Historically, hypertension diagnosis proceeds many other chronic health conditions within the African American community (Cooper, 2015). In the 20th century, theorists hypothesized that the incidence of hypertension diagnoses within the African American community was due to the amount of salt content in the food they ate, it was then considered a racial disease that only African Americans could acquire; however, this was later proven false (Curtin, 1992; Cooper, 2015). This illustrates how early theories inform disease diagnoses. These early theories regarding the health and wellbeing of African Americans have led to many misdiagnoses and mistreatment in the medical industry.

Additionally, native Africans from parts of West Africa, where 80-90% of enslaved people were from, do not currently have rates of hypertension as high as African Americans in the United States and did not at all have rates of hypertension until mid-twentieth century (Curtin, 1992; van de Vijver et. al., 2013).Therefore, it would be within the African American

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experience, during the emancipation era and after the emancipation era that would shed light on the true historical context of hypertension disparities in the United States.

The end of slavery, also known as the emancipation era, did not end racism, prejudice, or inequity in America (Woods, 2012). With direct reference to the systems of oppression, it is important to consider the history of, “bad nerves,” within the African American community. The antebellum era started in southern states around late 18th century to the late 19th century ending with the start of the American Civil War in 1861 (Woods, 2012). At this time, decisions regarding the continuation of slavery were at the forefront (Woods, 2012). According to psychiatrist Dr. Angela Neal-Barnett, after the antebellum era, African Americans considered what is now known as anxiety “bad nerves'' and were prescribed “nerve pills'' by their local doctors to cope with life’s stresses, anxiety, and anxiety related hypertension (Earl & Whaley, 2005). These “nerve pills'' are now called benzodiazepines and are still highly addictive;

however, at that time, local doctors could only provide benzodiazepines for treatment and care (Earl & Whaley, 2005; Re-evaluating the Use of Benzodiazepines, 2021).

Multiple research studies, including those from the American Heart Association, support the hypothesis that stress and anxiety contribute to hypertension (Cuffee, 2014; Spruill, 2010;

Pan, Cai, Cheng, Dong, An, Wang, 2015). Scholars argue that stress, hypervigilance, prejudice, and discrimination within and toward the African American community may be associated with slavery and slave practices, which have transformed into anxiety and chronic stress (Spruill, 2010). Understanding the basis of chronic stress and anxiety related to hypertension is important.

Post-slavery, many African Americans were forced into homelessness and given little to no access to resources to sustain life, especially in southern states where segregation made life increasingly difficult for descendants of freed slaves (Woods, 2012). These experiences further

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exacerbate the lifestyle of African Americans making it more difficult for them to access adequate health care, proper living environments, health education, and nutritious foods leading to feelings of stress (Powell, 2007). The differences in resources available to African American communities, compared to other communities well after slavery, show how stress induced

illnesses related to hypertension are tied to the history of oppression within the African American community (Powell, 2007; Kris-Etherton et. al., 2020).

The current state of the African American community is a product of past systems of oppression that are not dismantled. For this reason, consistent high rates of hypertension and other hypertension-related chronic diseases continue to plague the community.Systemic and social inequalities contribute to adverse health and wellbeing of populations (Diderichsen MD, PhD, 2021). Disparities in access to health foods, discrimination, and all forms of racism are often the driver of health inequities (The Environment That Racism Built - Center for American Progress, 2021). Therefore, given the decades of systemic oppression African Americans have faced, their disproportionate morbidities and mortalities due to hypertension implies the need for further actions to be taken to mitigate the effects of their most proximal exposures (e.g.,

neighborhood and social environments and/or working conditions).

Hypertension in the African American Community Today

Hypertension today is not different from hypertension of the past. Though genetic and behavioral factors provide some explanation for the prevalence of hypertension; various studies associate external stressors, such as discrimination and food insecurity, to the onset of

hypertension within the African American community (APA, 2017; Beck, 2020; Wells, 2016).

According to the American Heart Association, hypertension typically develops in African Americans earlier in life and is more severe compared to other ethnicities (High Blood Pressure

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and African Americans, 2021). Approximately 40% of all non-Hispanic blacks have high blood pressure today (High Blood Pressure and African Americans, 2021). Obesity and other

comorbidities such as diabetes are more prevalent in African American communities and could possibly provide an explanation for the prevalence of hypertension (What is High Blood Pressure, 2021).

