HHS Public Access Author manuscript Author Manuscript
Ethn Dis. Author manuscript; available in PMC 2015 March 05. Published in final edited form as: Ethn Dis. 2014 ; 24(3): 269–275.
Racial disparities in hypertension awareness and management: Are there differences among African Americans and Whites living in similar social and healthcare resource environments? R. J. Thorpe Jr., PhD1,2, J. V. Bowie, PhD, MPH1,3, J. R. Smolen, BA1,3, C. N. Bell, BS1, M. L. Jenkins Jr., MPH1,4, J. Jackson, BS5, and T. A. LaVeist, PhD1,2
Author Manuscript
1Hopkins
Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
2Department
of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
3Department
of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
4Department
of Epidemiology and Biostatistics, Drexel University School of Public Health, Philadelphia, PA 5Department
of Epidemiology, Harvard School of Public Health, Boston, MA
Author Manuscript
Abstract Background—Although racial disparities in hypertension awareness and management are well documented, studies have not accounted for the differing social contexts in which whites and African Americans live. Objective—To examine the nature of disparities in hypertension awareness, treatment, and control within a sample of whites and African Americans living in the same social context and with access to the same healthcare environment. Design—Cross-sectional study. Participants—949 hypertensive African American and white adults in the Exploring Health Disparities in Integrated Communities-Southwest Baltimore (EHDIC-SWB) Study.
Author Manuscript
Measurements—Logistic regression models were conducted to estimate the association between race and hypertension awareness, treatment and control adjusting for potential confounders. Results—African Americans had greater odds of being aware of their hypertension than whites (odds ratio=1.44; 95% confidence interval 1:04, 2.01). However, African Americans and whites had similar odds of being treated for hypertension, and having their hypertension under control.
Address correspondence to: Roland J. Thorpe, Jr., PhD, 624 N. Broadway, Ste 309, Baltimore, MD 21205, 443-287-5297/fax 410-614-8964, [email protected]. Conflict of Interest: None of the authors have a conflict of interest
Thorpe et al.
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Author Manuscript
Discussion—Within this racially integrated sample of hypertensive adults who share similar healthcare market, race differences in treatment and control of hypertension were eliminated. Accounting for the social context should be considered in public health campaigns targeting hypertension awareness and management.
Introduction
Author Manuscript
Several studies have documented that African Americans are more likely to be aware of their hypertension status, more likely to be in treatment, but less likely to to have their hypertension well-controlled. compared to whites. (Ong,K.L. 2007; Hertz,R.P. 2005; Sheats,N. 2005; Ostchega,Y. 2008; Howard,G. 2006; Cutler,J.A. 2008;) (Ong,K.L. 2007; Hertz,R.P. 2005; Sheats 2005; Ostchega 2008; Howard 2006; Cutler 2008; Hajjar 2003; Hicks 2004; Kramer 2004; Bosworth 2006; Cushman 2002;) The reasons for this set of findings is unclear, but it is critical to determine them if we are to eliminate disparities in cardiovascular morbidity and mortality.
Author Manuscript
There is a substantial literature examining a variety of factors in seeking to explain race disparities in hypertension management; (Hertz,R.P. 2005; Howard 2006; Bosworth 2006; Ashaye 2003; Ahluwalia 1997;) however, these studies have not accounted for the differing social and healthcare contexts in which whites and African Americans live. In a highly segregated society, African Americans experience greater exposure to health risks, and less access to medical care. (Gaskin,D.J. 2009; Williams,D.R. 2001; Morenoff,J.D. 2007;) That is, the communities where many African Americans reside are often plagued with high crime, poor housing quality, poor educational and employment opportunities, and fewer healthcare resources (Gaskin 2009; Williams 2001; Morenoff 2007; Kershaw,K.N. 2011; Mujahid 2008; Schulz 2008;). Because African Americans and whites tend to live in these very different social environments, (Iceland,J. 2004; Wilkes,R. 2004; Massey,D.S. 1993; Massey,D.S. 1995; Howard,G. 2006;) it is possible that race differences in hypertension awareness and management result from race differences in health risk exposures and/or healthcare resources resulting from residential segregation. (LaVeist,T.A. 2005;).
