Chronic Illness: Addressing Hypertension and Health Disparities in Communities
Yvonne Commodore-Mensah, Martha Hill, and Cheryl Dennison Himmelfarb
Chronic illnesses, including hypertension (HTN), represent a major global public health challenge, in part because of compelling ethnic and racial disparities in the quality and outcomes of care. Nurse scientists have conducted trials demonstrating the effectiveness of community-based interventions to improve HTN care and control. These trials have generated evidence that has shaped policy and practice to improve HTN care and reduce HTN disparities in communities.
Chronic Illnesses: A Global Context
Chronic illnesses, also known as noncommunicable diseases (NCDs), are one of the major public health challenges of the 21st century; they include cardiovascular diseases (CVDs), cancer, chronic respiratory diseases, and diabetes (World Health Organization, 2015). Of the 38 million deaths globally due to NCDs in 2012, more than 40% were premature and preventable (WHO, 2014). NCDs impose a substantial economic burden. They are projected to cost more than $30 trillion and will impoverish millions of people globally over the next 20 years (Bloom et al., 2011). Death from CVD, a major NCD, has been reduced dramatically in high-income countries due to medical advances in the management of CVD and related risk factors, including HTN and smoking. However, in low- and middle-income countries, this favorable shift has not been observed, and a concomitant epidemic of communicable and NCDs is under way (WHO, 2014). Globalization, rapid urbanization, aging of the population, and changes in individual lifestyle behaviors have contributed to the increased prevalence of NCDs. Although addressing medical management through evidence-based strategies is critical, combating the rising trend in NCDs also requires health policies that address social, economic, and behavioral contributors to this phenomenon.
The Global NCD Action Plan was instituted in 2013 by WHO to address the devastating socioeconomic and public health impact of NCDs. Targets include reducing harmful use of alcohol by at least 10%, insufficient physical activity by 10%, sodium intake by 30%, tobacco use by 30%, HTN by 25%; halting the rise of obesity and diabetes; improving coverage of treatment for prevention of heart attacks and strokes by at least 50% and providing 80% access to basic technologies and essential medicines (WHO, 2014). Notably, all nine targets are inextricably linked to HTN outcomes. The action plan also calls for all countries to set national NCD targets and be accountable for attaining them.
In the United States, NCDs, including CVDs, stroke, cancer, type 2 diabetes, and obesity, are the most common and preventable health conditions. Seven of the top 10 causes of death in 2010 were NCDs and together, CVDs and cancer account for nearly half of all deaths. About half of U.S. adults have at least one major CVD risk factor (Fryar, Chen, & Li, 2012), including excessive sodium intake (Cogswell et al., 2012) and physical inactivity (Centers for Disease Control and Prevention, 2014). These modifiable behaviors not only contribute to illness, suffering, and death related to NCDs, but also lead to costly treatment and poor outcomes. It is estimated that 68% of health care spending in the United States in 2010 was for NCDs (Gerteis et al., 2014). Effective interventions and policies to reduce the prevalence and improve management of NCDs are needed.
The positive direct association between HTN and CVD risk is strong, continuous, graded, independent, and predictive. This association has been established across sexes, age groups, racial/ethnic groups, and geographical boundaries (Whelton et al., 2002). Despite decades of progress in detection, treatment, and control of HTN in the United States, it remains a burdensome public health problem. The prevalence of HTN is 33% (Mozaffarian et al., 2016), and it is projected that by 2030, approximately 41% of U.S. adults will have HTN, which reflects an 8.4% increase from 2012 (Mozaffarian et al., 2016). The HTN awareness, treatment, and control rates from the 2009 to 2012 National Health and Nutrition Examination Survey (NHANES) are estimated as 83%, 77%, and 54% respectively (Mozaffarian et al., 2016). According to NHANES data from 2003 to 2004 through 2011 to 2012, awareness increased from 75.2% to 82.1%, treatment improved from 65.0% to 74.5%, and control improved from 39.4% to 51.8% (Mozaffarian et al., 2016). It is of great concern that between 2003 and 2013, the national mortality rate attributable to HTN increased by 8.2% and the number of deaths rose by 35% (Mozaffarian et al., 2016). Of note, awareness, treatment, and control of HTN vary across the country and the highest burden is in the southern United States (Olives, Myerson, Mokdad, Murray, & Lim, 2013).