In the state of Georgia, hypertension diagnoses have steadily increased to approximately 30% of all adults between 1996 and 2019 (America’s Health Ranking, 2020). When analyzed by race/ethnicity, African American adults comprised 34.8% of those diagnoses (America’s Health Ranking, 2020). In 2019 among all states, of the 32% of adults in the United States who were diagnosed with hypertension, 41.1% were African American (America’s Health Ranking, 2020).

These percentages today are not much different from the percentages and disparities in rates seen since the 1930s. Analyzing the causes for this disparity will explain how and why hypertension in the African American community could perpetuate for decades.

Analysis of Causes

Social Determinants of Health and Psychosocial Factors

Psychosocial factors as defined by the CDC are factors that influence an individual’s coping strategies, specifically racism, access to care, socioeconomic status, area of residence, availability of social support, personal attitudes toward one’s specific circumstance, and other factors that threaten the mental health of an individual (CDC, 2010). Psychosocial factors are a social determinant of health. Moreover, social relationships and a sense of community are crucial parts of human survival and are dependent on the quality of an individual’s immediate social environment (CDC, 2010). In the Jackson Heart Study, which examined 5,306 African American

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men and women, cumulative psychosocial factors were positively correlated with increased prevalence of hypertension (PR 1.16 95% CI 1.04-1.30) (Sims, 2020).This relationship

illustrates a statistically significant relationship between psychosocial factors and hypertension in African Americans. Similarly, with regard to one’s appraisal of their access to resources, studies have examined the social-economic influences at the community level. African Americans were more likely to have an increased incidence and prevalence of hypertension than whites due to poor social conditions — including differences in unemployment rates, access to healthcare, and/or access to supermarkets that provide nutrient rich foods (Beck, 2020; Sims, 2020).

Many mediating factors are seen among individuals of lower socioeconomic status and living in underserved populations (Diderichsen MD, PhD, 2021). Mediating factors are defined as potential causal chains that tend to cluster individuals in unfavorable conditions (Diderichsen MD, PhD, 2021). These causal chains are analyzed to understand population health, social norms and attitudes toward health. Within the Social Determinants of Health framework, health is framed as a social phenomenon that is the outcome of multiple intersecting pathways; it is more than the technology-based approach to medical care and public health interventions that health professionals typically consider (Diderichsen MD, PhD, 2021). To understand health or health equity using this framework we must also consider social justice. Health equity is described as

“the absence of unfair and avoidable or remediable differences in and among social groups”

(Diderichsen MD, PhD, 2021). Implementing protocols that remedy health inequities within communities, while emphasizing human rights is the basis of the social justice movement and understanding the social determinants of health (Social Justice in an Open World, 2006).

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The World Health Organization’s Social Determinants of Health Framework Social determinants of health are factors that contribute to adverse health outcomes within specific populations, not related to that population’s biology; they include housing, job security, food security, social inclusion, discrimination, structural conflict, access to affordable health services, working life conditions, and early childhood development (World Health Organization, 2021). The Social Determinants of Health framework was created by the World Health Organization (WHO) to help illustrate the potential pathways that drive health inequities.

The framework highlights systemic pathways that explain the reasons why African Americans and other minority groups may experience differential outcomes of health (Figure 4). With regard to hypertension rates, the Social Determinants of Health framework guides understanding of the prominent factors within different contexts that impact health equity and wellbeing.

Specifically, the WHO divides the framework into two main categories, the structural determinants of the social determinants of health and the intermediary determinants of the social determinants of health (Figure 4). Within the structural determinants lie the socioeconomic and political contexts which generate one’s socioeconomic position, broken down in categories of social class, gender, ethnicity/race, and income which is a proxy for education and occupation.

On the contrary, the intermediary determinants include the health system and psychosocial factors which are integrated with physical behaviors, biological factors and/or material circumstances. Social cohesion and social capital are the mechanisms by which structural determinants influence intermediary determinants. All together both structural and intermediary determinants shape health status and well-being. The heath equity and wellbeing data derived from populations interacting with the health system then informs the policies, socioeconomic contexts, and one’s socioeconomic position. A cyclical feedback loop is created through this process and directly affects income, social class, and other socioeconomic and political context;

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this loop serves as a guide to understand why and how health disparities persist. Furthermore, the WHO’s Social Determinants of Health framework guides policy making for interventions that address the mediating factors that contribute to poor health outcomes, while illustrating how structural and intermediary determinants can undermine the health and human rights of communities (Diderichsen MD, PhD, 2021).

Figure 4: WHO framework of social determinants of health [World Health Organization (WHO), 2010].

