Journal of Urban Health

, Volume 93, Issue 2, pp 345–363 | Cite as

Local Actors’ Frames of the Role of Living Conditions in Shaping Hypertension Risk and Disparities in a Colombian Municipality

  • Diego I. LucumiEmail author
  • Amy J. Schulz
  • Barbara A. Israel


Conditions in the social and physical environment influence population health and risk for CVD, including hypertension. These environmental conditions are influenced by the decisions of public officials, community leaders, and service providers. Examining the frames that local decision makers bring to understanding hypertension can provide important insights into the decisions that they make about strategies for addressing this problem in their jurisdiction. The goal of this study was to examine the frames that local decision makers in Quibdó, Colombia, bring to understanding hypertension risk, and in particular, whether and how they use frames that encompass associations between living conditions and hypertension risk. Data for this qualitative study were collected using a stratified sampling strategy. Semi-structured interviews were conducted in 2012 with 13 local decision makers and analyzed using a framework approach. Participants linked the structural conditions experienced in Quibdó, including displacement, limited economic opportunities, and the infrastructure of the city, to hypertension risk through multiple pathways, including behavioral risk factors for hypertension and physiologic responses to stress. They described the social patterning of these factors across socioeconomic, racial/ethnic, and gender hierarchies. Although several conditions associated with hypertension risk are widely distributed in the city’s population, social processes of marginalization and stratification create additional disadvantages for those on the lower rungs of the social hierarchy.


Hypertension Urban population Social inequity Social determinants of health Colombia 



First author received funds from University of Michigan Rackham Graduate Student Research Grant to conduct fieldwork. The authors would like to thank the participants and to Angela Cuesta and Jorge Torres who provide valuable support to the fieldwork of this study.