Author Manuscript
Failing to account for race differences in health risk exposure could lead to inaccurate conclusions regarding the etiology of racial disparities. (Fesahazion,R.G. 2012; Reese,A.M. 2012; Laveist 2011; Bleich,S.N. 2010; LaVeist 2009; Thorpe 2008; LaVeist 2008; Laveist 2007;) Race differences observed in national data may be a result of race differences in the health-risk environments. Not accounting for racial segregation may lead to a spurious conclusion that the individual-level factor (race) is responsible for the association rather than the community-level factor (health risk environment). Accounting for race differences in social context and healthcare resources can begin to disentangle race from context. This is important in determining how best to target resources and develop more effective tools to address health disparities in hypertension awareness and management. Another source of confounding in health disparities is the high correlation between race and socioeconomic status (SES). (LaVeist,T.A. 2005; Braveman,P.A. 2005;) Both are welldocumented correlates of hypertension. (Ashaye,M.O. 2003; Bell,A.C. 2004; Colhoun,H.M. 1998; Sharma,S. 2004;) However the high correlation between race and SES complicates
Ethn Dis. Author manuscript; available in PMC 2015 March 05.
Thorpe et al.
Page 3
Author Manuscript
efforts to determine whether race and SES operate independently or jointly to produce racial disparities in hypertension awareness and management. Studies that are adequately designed to overcome these challenges are rare. The objective of this study was to examine race disparities in hypertension awareness, treatment, and control within a sample of whites and African Americans living in the same social context and with access to the same healthcare environment.
Methods Data
Author Manuscript
EHDIC (Exploring Health Disparities in Integrated Communities) is an ongoing multisite study of race disparities within communities where African Americans and non-Hispanic whites live together and where there are no race differences in SES (as measured by median income). The first EHDIC study site was in Southwest Baltimore, Maryland (EHDIC-SWB). Future EHDIC locations are planned.
Author Manuscript
EHDIC-SWB, is a cross-sectional face-to-face survey of the adult population (age 18 and older) of two contiguous census tracts. In addition to being economically homogenous, the study site was also racially balanced and well integrated, with almost equal proportions of African American and non-Hispanic white residents. In the two census tracts, the racial distribution was 51% African American and 44% non-Hispanic white, and the median income for the study area was $24,002, with no race difference. The census tracts were block listed to identify every occupied dwelling in the study area. Of the 2618 structures identified, 1636 structures were determined to be occupied residential housing units (excluding commercial and vacant residential structures). After at most five attempts, contact was made with an eligible adult in 1244 occupied residential housing units. Of that number, 65.8% were enrolled in the study resulting in 1489 study participants (41.9% of the 3555 adults living in these two census tracts recorded in the 2000 Census). Because our survey had similar coverage across each census block group in the study area, the bias to geographic locale and its relationship with socioeconomic status should be minimal. (LaVeist,T. 2008;)
Author Manuscript
Comparisons to the 2000 Census for the study area indicated that the EHDIC-SWB sample included a higher proportion of blacks and women, but was otherwise similar with respect to other demographic and socioeconomic indicators. (LaVeist,T. 2008;) For instance, EHDICSWB was 59.3% African American and 44.4% male, whereas the 2000 Census data showed the population was 51% African American and 49.7% male. Age distributions in EHDICSWB and 2000 Census data were similar with a median age range of 35-44 years for both samples. The lack of race difference in median income in the census, $23,500 (African American) vs. $24,100 (non-Hispanic white) was replicated in EHDIC -- $23,400 (African American) vs. $24,900 (non-Hispanic white). The survey was administered in person by a trained interviewer and consisted of a structured questionnaire that included demographic and socioeconomic information, self-reported health behaviors and chronic conditions, and three blood pressure (BP) measurements. The
Ethn Dis. Author manuscript; available in PMC 2015 March 05.
Thorpe et al.
Page 4
Author Manuscript
EHDIC study has been described in greater detail elsewhere. (LaVeist,T. 2008;) The study was approved by the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health and all participants gave informed consent. The analyses for this project included 949 African American and non-Hispanic white hypertensive adults aged 20 and older. Measures
Author Manuscript
Hypertension status was based on the mean systolic and diastolic BP derived from up to three measurements obtained in a seated position using appropriate size electronic cuffs that were calibrated to an ambulatory standard.(Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS).;) Hypertension was defined as systolic BP ≥ 140 mm Hg, or diastolic BP ≥ 90 mm Hg, or respondent report of taking antihypertensive medications. (Chobanian,A.V. 2003; Ostchega,Y. 2008;) Hypertensive participants who reported having been diagnosed by a doctor were considered to be aware of their hypertension. (Chobanian,A.V. 2003; Ostchega,Y. 2008;) Among hypertensive adults aware of their condition, those who reported taking antihypertensive medications were classified as being in treatment. Among the treated hypertensive adults who were diabetic, those with systolic BP
Ethn Dis. Author manuscript; available in PMC 2015 March 05. Published in final edited form as: Ethn Dis. 2014 ; 24(3): 269–275.