When considering the social determinants of hypertension incidence and prevalence, it is important for health professionals involved in health equity and wellbeing to capture the

structural determinants as well as the intermediary determinants. This is important information to gather and understand because it will help bring clarity to why and how disparities persist within African American communities. The following literature highlights the relationship between

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social determinants of health from the WHO’s framework and cardiovascular health in African Americans.

Analysis of the Structural Determinants of the Social Determinants of Health

According to the WHO, social determinants of health could have more of an impact on morbidity and mortality than lifestyle or health care choices, as approximately 55% of health outcomes are related to social determinants (World Health Organization, 2021). The most powerful determinants lie within social and political norms that maintain social hierarchy within the education system, policy making, and workforce (Diderichsen MD, PhD, 2021). With regard to policy making, national attention and funding has decreased for hypertension since the 1970s despite the evidence of hypertension being a preventable threat to the health of African

Americans (Institute of Medicine (US), 2010). The CDC’s Division for Heart Disease and Stroke Prevention address hypertension through creating policy, receiving funding, and focusing on the broader outcomes like heart disease and stroke prevention programs (Institute of Medicine (US), 2010).

Moreover, the CDC’s cardiovascular disease program, which includes the hypertension program, receives $54 million annually for all activities, when hypertension-related morbidity and mortality alone exceeds $73 billion annually in health care costs (Institute of Medicine (US), 2010). Inadequate funding makes it difficult to conduct proper programming. Thus, the

government’s allocation of funding for programs aimed to alleviate the burden of hypertension is driven by societal values and governance. Similarly, funding is the primary driver for successful health outcomes (Institute of Medicine (US), 2010). The allocation of funding alludes to the macroeconomic mediators of policy. Hypertension related programming is dependent on policy funding which is at the discretion of government agencies. Creation of policies driven toward

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reducing the rates in hypertension, would benefit individuals who are most at risk; however, inadequacies in funding make that more difficult.

To compensate for opportunity cost, which health economists define as “the loss of the benefits resources could have produced had they been put to the next best use,” the cost for prescription medication for hypertension and its affiliated treatments have increased (Alcocer &

Cueto, 2008). As a result, African American communities experience financial strain and are unable to afford the medication needed to control hypertension (Alcocer & Cueto, 2008).

Socioeconomic position, income, and occupation are all factors to consider for this disparity.

Over the course of a decade, the cost for prescription hypertension medication increased by 22.7% averaging about $1,500 annually per individual which increased the national average by 46% averaging $109.1 billion annually for all individuals with hypertension (Zhang et. al., 2017). The national increase in cost is due to the increase in number of individuals treated for hypertension (Zhang et. al., 2017).

Cardiovascular disease outcomes are inversely correlated with socioeconomic status (Alcocer & Cueto, 2008). With financial strain considered and the majority of individuals who suffer from hypertension being African Americans of lower and middle class, socioeconomic position can be considered a proxy for barriers related to income and occupation opportunities.

For this reason, the rising cost of medication may determine individual adherence to health system treatment plans for hypertension and ability to afford healthy foods. Current research examining socioeconomic status, mental health outcomes, and chronic disease, note those who live in poverty typically have poorer mental health; in turn, these situations combined, contribute to more chronic disease diagnoses and shorter lifespans within communities of lower

socioeconomic status (APA, 2017).

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Analysis of the Intermediary Determinants of the Social Determinants of Health

Individual behavior is only a piece of the puzzle, where material circumstances and psychosocial factors also play a role. The WHO’s framework identified material circumstances, such as living and working environments and food conditions, as intermediary determinants of the social determinants of health. The development of hypertension involves a sympathetic nervous system response where stress contributes to a consistently elevated blood pressure reading (Spruill, 2010). It is likely that stress induced inflammatory responses such as increased activation of the sympathetic nervous system increases risk of depression, anxiety, other

psychiatric disorders, and the pathogenesis of hypertension (Lui, Wang, and Jiang, 2017).

Additionally, prospective studies from 2019 indicate poor recovery back to pre-stress blood pressure levels after initial activation of the sympathetic nervous system, predicts more elevated blood pressure readings if the stressor persists (Spruill et. al., 2019). Poor recovery back to pre- stress blood pressure levels places patients at a higher risk for cardiovascular diseases (Spruill, 2010; Spruill et. al., 2019). Low-income individuals and those of racial or ethnic minorities are disproportionately affected by stress exposure, which subsequently leads to adverse health issues (APA, 2017).

