Journal of General Internal Medicine

, Volume 23, Issue 5, pp 692–698 | Cite as

Racial Differences in Blood Pressure Control: Potential Explanatory Factors

  • Hayden B. Bosworth
  • Benjamin Powers
  • Janet M. Grubber
  • Carolyn T. Thorpe
  • Maren K. Olsen
  • Melinda Orr
  • Eugene Z. Oddone
Populations at Risk

Summary

Objective

The objective of the study was to identify potential explanatory factors for racial differences in blood pressure (BP) control.

Design

The design of the study was a cross-sectional study

Patients/Participants

The study included 608 patients with hypertension who were either African American (50%) or white (50%) and who received primary care in Durham, NC.

Measurements and Main Results

Baseline data were obtained from the Take Control of Your Blood pressure study and included clinical, demographic, and psychosocial variables potentially related to clinic BP measures. African Americans were more likely than whites to have inadequate baseline clinic BP control as defined as greater than or equal to 140/90 mmHg (49% versus 34%; unadjusted odds ratio [OR] 1.8; 95% confidence interval [CI] 1.3–2.5). Among factors that may explain this disparity, being older, reporting hypertension medication nonadherence, reporting a hypertension diagnosis for more than 5 years, reporting high levels of stress, being worried about hypertension, and reporting an increased number of medication side effects were related to inadequate BP control. In adjusted analyses, African Americans continue to have poor BP control relative to whites; the magnitude of the association was reduced (OR = 1.5; 95% CI 1.0–2.1). Medication nonadherence, worries about hypertension, and older age (>70) continued to be related to poor BP control.

Conclusions

In this sample of hypertensive patients, there were a number of factors associated with poor BP control that partially explained the observed racial disparity in hypertension control including age, medication nonadherence, and worry about BP. Medication nonadherence is of particular interest because it is a potentially modifiable factor that might be used to reduce the racial disparity in BP control.