  1. 1.
    Lawes CMM, Vander Hoorn S, Rodgers A, Int Soc H. Global burden of blood-pressure-related disease, 2001. Lancet. 2008; 371(9623): 1513–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Ministerio de la Protección Salud. Situacion de Salud de Colombia. Indicadores Basicos 2008. Bogota D.C.: Ministerio de la Protección Salud; 2008.Google Scholar
  3. 3.
    Martínez E, Díaz P. Morbilidad y Mortalidad de la Población Colombiana. Enfermedad Cardiovascular. Bogotá, DC: Ministerio de la Protección Social y Universidad de Antioquia; 2010.Google Scholar
  4. 4.
    Schulz A, Kannan S, Dvonch JT, et al. Social and physical environments and disparities in risk for cardiovascular disease: the healthy environments partnership conceptual model. Environ Health Perspect. 2005; 113(12): 1817–25.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Diez Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003; 80(4): 569–89.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Daniel M, Moore S, Kestens Y. Framing the biosocial pathways underlying associations between place and cardiometabolic disease. Health Place. 2008; 14(2): 117–32.CrossRefPubMedGoogle Scholar
  7. 7.
    Schmidt M, Joosen I, Kunst AE, Klazinga NS, Stronks K. Generating political priority to tackle health disparities: a case study in the Dutch City of The Hague. Am J Public Health. 2010; 100: S210–5.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Galea S, Freudenberg N, Vlahov D. Cities and population health. Soc Sci Med. 2005; 60(5): 1017–33.CrossRefPubMedGoogle Scholar
  9. 9.
    Kraus N. Local policymaking and concentrated poverty: the case of Buffalo, New York. Cities. 2004; 21(6): 481–90.CrossRefGoogle Scholar
  10. 10.
    Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. Social Determinants of Health Discussion Paper 2. Geneva, Switzerland: World Health Organization; 2010.Google Scholar
  11. 11.
    Congreso de Colombia. Ley 136. Por la cual se dictan normas tendientes a modernizar la organización y el funcionamiento de los municipios. In: Congreso de Colombia, editor. Gaceta Oficial: Imprenta Nacional; 1994.Google Scholar
  12. 12.
    Knai C, McKee M. Tackling childhood obesity: the importance of understanding the context. J Public Health. 2010; 32(4): 506–11.CrossRefGoogle Scholar
  13. 13.
    Khan MM, Van den Heuvel W. The impact of political context upon the health policy process in Pakistan. Public Health. 2007; 121(4): 278–86.CrossRefPubMedGoogle Scholar
  14. 14.
    Schulz A, Northridge M. Social determinants of health: implications for environmental health promotion. Health Educ Behav. 2004; 31(4): 455–71.CrossRefPubMedGoogle Scholar
  15. 15.
    McLeroy KR, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Health Educ Q. 1988; 15(4): 351–77.CrossRefPubMedGoogle Scholar
  16. 16.
    Stokols D. Translating social ecological theory into guidelines for community health promotion. Am J Health Promot. 1996; 10(4): 282–98.CrossRefPubMedGoogle Scholar
  17. 17.
    Coburn CE. Framing the problem of reading instruction: using frame analysis to uncover the microprocesses of policy implementation. Am Educ Res J. 2006; 43(3): 343–79.CrossRefGoogle Scholar
  18. 18.
    Benford RD, Snow DA. Framing processes and social movements: an overview and assessment. Annu Rev Sociol. 2000; 26: 611–39.CrossRefGoogle Scholar
  19. 19.
    Kwan S. Framing the fat body: contested meanings between government, activists, and industry. Sociol Inq. 2009; 79(1): 25–50.CrossRefGoogle Scholar
  20. 20.
    Verloo M. Mainstreaming gender equality in Europe. A critical frame analysis approach. Greek Rev Soc Res. 2005; 117(B): 11–34.Google Scholar
  21. 21.
    Patton MQ. Qualitative Evaluation and Research Methods. 2nd ed. Newbury Park, CA: SAGE; 1990.Google Scholar
  22. 22.
    Yin RK. Case Study Research. Design and Methods, vol. 5. Thousands Oaks, CA: Sage Publications; 2003.Google Scholar
  23. 23.
    OPS. Indicadores Básicos en Salud Quibdó. Chocó, Colombia—2008. Bogotá D.C.: Organización Panamericana de la Salud; 2008.Google Scholar
  24. 24.
    Lucumi DI. Prevalence of Hypertension in Colombia. Ann Arbor, MI: Department of Health Behavior and Health Education. School of Public Health. University of Michigan; 2012.Google Scholar
  25. 25.
    Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess RG, eds. Analyzing qualitative data. New York: Routledge; 1994: 173–94.CrossRefGoogle Scholar
  26. 26.