Anxiety transcends all socioeconomic classes and is only one outcome of stress. Anxiety is defined by the American Psychology Association as an emotion that is characterized by intense feelings of tension or worry, typically due to intrusive thoughts or concerns, which may cause physical changes like increased blood pressure (APA, 2020). The effects of systemic racism, food insecurity, racial discrimination, police brutality, and other psychosocial factors African Americans continue to face, perpetuate stress and anxiety within the community (Cuffee, 2014). Moreover, a recent systematic review and meta-analysis conducted on 21 epidemiological

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studies showed a positive correlation between anxiety and increased risk of hypertension (Pan, 2015). Understanding hypertension that is induced by the infrastructure of the United States, gives perspective on why the high incidence and prevalence of hypertension within the African American community persist today. This context sheds light on the history of structural racism that contributes to differential exposures to stress, thus increased incidence and prevalence of hypertension within the African American community.

Comparatively, studies analyzing hypertension prevalence show that socioeconomic status of the neighborhood is simply an indicator of the type of food available to that community (Kaiser et. al., 2016). However, as a compounded effect, neighborhood safety, availability of healthy foods and favorable walking environments were associated with lower prevalence of hypertension (Kaiser et. al., 2016). Further analysis of socioeconomic status as a social determinant of health, provides information about how African Americans of lower

socioeconomic status have decreased access to often expensive healthy foods (Health Equity Considerations & Racial & Ethnic Minority Groups, 2021). Considering compromised safety already leads to feelings of isolation and stress, availability of healthy food could further exacerbate feelings of stress and anxiety for those with hypertension.

Though genetic and behavioral factors provide some explanation to the prevalence of hypertension; various studies associate food insecurity heavily to hypertension within the African American community (APA, 2017; Beck et. al., 2020; Bower, 2014; Wells, 2016).A healthy, balanced diet is one protective factor against hypertension (Bower, 2014). However, the extent of healthy food alternatives and whole food supermarkets differed greatly by

neighborhood poverty and race (Bower, 2014). This disparity in grocery store availability is still evident today with the displacement of communities due to gentrification (Beck, 2020). There is

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a direct relationship between poverty, the availability of grocery stores, and hypertension;

African American neighborhoods were seen to have higher rates of poverty and low availability of supermarkets (Bower, 2014). One study, based on the 2000 Census, found that supermarket chains within predominantly African American neighborhoods are 52% (p<0.01) fewer in number than in White neighborhoods in the United States (Powell, 2007). When compared to more affluent or white neighborhoods, African American neighborhoods were more likely to have an increased incidence of hypertension due to access to supermarkets (Beck, 2020).

Furthermore, to combat the effects of hypertension on the body it is important to note that oxidative stress takes place in the body during times of perceived crisis. Oxidative stress is believed to be a precursor to hypertension and can be alleviated by a diet rich in nutritious foods (Baradaran et. al., 2014).Access to healthy foods can help alleviate hypertension within the African American community; however, neighborhood poverty, segregation, and availability of supermarkets prove to be a barrier (Bower, 2014; Beck 2020).

With regard to work conditions, in a 2019 study conducted on over 40 million United States workers over 48 years old, African American men and women note a 60% higher rate of discrimination in the workplace (Fekedulegn et. al., 2019). Of the 60% who reported

discrimination, mistreatment in the workplace was eight-times more prevalent (Fekedulegn et.

al., 2019). According to a meta-analysis of 44 studies including mostly older African American men with lower levels of education, elevated levels in blood pressure was seen an outcome of self-reported mistreatment or discrimination (Benjamin et. al., 2019). Social determinants of health are usually more proximal to the community being affected. These examples shed light on the social determinants of health that often go overlooked but are equally as important as

genetics and biology.

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Because of proximity, the health system can be viewed as the connection between community wellbeing and individual health. Hypertension measured within hospital settings are greater than when patients monitor and record their blood pressure at home (Carey et. al., 2018).

This is considered white coat hypertension and is more prevalent in African Americans, especially mothers with children or pregnant women (Carey et. al, 2018). White coat hypertension is specific to elevated blood pressure when readings take place within clinical settings (Carey et. al, 2018). Similarly, African American women are more likely to suffer from hypertension during pregnancy due to the white coat hypertension phenomena and other social determinants of health; as a result, maternal mortality is highest among African American women (Wegner et. al., 2018). To combat this, The U.S. Preventative Task Force advise those with high blood pressure to use home blood pressure monitoring systems to exclude white coat hypertension (Kronish et. al., 2017). However, a study conducted with 63 United States

physicians report many physicians do not offer this system to their patients because of concerns of accuracy in patient self-measuring, the cost of providing that equipment to patients, the lack of reimbursement for providing the equipment, and the time it takes to teach the patients how to use the equipment (Kronish et. al., 2017). This is a major cause for concern considering the vast disparities in hypertension among African Americans.