A tripling of real (2008 dollars) total direct medical costs of CVD has been projected to occur between 2010 and 2030, raising costs from $272.5 billion to $818.1 billion (Heidenreich et al., 2011). HTN is the most expensive component contributing to this economic burden, with annual costs projected to increase by $130.4 billion from 2010 to 2030 (Heidenreich et al., 2011). The mean expenditure per person for HTN treatment was higher for non-Hispanic Blacks ($887) and Hispanics ($981) than for non-Hispanic Whites ($679) in 2010 (Davis, 2013). Effective prevention strategies are needed to limit the growing disease and economic burden related to HTN, particularly where racial and ethnic disparities exist.
In order to reach the WHO target of 25% relative reduction and contain the prevalence of HTN and reduce the associated economic burden, community- and population-based strategies are required to address modifiable risk factors for HTN. HTN can be prevented and managed with complementary primordial, primary, and secondary prevention strategies that target the populace as well as individuals at higher risk. Additionally, current evidence suggests that the most effective strategies to improve cardiovascular health include (a) individually focused approaches that target individual behavior change; (b) health care system approaches that encourage and reward efforts by providers and patients; and (c) population-based approaches that target broader populations (Mozaffarian et al., 2016).
Population-based and clinical studies have highlighted the importance of primordial and primary secondary prevention of HTN. Primordial prevention is defined as the prevention of the development of risk factors in the first place, whereas primary prevention is defined as interventions to modify adverse levels of risk factors once present to prevent the occurrence of HTN (Kavey et al., 2003; Lenfant, 1996). Primordial and primary preventions of HTN provide a unique opportunity to interrupt the continuous costly cycle of HTN management and associated complications. Healthy lifestyle interventions that are applied earlier in life provide the biggest long-term potential for avoiding the precursors that lead to HTN and ultimately reducing the burden on communities (Whelton et al., 2002). Intensive targeted strategies must be utilized in high-risk groups such as those with social and environmental risks, family history of HTN, African American ancestry, and sedentary lifestyles. Further, these strategies must be culturally acceptable, affordable, and sustainable.
HTN rarely occurs in isolation. Instead, it often occurs with other comorbidities such as diabetes and obesity. Approximately 50% of patients with diabetes have HTN (Barnett, 1994), and approximately 75% of the incidence of HTN is directly related to overweight and obesity (Mozaffarian et al., 2016). The associations between and among HTN, obesity, and diabetes are multifactorial with complex hemodynamic, metabolic, and endocrine pathways involved (Barnett, 1994; Mozaffarian et al., 2016). Numerous clinical trials have shown that HTN treatment and control markedly reduce incident stroke (by 35%–40%), myocardial infarction (by 15%–25%), and heart failure (by up to 64%; Chobanian et al., 2003; Psaty et al., 1997; SPRINT Research Group et al., 2015). In addition to management with antihypertensive medication, intensive lifestyle modification alone or in combination with medication are effective strategies to treat and control HTN and related comorbidities (Ornish et al., 1998; Ratner et al., 2005). Patients must be counseled on the importance of smoking cessation, dietary modification, regular physical activity, and stress management using effective strategies (Artinian et al., 2010; Commodore-Mensah & Himmelfarb, 2012).
In the landmark report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine outlined disparities in health outcomes and quality of care experienced by racial/ethnic minorities (Institute of Medicine [U.S.] Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2003). The report defined disparities in health care as racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.
Despite advances in health care in the United States and reduction in CVD mortality since the 1970s, a large body of published research suggests that racial and ethnic minorities experience a lower quality of health services, and are less likely to receive even routine medical procedures than Whites (Agency for Healthcare Research and Quality, 2014; Institute of Medicine (U.S.) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2003). For instance, African Americans are less likely to receive appropriate cardiac medication (Herholz et al., 1996) even when confounders are controlled for.