KEY WORDS

racial disparity hypertension adherence psychosocial 

References

  1. 1.
    Chobanian AV , Bakris GL, Black H, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003;289(19):2560–71.PubMedCrossRefGoogle Scholar
  2. 2.
    Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in middle-aged women and men: the Framingham Heart Study. JAMA. 2002;287(8):1003–10.PubMedCrossRefGoogle Scholar
  3. 3.
    Stamler J, Stamler, Neaton J. Blood pressure, systolic and diastolic, and cardiovascular risks: U.S. population data. Arch Intern Med. 1993;153:598–615.PubMedCrossRefGoogle Scholar
  4. 4.
    Perry H, Roccella EJ. Conference report on stroke mortality in the southeastern United States. Hypertens. 1998;31:1206–15.Google Scholar
  5. 5.
    Kannel W. Blood pressure as a cardiovascular risk factor, prevention and treatment. JAMA. 1996;275:1571–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Wong MD, Shapiro MF, Boscardin WJ, Ettner SL. Contribution of major diseases to disparities in mortality. N Engl J Med. 2002;347(20):1585–92.PubMedCrossRefGoogle Scholar
  7. 7.
    Hertz RP, Unger AN, Cornell JA, Saunders E. Racial disparities in hypertension prevalence, awareness, and management. Arch Intern Med. 2005;165(18):2098–104.PubMedCrossRefGoogle Scholar
  8. 8.
    Bosworth HB, Oddone EZ. A model of psychosocial and cultural antecedents of blood pressure control. J Natl Med Assoc. 2002;94(4):236–48.PubMedGoogle Scholar
  9. 9.
    Kotchen JM, Shakoor-Abdullah B, Walker WE, Chelius TH, Hoffmann RG, Kotchen TA. Hypertension control and access to medical care in the inner city. Am J Public Health. 1998;881(11):696–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998;339(27):1957–63.PubMedCrossRefGoogle Scholar
  11. 11.
    Weinick RM, Zuvekas SH, Cohen JW. Racial and ethnic differences in access to and use of health care services, 1977 to 1996. Med Care Res Rev. 2000;57(Suppl 1):36–54.PubMedCrossRefGoogle Scholar
  12. 12.
    Bosworth HB, Olsen MK, Dudley T, et al. The Take Control of Your Blood pressure (TCYB) study: study design and methodology. Contemp Clin Trials. 2007;28(1):33–47.PubMedCrossRefGoogle Scholar
  13. 13.
    Bosworth HB, Bastian LA, Kuchibhatla MN, et al. Depressive symptoms, menopausal status, and climacteric symptoms in women at midlife. Psychosom Med. 2001;63(4):603–8.PubMedGoogle Scholar
  14. 14.
    Parker R, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10:537–41.PubMedCrossRefGoogle Scholar
  15. 15.
    Davis T, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Family Med. 1993;25:391–5.Google Scholar
  16. 16.
    Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38(1):33–42.PubMedCrossRefGoogle Scholar
  17. 17.
    Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19(12):1228–39.PubMedCrossRefGoogle Scholar
  18. 18.
    Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAuliffe TL. Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychol. 2000;19(2):124–33.PubMedCrossRefGoogle Scholar
  19. 19.
    Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986;24(1):67–74.PubMedCrossRefGoogle Scholar
  20. 20.
    Lowry KP, Dudley TK, Oddone EZ, Bosworth HB. Intentional and unintentional nonadherence to antihypertensive medication. Ann Pharmacother. 2005;39(7–8):1198–203.PubMedGoogle Scholar
  21. 21.
    Jette A, Cummings KM, Brock BM, Phelps MC, Naessens J. The structure and reliability of health belief indices. Health Serv Res. 1981;16:81–98.PubMedGoogle Scholar
  22. 22.
    Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in blood pressure control: potential explanatory factors. Am J Med. 2006;119(1):70 e9–15.PubMedCrossRefGoogle Scholar
  23. 23.
    Hong TB, Oddone EZ, Dudley TK, Bosworth HB. Subjective and objective evaluations of health among middle-aged and older veterans with hypertension. J Aging Health. 2005;17(5):592–608.PubMedCrossRefGoogle Scholar
  24. 24.
    Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision-making style. Results from the Medical Outcomes Study. Med Care. 1995;33(12):1176–87.PubMedCrossRefGoogle Scholar
  25. 25.
    Williams RB, Barefoot JC, Califf RM, et al. Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease. JAMA. 1992;267:520–4.PubMedCrossRefGoogle Scholar
  26. 26.
    Bosworth HB, Hoff J, Box T et-al. Patient factors related to poor blood pressure control. Poster presented at the 19th Annual Health Service Research and Development Meetings. Washington, DC; 2001.Google Scholar
  27. 27.
    Rothman K, Greenland S. Modern Epidemiology. 2nd ed. Philadelphia, PA: Lippincott-Raven; 1998.Google Scholar
  28. 28.
    Schildkraut J, Demark-Wahnefried W, Wenham RM, et al. IGF1(CA)19 Repeat and IGFBP3 -202 A/C Genotypes and the Risk of Prostate Cancer in Black and White Men. Cancer Epidemiol Biomarkers Prev. 2005;14(2):403–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Cooper R, Sempos C, Hsieh SC, Kovar MG. Slowdown of the decline of stroke mortality in the United States, 1978–1986. Stroke. 1990;21:1274–9.PubMedGoogle Scholar
  30. 30.