Given the decades of oppression African Americans have faced and the disproportionate rates in morbidities and mortalities related to hypertension, the need for further actions to mitigate the health inequities that are most proximal to African Americans in the United States are necessary. Though the Social Determinants of Health framework appears linear, the

experiences of African Americans are not. Health status and wellbeing is a result of a macrocosm of factors. Though each pathway is unique in how it affects health, they all come together to

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perpetuate hypertension in the African American community. With 75-90% of cardiovascular diseases being related to activation of the sympathetic nervous system and the increased emotional and mental demand that society places on African Americans, interventions that alleviate these disparities should be considered (Lui, Wang, and Jiang, 2017). Some behavioral health interventions are put in place to address hypertension; however, psychosocial factors and circumstances that are more proximal to the population being affected could be internalized and difficult to solve.

Overview of Interventions for Hypertension Prevention and Control

Despite the ever-present burden of hypertension and the ongoing systemic factors that contribute to the perpetuation of hypertension, there are public health interventions set in place to prevent the development of chronic cardiovascular diseases. Lifestyle factors, such as adequate nutrition following the DASH diet, is a proven mechanism that improves the immune system and prevents hypertension (Spirulli et. al., 2019). Moreover, preventing the progression of

hypertension is ideal during times of high stress to reduce risk of heart attack, stroke and even death (Spirulli, 2019). Some interventions are tailored to consider the stress associated with hypertension and teach individuals how to properly manage their stress. Stress control

interventions like Transcendental Meditation that complement prescription medication are often recommended (Ooi et. al., 2017 & Loucks et. al., 2019).

Additionally, patients are typically on one or more medications to control their

hypertension, therefore, patient adherence to prescribed medication is integral for hypertension regulation (Pettey et. al., 2016). Furthermore, African Americans who suffer from hypertension typically also suffer from other coexisting conditions such as high cholesterol, chronic stress, and type 2 diabetes which also require medication for control (Ferdinand, 2010). Team-based

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approaches to healthcare are proven ways to decrease patient stress, improve medication adherence, and feelings of support (Control High Blood Pressure | 6|18 Initiative | CDC, 2021).

For this reason, the Community Preventive Services Task Force recommends a team-based approach to controlling hypertension (Control High Blood Pressure | 6|18 Initiative | CDC, 2021).

Lifestyle Change Intervention: The DASH Diet

Eating behavior is a modifiable behavior associated with improved rates of hypertensive control (Borgi et. al., 2016). The Dietary Approach to Stopping Hypertension (DASH) Diet is a common lifestyle change that focuses on increased fruit and vegetable intake with reduction in red meat and dairy consumption (Borgi et. al., 2016). In 2015, the DASH diet was found to be both acceptable and effective among African Americans who enrolled in the clinical diet (Borgi et. al., 2016). Randomized trials and prospective cohort studies on the DASH diet show

impressive results in increased consumption of fruits and vegetables and reduction in

hypertension (Borgi et. al., 2016). Research on the DASH diet also shows lower sodium levels lead to a reduction in blood pressure, with a more significant level of improvement among African Americans compared to other race/ethnicities (Institute of Medicine Committee on Public health Priorities to Reduce and Control Hypertension, 2010).

Moreover, diets high in antioxidants, which are vital nutrients found fruits and vegetables, reinforce the immune system and are capable of reducing blood pressure and cardiovascular disease outcomes (Baradaran, Nasri, & Rafieian-Kopaei, 2014). Three large prospective cohort studies were pooled and analyzed; results of the pooled study found that individuals who consumed four or more servings of whole fruit and vegetables daily compared to those who consumed less than four servings, had a statistically significant 0.92 (0.83–1.03; P

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trend=0.01) lower rate of incident hypertension (Borgi et. al., 2016). Therefore, implementing diets high in antioxidants and composed mostly of fruits and vegetables could have a

compounded benefit on the health of those with hypertension.