Racial disparities in hypertension awareness and management: Are there differences among African Americans and Whites living in similar social and healthcare resource environments? R. J. Thorpe Jr., PhD1,2, J. V. Bowie, PhD, MPH1,3, J. R. Smolen, BA1,3, C. N. Bell, BS1, M. L. Jenkins Jr., MPH1,4, J. Jackson, BS5, and T. A. LaVeist, PhD1,2
Author Manuscript
1Hopkins
Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
2Department
of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
3Department
of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
4Department
of Epidemiology and Biostatistics, Drexel University School of Public Health, Philadelphia, PA 5Department
of Epidemiology, Harvard School of Public Health, Boston, MA
Author Manuscript
Abstract Background—Although racial disparities in hypertension awareness and management are well documented, studies have not accounted for the differing social contexts in which whites and African Americans live. Objective—To examine the nature of disparities in hypertension awareness, treatment, and control within a sample of whites and African Americans living in the same social context and with access to the same healthcare environment. Design—Cross-sectional study. Participants—949 hypertensive African American and white adults in the Exploring Health Disparities in Integrated Communities-Southwest Baltimore (EHDIC-SWB) Study.
Author Manuscript
Measurements—Logistic regression models were conducted to estimate the association between race and hypertension awareness, treatment and control adjusting for potential confounders. Results—African Americans had greater odds of being aware of their hypertension than whites (odds ratio=1.44; 95% confidence interval 1:04, 2.01). However, African Americans and whites had similar odds of being treated for hypertension, and having their hypertension under control.
Address correspondence to: Roland J. Thorpe, Jr., PhD, 624 N. Broadway, Ste 309, Baltimore, MD 21205, 443-287-5297/fax 410-614-8964, [email protected]. Conflict of Interest: None of the authors have a conflict of interest
Thorpe et al.
Page 2
Author Manuscript
Discussion—Within this racially integrated sample of hypertensive adults who share similar healthcare market, race differences in treatment and control of hypertension were eliminated. Accounting for the social context should be considered in public health campaigns targeting hypertension awareness and management.
Introduction
Author Manuscript
Several studies have documented that African Americans are more likely to be aware of their hypertension status, more likely to be in treatment, but less likely to to have their hypertension well-controlled. compared to whites. (Ong,K.L. 2007; Hertz,R.P. 2005; Sheats,N. 2005; Ostchega,Y. 2008; Howard,G. 2006; Cutler,J.A. 2008;) (Ong,K.L. 2007; Hertz,R.P. 2005; Sheats 2005; Ostchega 2008; Howard 2006; Cutler 2008; Hajjar 2003; Hicks 2004; Kramer 2004; Bosworth 2006; Cushman 2002;) The reasons for this set of findings is unclear, but it is critical to determine them if we are to eliminate disparities in cardiovascular morbidity and mortality.
Author Manuscript
There is a substantial literature examining a variety of factors in seeking to explain race disparities in hypertension management; (Hertz,R.P. 2005; Howard 2006; Bosworth 2006; Ashaye 2003; Ahluwalia 1997;) however, these studies have not accounted for the differing social and healthcare contexts in which whites and African Americans live. In a highly segregated society, African Americans experience greater exposure to health risks, and less access to medical care. (Gaskin,D.J. 2009; Williams,D.R. 2001; Morenoff,J.D. 2007;) That is, the communities where many African Americans reside are often plagued with high crime, poor housing quality, poor educational and employment opportunities, and fewer healthcare resources (Gaskin 2009; Williams 2001; Morenoff 2007; Kershaw,K.N. 2011; Mujahid 2008; Schulz 2008;). Because African Americans and whites tend to live in these very different social environments, (Iceland,J. 2004; Wilkes,R. 2004; Massey,D.S. 1993; Massey,D.S. 1995; Howard,G. 2006;) it is possible that race differences in hypertension awareness and management result from race differences in health risk exposures and/or healthcare resources resulting from residential segregation. (LaVeist,T.A. 2005;).