    Departamento Administrativo Nacional de Estadísiticas (DANE). Principales indicadores del mercado laboral. Diciembre 2012. Bogotá, DC: Departamento Administrativo Nacional de Estadísiticas (DANE); 2013.Google Scholar
  27. 27.
    Institute of Medicine. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington, DC: The National Academic Press; 2010.Google Scholar
  28. 28.
    Smit W, de Lannoy A, Dover RV, Lambert EV, Levitt N, Watson V. Making unhealthy places: the built environment and non-communicable diseases in Khayelitsha, Cape Town. Health Place. 2015; 35: 11–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Thomas SL, Thomas SD. Displacement and health. Br Med Bull. 2004; 69: 115–27.CrossRefPubMedGoogle Scholar
  30. 30.
    Roberts B, Odong VN, Browne J, Ocaka KF, Geissler W, Sondorp E. An exploration of social determinants of health amongst internally displaced persons in northern Uganda. Confl Health. 2009; 3: 10.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Roberts B, Browne J. A systematic review of factors influencing the psychological health of conflict-affected populations in low- and middle-income countries. Glob Public Health. 2011; 6(8): 814–29.CrossRefPubMedGoogle Scholar
  32. 32.
    Shami S. The social implications of population displacement and resettlement: an overview with a focus on the Arab Middle East. Int Migr Rev. 1993; 27(1): 4.CrossRefGoogle Scholar
  33. 33.
    Roberts B, Patel P, McKee M. Noncommunicable diseases and post-conflict countries. Bull World Health Organ. 2012; 90(1): 2–2a.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Robertson CL, Hoffman SJ. Conflict and forced displacement: human migration, human rights, and the science of health. Nurs Res. 2014; 63(5): 307–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Dressler WW, Balieiro MC, Dos Santos JE. Culture, skin color, and arterial blood pressure in Brazil. Am J Hum Biol. 1999; 11(1): 49–59.CrossRefPubMedGoogle Scholar
  36. 36.
    Dressler WW, Balieiro MC, Ribeiro RP, Dos Santos JE. Cultural consonance and arterial blood pressure in urban Brazil. Soc Sci Med. 2005; 61(3): 527–40.CrossRefPubMedGoogle Scholar
  37. 37.
    Spruill TM. Chronic psychosocial stress and hypertension. Curr Hypertens Rep. 2010; 12(1): 10–6.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Sparrenberger F, Cichelero FT, Ascoli AM, et al. Does psychosocial stress cause hypertension? A systematic review of observational studies. J Hum Hypertens. 2009; 23(1): 12–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Niakara A, Fournet F, Gary J, Harang M, Nebie LVA, Salem G. Hypertension, urbanization, social and spatial disparities: a cross-sectional population-based survey in a West African Urban Environment (Ouagadougou, Burkina Faso). Trans R Soc Trop Med Hyg. 2007; 101: 1136–42.CrossRefPubMedGoogle Scholar
  40. 40.
    Glanz K, Schwartz M. Stress, coping and health behavior. In: Glanz K, Rimer B, Viswanath K, eds. Health education and health behavior. San Francisco, CA: Jossey-Bass; 2008: 211–30.Google Scholar
  41. 41.
    Heaney CA, Israel B. Social networks and social support. In: Glanz K, Rimer B, Viswanath K, eds. Health Behavior and Health Education. Theory, Research and Practice. 2nd ed. San Francisco, CA: Jossey-Bass; 2008: 189–207.Google Scholar
  42. 42.
    Hamano T, Fujisawa Y, Yamasaki M, Ito K, Nabika T, Shiwaku K. Contributions of social context to blood pressure: findings from a multilevel analysis of social capital and systolic blood pressure. Am J Hypertens. 2011; 24(6): 643–6.CrossRefPubMedGoogle Scholar
  43. 43.
    Brondolo E, Rieppi R, Kelly KP, Gerin W. Perceived racism and blood pressure: a review of the literature and conceptual and methodological critique. Ann Behav Med. 2003; 25(1): 55–65.CrossRefPubMedGoogle Scholar
  44. 44.
    Barksdale DJ, Farrug ER, Harkness K. Racial discrimination and blood pressure: perceptions, emotions, and behaviors of Black American adults. Issues Ment Health Nurs. 2009; 30(2): 104–11.CrossRefPubMedGoogle Scholar
  45. 45.
    Weaver H, Roberts B. Drinking and displacement: a systematic review of the influence of forced displacement on harmful alcohol use. Subst Use Misuse. 2010; 45(13): 2340–55.CrossRefPubMedGoogle Scholar
  46. 46.
    Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet. 2012; 380(9841): 611–9.CrossRefPubMedGoogle Scholar
  47. 47.