Evidence supports dietary vitamins work to reduce blood pressure levels and prevent the progression of disease (Bronzato & Durante, 2018). Many African Americans with hypertension do not have access to adequate supplies of nutrient rich foods and are food insecure (Kris-

Etherton et. al., 2020). A household that is food insecure does not have adequate or quality food and could also have reduced food intake compared to households that are food secure (Kris- Etherton et. al., 2020). Therefore, nutrients may need to be supplemented to not only meet dietary recommendations, but also to provide an environment for the body to thrive (Kris- Etherton et. al., 2020). Along with the DASH diet, coenzymeQ10, omega 3 fatty acids and vitamin D inhibit the buildup of plaque within blood vessels and regulate LDL cholesterol levels (Bronzato & Durante, 2018). Plaque buildup is the precursor to hypertension and cardiovascular disease; therefore, reducing its abundance in the bloodstream will reduce the likelihood of hypertension (Bronzato & Durante, 2018). A combination of key nutrients such as vitamin C, beta-carotene, potassium and zinc, all found in fruits and vegetables, prove to significantly reduce systolic blood pressure (Baradaran, Nasri, & Rafieian-Kopaei, 2014). With these results, incorporating a diet that follows the DASH model, which inherently includes many key vitamins and nutrients, is likely to reduce morbidity due to hypertension in the African American

community.

Mind-Body Therapy: Transcendental Meditation

Transcendental Meditation is a program-based form of meditation that involves low risk behavioral intervention and is a pivotal resource within the field of cardiovascular disease

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prevention (Ooi, Giovino, & Pak, 2017; Walton et. al., 2002). Specifically, it is defined as “a technique for detaching oneself from anxiety and promoting harmony and self-realization by meditation, repetition of a mantra, and other yogic practices” (How does TM work?, 2021).

Randomized control trials, observational studies, and meta-analyses results show Transcendental Meditation slows or even reverses the progression of cardiovascular disease risk factors

including hypertension (Ooi, Giovino, & Pak, 2017; Walton et. al., 2002, Schneider et. al., 2012). This is especially true within African Americans. A randomized control trial of

Transcendental Meditation along with health education show a 48% reduction in cardiovascular disease risk factors and cardiovascular hospitalizations over a 5.4-year follow-up period

(Schneider et. al., 2012).

The American Heart Association recommends mind-body therapies like Transcendental meditation to be considered in clinical practice (Brook et. al., 2013). In recent years interest in meditation for stress relief and cardiovascular disease prevention has grown. Findings of clinical trials conducted by the American Heart Association, noted an 81% reduction in relative risk for cardiovascular disease mortality with Transcendental Meditation techniques, making it two to three times more effective in comparison to other mindfulness approaches (Meditation and Cardiovascular Risk Reduction: A Scientific Statement from the American Heart Association, 2019). Qualitative results from research participants of diverse backgrounds show that the majority of individuals accept this form of meditation and are compliant to all parts of the program (Ooi, Giovino, & Pak, 2017). Therefore, implementing Transcendental Meditation into African American communities may be more effective and well received. As a result of the benefits of including Transcendental Meditation in clinical settings, if adapted nationwide, long- term reduced cardiovascular disease outcomes are promising.

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Team-Based Approach and Medication Adherence

Interventions and recommendations given by primary care physicians to reduce the onset of cardiovascular diseases in patients with known risk factors or a family history of risk factors, are typically monitored and require periodic evaluation (Koskinas et. al., 2018). For example, medications prescribed to control hypertension, and other risk factors associated with

cardiovascular disease, require review by the physician (Koskinas et. al., 2018). Medications such as low-dose aspirin and ACE inhibitors have shown positive outcomes for cardiovascular disease prevention and reduction in cardiovascular disease related mortalities (Koskinas et. al., 2018). In addition, glucose and cholesterol lowering medications show the same effect (Koskinas et. al., 2018). Additionally, warfarin therapy, a very popular medication, uses anticoagulation mechanisms to reduce the risk of recurrent cardiovascular episodes; however, public concern involving medically prescribed blood thinners has increased over decades (Pirmohamed, 2006;

Zahid et. al., 2020). Once diagnosed with hypertension, managing hypertension medication could become burdensome both financially and emotionally.