Author Manuscript
Failing to account for race differences in health risk exposure could lead to inaccurate conclusions regarding the etiology of racial disparities. (Fesahazion,R.G. 2012; Reese,A.M. 2012; Laveist 2011; Bleich,S.N. 2010; LaVeist 2009; Thorpe 2008; LaVeist 2008; Laveist 2007;) Race differences observed in national data may be a result of race differences in the health-risk environments. Not accounting for racial segregation may lead to a spurious conclusion that the individual-level factor (race) is responsible for the association rather than the community-level factor (health risk environment). Accounting for race differences in social context and healthcare resources can begin to disentangle race from context. This is important in determining how best to target resources and develop more effective tools to address health disparities in hypertension awareness and management. Another source of confounding in health disparities is the high correlation between race and socioeconomic status (SES). (LaVeist,T.A. 2005; Braveman,P.A. 2005;) Both are welldocumented correlates of hypertension. (Ashaye,M.O. 2003; Bell,A.C. 2004; Colhoun,H.M. 1998; Sharma,S. 2004;) However the high correlation between race and SES complicates
Ethn Dis. Author manuscript; available in PMC 2015 March 05.
Thorpe et al.
Page 3
Author Manuscript
efforts to determine whether race and SES operate independently or jointly to produce racial disparities in hypertension awareness and management. Studies that are adequately designed to overcome these challenges are rare. The objective of this study was to examine race disparities in hypertension awareness, treatment, and control within a sample of whites and African Americans living in the same social context and with access to the same healthcare environment.
Methods Data
Author Manuscript
EHDIC (Exploring Health Disparities in Integrated Communities) is an ongoing multisite study of race disparities within communities where African Americans and non-Hispanic whites live together and where there are no race differences in SES (as measured by median income). The first EHDIC study site was in Southwest Baltimore, Maryland (EHDIC-SWB). Future EHDIC locations are planned.
Author Manuscript
EHDIC-SWB, is a cross-sectional face-to-face survey of the adult population (age 18 and older) of two contiguous census tracts. In addition to being economically homogenous, the study site was also racially balanced and well integrated, with almost equal proportions of African American and non-Hispanic white residents. In the two census tracts, the racial distribution was 51% African American and 44% non-Hispanic white, and the median income for the study area was $24,002, with no race difference. The census tracts were block listed to identify every occupied dwelling in the study area. Of the 2618 structures identified, 1636 structures were determined to be occupied residential housing units (excluding commercial and vacant residential structures). After at most five attempts, contact was made with an eligible adult in 1244 occupied residential housing units. Of that number, 65.8% were enrolled in the study resulting in 1489 study participants (41.9% of the 3555 adults living in these two census tracts recorded in the 2000 Census). Because our survey had similar coverage across each census block group in the study area, the bias to geographic locale and its relationship with socioeconomic status should be minimal. (LaVeist,T. 2008;)
Author Manuscript
Comparisons to the 2000 Census for the study area indicated that the EHDIC-SWB sample included a higher proportion of blacks and women, but was otherwise similar with respect to other demographic and socioeconomic indicators. (LaVeist,T. 2008;) For instance, EHDICSWB was 59.3% African American and 44.4% male, whereas the 2000 Census data showed the population was 51% African American and 49.7% male. Age distributions in EHDICSWB and 2000 Census data were similar with a median age range of 35-44 years for both samples. The lack of race difference in median income in the census, $23,500 (African American) vs. $24,100 (non-Hispanic white) was replicated in EHDIC -- $23,400 (African American) vs. $24,900 (non-Hispanic white). The survey was administered in person by a trained interviewer and consisted of a structured questionnaire that included demographic and socioeconomic information, self-reported health behaviors and chronic conditions, and three blood pressure (BP) measurements. The
Ethn Dis. Author manuscript; available in PMC 2015 March 05.
Thorpe et al.
Page 4
Author Manuscript
EHDIC study has been described in greater detail elsewhere. (LaVeist,T. 2008;) The study was approved by the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health and all participants gave informed consent. The analyses for this project included 949 African American and non-Hispanic white hypertensive adults aged 20 and older. Measures
Author Manuscript
Hypertension status was based on the mean systolic and diastolic BP derived from up to three measurements obtained in a seated position using appropriate size electronic cuffs that were calibrated to an ambulatory standard.(Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS).;) Hypertension was defined as systolic BP ≥ 140 mm Hg, or diastolic BP ≥ 90 mm Hg, or respondent report of taking antihypertensive medications. (Chobanian,A.V. 2003; Ostchega,Y. 2008;) Hypertensive participants who reported having been diagnosed by a doctor were considered to be aware of their hypertension. (Chobanian,A.V. 2003; Ostchega,Y. 2008;) Among hypertensive adults aware of their condition, those who reported taking antihypertensive medications were classified as being in treatment. Among the treated hypertensive adults who were diabetic, those with systolic BP