    Sempos C, Cooper R, Kovar MG, McMillen M. Divergence of the recent trends in coronary mortality for the four major race–sex groups in the United States. Am J Public Health. 1988;78(11):1422–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Kramer H, Han C, Post W, et al. Racial/ethnic differences in hypertension and hypertension treatment and control in the multi-ethnic study of atherosclerosis (MESA). Am J Hypertens. 2004;17(10):963–70.PubMedCrossRefGoogle Scholar
  32. 32.
    Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988–2000. JAMA. 2003;290(2):199–206.PubMedCrossRefGoogle Scholar
  33. 33.
    Svetkey LP, George LK, Tyroler HA, Timmons PZ, Burchett BM, Blazer DG. Effects of gender and ethnic group on blood pressure control in the elderly. Am J Hypertens. 1996;9(6):529–35.PubMedCrossRefGoogle Scholar
  34. 34.
    McCaul KD, Schroeder DM, Reid PA. Breast cancer worry and screening: some prospective data. Health Psychol. 1996;15(6):430–3.PubMedCrossRefGoogle Scholar
  35. 35.
    Psaty B, Koepsell TD, Yanez D, et al. Temporal patterns of antihypertensive medication use among adults, 1989 through 1992. JAMA. 1995;273:1436–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Caro JJ, Speckman JL, Salas M, Raggio G, Jackson JD. Effect of initial drug choice on persistence with antihypertensive therapy: the importance of actual practice data. CMAJ. 1999;160(1):41–6.PubMedGoogle Scholar
  37. 37.
    Bosworth HB, Olsen MK, Gentry P, et al. Nurse administered telephone intervention for blood pressure control: a patient-tailored multifactorial intervention. Patient Educ Couns. 2005;57(1):5–14.PubMedCrossRefGoogle Scholar
  38. 38.
    Charles H, Good CB, Hanusa BH, Chang CC, Whittle J. Racial differences in adherence to cardiac medications. J Natl Med Assoc. 2003;95(1):17–27.PubMedGoogle Scholar
  39. 39.
    Black D, Brand RJ, Greenlick M, Hughes G, Smith J. For the SHEP Pilot Research Group. Compliance to treatment for hypertension in elderly patients: The SHEP pilot study. J Gerontol. 1987;42:552–7.PubMedGoogle Scholar
  40. 40.
    Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Levin R, Avorn J. Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender, and race. Am J Pub Health. 1996;86(12):1805–8.CrossRefGoogle Scholar
  41. 41.
    Psaty BM, Manolio TA, Smith NL, et al. Time trends in high blood pressure control and the use of antihypertensive medications in older adults: the cardiovascular health study. Arch Intern Med. 2002;162(20):2325–32.PubMedCrossRefGoogle Scholar
  42. 42.
    Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med. 2001;345(7):479–86.PubMedCrossRefGoogle Scholar
  43. 43.
    Burt V, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population: results from the third National Health and Nutrition Examination Survey. 1988–1991. Hypertens. 1995;25:305–13.Google Scholar
  44. 44.
    Schectman JM, Bovbjerg VE, Voss JD. Predictors of medication-refill adherence in an indigent rural population. Med Care. 2002;12:1294–300.CrossRefGoogle Scholar
  45. 45.
    Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Levin R, Avorn J. Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender, and race. Am J Pub Health. 1996;86(12):1805–8.CrossRefGoogle Scholar
  46. 46.
    Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57(Suppl 1):181–217.PubMedCrossRefGoogle Scholar
  47. 47.
    Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283(19):2579–84.PubMedCrossRefGoogle Scholar
  48. 48.
    Franklin SS, Gustin WT, Wong ND, et al. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation. 1997;96(1):308–15.PubMedGoogle Scholar
  49. 49.
    Messerli FH, Mancia G, Conti CR, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med. 2006;144(12):884–93.PubMedGoogle Scholar
  50. 50.
    Ong KL, Cheung BM, Man YB, Lau CP, Lam KS. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999–2004. Hypertens. 2007;49(1):69–75.CrossRefGoogle Scholar
  51. 51.
    Holmes JS, Arispe IE, Moy E. Heart disease and prevention: race and age differences in heart disease prevention, treatment, and mortality. Med Care. 2005;43(3 Suppl):I33–41.PubMedGoogle Scholar
  52. 52.
    Howard G, Prineas R, Moy C, et al. Racial and geographic differences in awareness, treatment, and control of hypertension: the REasons for Geographic And Racial Differences in Stroke study. Stroke. 2006;37(5):1171–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Cho AH, Voils CI, Yancy WS Jr, Oddone EZ, Bosworth HB. Does participatory decision making improve hypertension self-care behaviors and outcomes? J Clin Hypertens (Greenwich). 2007;9(5):330–6.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Hayden B. Bosworth
    • 1
    • 2
    • 3
  • Benjamin Powers
    • 1
    • 2
  • Janet M. Grubber
    • 1
    • 2
  • Carolyn T. Thorpe
    • 1
  • Maren K. Olsen
    • 1
    • 4
  • Melinda Orr
    • 1
  • Eugene Z. Oddone
    • 1
    • 2
  1. 1.Center for Health Services Research in Primary Care Durham Veterans Affairs Medical Center (152)DurhamUSA
  2. 2.Department of Medicine, Division of General Internal MedicineDuke UniversityDurhamUSA
  3. 3.Department of Psychiatry and Behavioral Sciences and Center for Aging and Human DevelopmentDuke UniversityDurhamUSA
  4. 4.Department of Biostatistics and BioinformaticsDuke UniversityDurhamUSA

Personalised recommendations