As mentioned in section two, there are a multitude of community and organizational factors that present barriers for individuals with hypertension to receive adequate health care. In attempts to resolve this barrier, team-based approaches have proven to be the most effective in hypertension management and reduction in adverse cardiovascular disease outcomes (Control High Blood Pressure | 6|18 Initiative | CDC, 2021). A team-based approach ensures medical doctors, nurses, pharmacists, community health workers and dietitians work in tandem to create a regime for individuals who are at risk of developing hypertension or already have hypertension (Control High Blood Pressure | 6|18 Initiative | CDC, 2021). A team-based approach uses referral systems and e-prescriptions which lowers the risk of loss of patient records, reduces risk of

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adverse effects, and places management of the responsibility on health care personnel (Control High Blood Pressure | 6|18 Initiative | CDC, 2021). There is evidence that suggests that team- based systems that include social workers reinforce feelings of social support for patients and create consistency in treatment protocols, thus improving cardiovascular outcomes and medication adherence (Control High Blood Pressure | 6|18 Initiative | CDC, 2021). Figure 5 highlights the intersectionality of hypertension management where the patient, the providers, and the health system all play a role in optimizing health.

Figure 5: Factors associated with hypertension awareness, treatment, and control, and the components of a systems-level algorithm designed to increase blood pressure (BP) control Carey, R.M. et al. J Am Coll Cardiol.

2018;72(11):1278-93.

An additional measure that is used to improve patient medication adherence and improve blood pressure control is clinical support and recommendation of self-measure blood pressure monitoring systems (SMBP) (Control High Blood Pressure | 6|18 Initiative | CDC, 2021). After consultation with a primary care physician, the patient is given a blood pressure reading device with instructions to regularly measure their blood pressure (Control High Blood Pressure | 6|18 Initiative | CDC, 2021). Since hypertension is commonly known as the “silent killer,” consistent

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self-measurement and monitoring of blood pressure values is essential for hypertension management and control (What is High Blood Pressure, 2021). One U.S. study found that African Americans were more likely to maintain consistent use of self-blood pressure home monitoring systems than any other race or ethnicity (Heart Disease and Stroke Statistics—2019 Update: A Report from the American Heart Association, 2021). The CDC recommend patients have the right amount of clinical support needed to properly take and send their blood pressure readings, a team-based approach is necessary for self-blood pressure home monitoring systems (Control High Blood Pressure | 6|18 Initiative | CDC, 2021). Based on these reports, team-based approaches prove to be effective in hypertension regulation and control, even more so in African American communities. Team-based approaches as primary care for patients who are at risk of developing hypertension or already have hypertension could greatly improve cardiovascular disease outcomes.

Recommendations and Future Directions

Health inequities fuel disease disparities. Cardiovascular morbidity and mortality can be prevented if addressed at the early stages of hypertension development (What is High Blood Pressure, 2021). With the prevalence of hypertension being the number one risk factor for the development of cardiovascular disease, additional research is needed to discover ways to reduce hypertension prevalence and explore other methods of prevention. Primary methods of

hypertension prevention, such as having access to nutritious foods, typically fail due to social and structural inequities (Beck, 2020; Wells, 2016). To develop methods for cardiovascular disease prevention, it is important to get to the root of causes of hypertension, especially within the most affected populations. Once the causes are identified, then the focus can shift to creating effective interventions, research protocols, and policies. Throughout this review, hypertension

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and its root causes within the African American community were discussed. With these findings and understanding the interventions that are already in place, state and federal government health agencies can work to adjust future programs and policies accordingly. Review of the World Health Organization’s Social Determinants of Health framework and empirical literature on hypertension in the African American community, have led to the creation of four

recommendations for future policies, interventions, and programs.

Information regarding hypertension disparity within the African American community is abundant; however, funding that drives program success is lacking at the policy level. Therefore, increasing funding for culturally tailored interventions that improve self-efficacy and foster better self-management of hypertension should be considered. To garner more funding, local and state health offices should conduct community needs assessments designed specifically to

understand the experiences of African Americans living with hypertension. The community needs assessments will not only allow state and local offices to tailor their programs to the specific needs of the African American community but will also provide the raw data necessary to validate reason for more funding. According to the CDC, one of the main outcomes of community needs assessments are policy change and increased funding for programs (Community Needs Assessment, 2021). Sufficient epidemiology studies have already been conducted documenting hypertension health disparities. Therefore, emphasis needs to be given on community-engaging projects to address hypertension specifically within the African American community. Results from the community needs assessments could then be used to bring attention to the specific barriers to care within the community and potentially increase funding for culturally tailored programs.