Studies of racial/ethnic differences in CVDs provide compelling evidence of health disparities. For instance, African American adults have among the highest prevalence of HTN in the world (Mozaffarian et al., 2016). The age-adjusted prevalence of HTN is 44.9% and 46.1% among African American men and women, respectively (Mozaffarian et al., 2016). African Americans are more likely to develop HTN at a younger age, develop CVD and end-stage renal disease, and die from CVD than other racial/ethnic groups. HTN awareness, treatment, and control rates are lowest among Mexican Americans compared with Whites and Blacks (Centers for Disease Control and Prevention, 2012). In addition to socioeconomic, genetic, and behavioral factors that drive these disparities, differences in health care quality are important contributors. African Americans receive worse care than Whites for about 40% of quality measures, including HTN, and worse access to care for 33% of measures, such as insurance coverage and wait times (Agency for Healthcare Research and Quality, 2014).
The sources of HTN and health disparities in communities are complex. They are rooted in historic inequities in the United States and involve health systems, health care professionals, utilization managers, and patients. Racial and ethnic minorities experience a range of barriers to accessing adequate care, even when insured at the same level as Whites, including barriers of language, geography, and cultural familiarity (Institute of Medicine [U.S.] Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2003). The sources of HTN and health disparities may be grouped under patient-level, provider-level, and system-level factors.
At the patient level, racial and ethnic minorities are more likely to refuse provider-recommended services (Sedlis et al., 1997), adhere poorly to treatment regimens, and delay seeking appropriate care (Mitchell & McCormack, 1997). However, differences in refusal rates are small and do not fully account for racial and ethnic disparities in receipt of treatments (Institute of Medicine [U.S.] Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2003). These behaviors may be attributed to a cultural mismatch between the patient and provider, mistrust, misunderstanding of provider recommendations, and/or lack of knowledge on how to effectively utilize health services. Although it has been postulated that biological-based racial differences in response to treatment (for instance, enalapril, an antihypertensive used to reduce the risk of heart failure; Exner, Dries, Domanski, & Cohn, 2001) may account for the racial differences in the type and intensity of care provided, these differences are not due to “race” but are attributable to differences in the distribution of polymorphic traits between populations (Wood, 2001).
At the provider level, bias toward racial/ethnic minorities, clinical uncertainty when interacting with minority patients, and beliefs and stereotypes held by the provider about the behavior or health of minorities may contribute to HTN disparities. However, research on how patient race/ethnicity influences provider decision making is limited. In addition, health care providers whether or not racial/ethnic minorities may not recognize expressions of prejudice in their own behavior.
Health care providers’ diagnostic and treatment decisions may be influenced by their patient’s race/ethnicity. For instance, Schulman et al. (1999) found that physicians referred White male, Black male, and White female hypothetical “patients” for cardiac catheterization at the same rates (approximately 90% for each group), but were significantly less likely to recommend catheterization procedures for Black female patients exhibiting the same symptoms. Minority patients also report a higher perception of racial discrimination in health care than nonminorities (LaVeist, Nickerson, & Bowie, 2000). Although providers may not deliberately provide inequitable care to minorities, several characteristics of the clinical encounter may contribute to these inequities. Providers may make medical decisions under time and resource constraints and with limited information. Time constraints may hamper a provider’s ability to accurately assess symptoms of patients when cultural or linguistic barriers exist.
The fragmented nature of the health care system and deficiencies in the availability of culturally appropriate services inevitably contribute to and exacerbate health disparities in minorities. Language barriers pose a problem for the foreign-born in health care systems that lack resources, knowledge, and institutional priority to provide adequate translation services. This is particularly relevant as 41% of Americans have limited English proficiency and 20% of Spanish-speaking Latinos do not seek care due to language barriers (Zong & Batalova, 2015). The lack of or limited navigation services for underserved communities may have a differential impact on racial and ethnic minorities. Moreover, the geographic distribution and access to convenient community-based centers may influence the quality of care ethnic minorities receive, regardless of insurance status.
SUCCESSFUL STRATEGIES TO REDUCE HYPERTENSION AND HEALTH DISPARITIES IN COMMUNITIES