    Allender S, Wickramasinghe K, Goldacre M, Matthews D, Katulanda P. Quantifying urbanization as a risk factor for noncommunicable disease. J Urban Health. 2011; 88(5): 906–18.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Allender S, Foster C, Hutchinson L, Arambepola C. Quantification of urbanization in relation to chronic diseases in developing countries: a systematic review. J Urban Health. 2008; 85(6): 938–51.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Lu Y. Rural–urban migration and health: evidence from longitudinal data in Indonesia. Soc Sci Med. 2010; 70(3): 412–9.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    UN-Habitat. The Challenge of Slums: Global Report on Human Settlements 2003. London, UK: Earthscan Publications Ltd; 2003.Google Scholar
  51. 51.
    World Health Organization. Global Health Risks. Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva, Switzerland: World Health Organization; 2009.Google Scholar
  52. 52.
    Etyang A, Harding S, Cruickshank JK. Slum living and hypertension in tropical settings: neglected issue, statistical artifact or surprisingly slight? Insights amidst adversity. J Hypertens. 2013; 31(5): 877–9.CrossRefPubMedGoogle Scholar
  53. 53.
    Riley LW, Ko AI, Unger A, Reis MG. Slum health: diseases of neglected populations. BMC Int Health Hum Rights. 2007; 7: 2.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Daniel OJ, Adejumo OA, Adejumo EN, Owolabi RS, Braimoh RW. Prevalence of hypertension among urban slum dwellers in Lagos, Nigeria. J Urban Health. 2013.Google Scholar
  55. 55.
    Unger A, Felzemburgh RD, Snyder RE, et al. Hypertension in a Brazilian urban slum population. J Urban Health. 2015; 92(3): 446–59.CrossRefPubMedGoogle Scholar
  56. 56.
    Sobngwi E, Mbanya JC, Unwin NC, et al. Exposure over the life course to an urban environment and its relation with obesity, diabetes, and hypertension in rural and urban Cameroon. Int J Epidemiol. 2004; 33(4): 769–76.CrossRefPubMedGoogle Scholar
  57. 57.
    Addo J, Smeeth L, Leon DA. Hypertension in sub-Saharan Africa: a systematic review. Hypertension. 2007; 50(6): 1012–8.CrossRefPubMedGoogle Scholar
  58. 58.
    Rumball-Smith J, Nandi A, Kaufman JS. Working and hypertension: gaps in employment not associated with increased risk in 13 European countries, a retrospective cohort study. BMC Public Health. 2014; 14: 536.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Nygren K, Gong W, Hammarström A. Is hypertension in adult age related to unemployment at a young age? Results from the Northern Swedish Cohort. Scand J Public Health. 2015; 43(1): 52–8.CrossRefPubMedGoogle Scholar
  60. 60.
    Banerjee D, Das PP, Fouzdar A. Urban residential road traffic noise and hypertension: a cross-sectional study of adult population. J Urban Health. 2014; 91(6): 1144–57.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    van Kempen E, Babisch W. The quantitative relationship between road traffic noise and hypertension: a meta-analysis. J Hypertens. 2012; 30(6): 1075–86.CrossRefPubMedGoogle Scholar
  62. 62.
    Ritchie J, Spencer L. Qualitative Research Practice. A Guide for Social Science Students and Researchers. London, UK: SAGE Publications Ltd; 2003.Google Scholar
  63. 63.
    Rubistein A, Alcocer L, Chagas A. High blood pressure in Latin America: a call to action. Ther Adv Cardiovasc Dis. 2009; 3: 259–85.CrossRefGoogle Scholar
  64. 64.
    Burroughs Pena MS, Mendes Abdala CV, Silva LC, Ordunez P. Usefulness for surveillance of hypertension prevalence studies in Latin America and the Caribbean: the past 10 years. Rev Panam Salud Publica. 2012; 32(1): 15–21.CrossRefPubMedGoogle Scholar
  65. 65.
    Pramparo P. The epidemiology of hypertension in South America. J Hum Hypertens. 2002; 16(Suppl 1): S3–6.CrossRefPubMedGoogle Scholar
  66. 66.
    Davidson R, Mitchell R, Hunt K. Location, location, location: the role of experience of disadvantage in lay perceptions of area inequalities in health. Health Place. 2008; 14(2): 167–81.CrossRefPubMedGoogle Scholar
  67. 67.
    Draus PJ. Substance abuse and slow-motion disasters: the case of Detroit. Sociol Q. 2009; 50(2): 360–82.CrossRefGoogle Scholar

Copyright information

© The New York Academy of Medicine 2016

Authors and Affiliations

  • Diego I. Lucumi
    • 1
    Email author
  • Amy J. Schulz
    • 2
  • Barbara A. Israel
    • 2
  1. 1.School of MedicineUniversidad El BosqueBogotáColombia
  2. 2.Department of Health Behavior and Health EducationUniversity of Michigan, School of Public HealthAnn ArborUSA

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