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Within the African American community, the trends in hypertension make access to both adequate and stable health care from an early age imperative. Due to the silent nature of

hypertension, blood pressure should be monitored from an early age especially for those most at risk for developing cardiovascular diseases (What is High Blood Pressure, 2021). In African Americans who have hypertension, the team-based approach is proven to work significantly well (Control High Blood Pressure | 6|18 Initiative | CDC, 2021). However, along with the team- based approach, primary care clinics should implement holistic care. Holistic care is defined as

“complete or total patient care that considers the physical, emotional, social, economic, and spiritual needs of the person, his or her response to illness and the effect of the illness on the ability to meet self-care needs” (Ventegodt et. al., 2016). Holistic care is a form of patient- centered care which focuses treatment on the patient or community, and not solely on disease treatment and management ("What are integrated people-centered health services?", 2021). A system that incorporates both holistic care and a team-based approach would recognize the patient’s actual health and perceived health, along with other social determinants of health.

Where the team-based approach involves delegation of tasks by the primary care

physician to other health professionals to balance patient care, holistic care considers the nuances in the patient’s life that could be missed (Carey et. al., 2019). Primary care is usually an

individual’s first introduction to the healthcare system before adulthood. Creating a stable foundation in healthcare for individuals during early years of life is proven to prevent chronic disease outcomes (Lopes et. al., 2003). Therefore, creating a health system that integrates holistic care with primary, team-based care could reduce the inconsistencies in the health care while increasing patient trust in the health system, feelings of social support, and self-efficacy in managing one’s own blood pressure. In some cases, hypertension is diagnosed in early teenage

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years for African Americans, so proper holistic care from early on in life could prevent morbidity and mortality from cardiovascular diseases all together (Kokubo & Iwashima, 2015).

Community gardens as an intervention in predominantly African American communities were shown to improve health significantly (Malberg et. al., 2019). Increasing patient access to more fruits and vegetables by creating local community gardens, increases feelings of

satisfaction and sense of community, promotes moderate physical exercise, increases access to healthy foods, and as a result, decreases chronic disease outcomes (Community gardens, 2021).

The availability of community gardens or even teaching individuals how to create their own garden, reinforces the principles of the DASH diet, and reduces barriers to healthy food.

Furthermore, research shows participation in community gardens reduces body weight and hypertension while improving one’s knowledge of food (Malberg et. al., 2019). Along with lifestyle changes, access to community gardens could help reduce the prevalence of hypertension and enhance the overall mental and physical health of African Americans.

Lastly, increasing patient access to programs that use modalities that complement conventional medicine, like Transcendental Meditation, in efforts to reduce the incidence and prevalence of hypertension in African Americans would be beneficial. Since stress is a root cause of hypertension, programs that reduce stress and anxiety should be incorporated into patient health care. As mentioned, Transcendental Meditation is a program that uses mind-body therapy. Mind-body therapies alone, like yoga and meditation, have been shown to reduce cardiovascular disease risk factors from 4-61% (Qidwai et. al., 2013). However, patient

knowledge about programs that incorporate mind-body therapies, and subsequently their access to these programs is lacking. As discussed, African American women of lower socioeconomic status tend to have a higher prevalence of hypertension later in life. Evidence from programs that

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incorporate mind-body therapies show reduced feelings of stress, anxiety, and depression in African American women who were at risk for developing hypertension-induced

cardiometabolic diseases related to their social environment (Johnson, Sheffield, & Brown, 2018). For these reasons, providing high risk patients with information to educate them on the benefits of mind-body therapies and provide them with resources for treatment could help reduce stress and anxiety that stem from psychosocial factors.

Conclusion

The burden of hypertension has been around for decades, but it does not have to be here for eternity. Reinforcing and making available interventions that focus on hypertension

prevention during the early stages of health care will result in healthier outcomes. For this reason, it is important to consider lifestyle changes, like the DASH diet, that reduce mortality from hypertension-related chronic disease. Additionally, there is power in advocacy. In some situations, systemic hindrances make it difficult to reduce risk factors for cardiovascular disease.

However, advocating for holistic care measures and focusing on the root cause of disease, versus only focusing on the disease itself, could promote a shift in policy and improve patient health outcomes. Health professionals should seek out information, inform their patients with knowledge, and advocate for change, especially for African Americans who are

disproportionately affected. In order to improve public health, we have to also on the health of those disproportionately affected by disease. One cannot solely focus on the health of society without first analyzing and resolving the underlying issues within each respective population.

Focusing on the health of people within each population will help health professionals discover interventions that are suitable for that specific population. Great community health yields great population health. With that, health equity should be top priority.

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