Achieving Health Equity in Hypertension Management Through Addressing the Social Determinants of Health

  • Shannon K. Doyle
  • Anna Marie Chang
  • Phillip Levy
  • Kristin L. RisingEmail author
Hypertension and Emergency Medicine (T Rainer and P Levy, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Hypertension and Emergency Medicine


Purpose of Review

The goals of this paper were to examine recent literature on the social determinants of health as they relate to hypertension and cardiovascular disease, and discuss relevance to the practice of emergency medicine.

Recent Findings

Social determinants of health, defined by the World Health Organization as “the conditions in which people are born, grow, live, work, and age” ( play a complex role in the development of hypertension and cardiovascular disease and the persistence of racial disparities in related health outcomes. Deciphering the independent association between minority status and social determinants in the United States is challenging. As a result, much of the recent interventional work has targeted populations by race or ethnicity in order to address these disparities.


There is opportunity to expand the work on social determinants of health and hypertension. This includes exploring innovative approaches to identifying at-need individuals and breaking down traditional siloes to develop multidimensional interventions. New funding and payment mechanisms will allow for providers and health systems to identify and target modifiable social determinants of health at the level of the individual patient to improve outcomes.


Disparities Social determinants of health Race Ethnicity Population health Innovative care models 


Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. J Am Coll Cardiol. 2018;71(19):e127 LP–e248 Available from: Scholar
  2. 2.
    National Center for Health Statistics FastStats: hypertension [Internet]. 2015 [cited 2019 Apr 10]. Available from:
  3. 3.
    Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. AHA statistical update heart disease and stroke statistics — 2016 update: a report from the American Heart Association. 2016.Google Scholar
  4. 4.
    Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation. 2013;127(1):e6–245 Available from: Scholar
  5. 5.
  6. 6.
    OECD. Life expectancy at birth (indicator). 2019.Google Scholar
  7. 7.
    Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129(Suppl 2(Suppl 2)):19–31 Available from: Scholar
  8. 8.
    Rosen G. A history of public health. Expanded e. Baltimore: Johns Hopkins University Press; 1993.Google Scholar
  9. 9.
    University of Wisconsin Population Health Institute. County Health Rankings and Roadmaps [Internet]. 2019 [cited 2019 Feb 4]. Available from:
  10. 10.
    Closing the gap in a generation: health equity through action on the social determinants of health: Commission on Social Determinants of Health final report [Internet]. Geneva; 2008. Available from:
  11. 11.
    •• Schultz WM, Kelli HM, Lisko JC, Varghese T, Shen J, Sandesara P, et al. Socioeconomic status and cardiovascular outcomes: challenges and interventions. Circulation. 2018;137(20):2166–78 Available from: This is a comprehensive review of the associations between socioeconomic status and cardiovascular outcomes. CrossRefGoogle Scholar
  12. 12.
    Kucharska-Newton AM, Harald K, Rosamond WD, Rose KM, Rea TD, Salomaa V. Socioeconomic indicators and the risk of acute coronary heart disease events: comparison of population-based data from the United States and Finland. Ann Epidemiol. 2011;21(8):572–9 Available from: Scholar
  13. 13.
    Gerber Y, Diab DL, Yerian L, Schauer P, Kashyap SR, Lopez R, et al. Neighborhood income and individual education: Effect on survival after myocardial infarction 2008;6(11):1249–54.Google Scholar
  14. 14.
    Elfassy T, Swift SL, Gymour MM, Calonica S, Jacobs DR Jr, Mayeda ER, et al. Associations of income volatility with incident cardiovascular disease and all-cause mortality in a US cohort. Circulation. 2019;139(7):850–9.CrossRefGoogle Scholar
  15. 15.
    • Kershaw KN, Droomers M, Robinson WR, Carnethon MR, Daviglus ML, Monique Verschuren WM. Quantifying the contributions of behavioral and biological risk factors to socioeconomic disparities in coronary heart disease incidence: the MORGEN study. Eur J Epidemiol. 2013;28(10):807–14 Available from: This analysis demonstrates the complexity of the relationship between behavioral risk factors and hypertension along the causal pathway of coronary heart disease, suggesting that hypertension should not be treated in isolation from these other factors. CrossRefGoogle Scholar
  16. 16.
    Dupre ME, George LK, Liu G, Peterson ED. The cumulative effect of unemployment on risks for acute myocardial infarction unemployment and risks for acute MI. Arch Intern Med. 2012;172(22):1731–7. Available from. Scholar
  17. 17.
    Roux AVD, Merkin SS, Arnett D, Chambless L, Massing M, Nieto FJ, et al. Neighborhood of residence and incidence of coronary heart disease. N Engl J Med. 2001;345(2):99–106. Available from. Scholar
  18. 18.
    Kaiser P, Diez Roux AV, Mujahid M, Carnethon M, Bertoni A, Adar SD, et al. Neighborhood environments and incident hypertension in the multi-ethnic study of atherosclerosis. Am J Epidemiol. 2016;183(11):988–97.CrossRefGoogle Scholar
  19. 19.
    Gebreab SY, Davis SK, Symanzik J, Mensah GA, Gibbons GH, Diez-Roux AV. Geographic variations in cardiovascular health in the United States: contributions of state- and individual-level factors. J Am Heart Assoc. 2015;4(6):e001673.PubMedPubMedCentralGoogle Scholar
  20. 20.
    • Brewer L, Carson KA, Williams DR, Allen A, Jones CP, Cooper LA. Association of race consciousness with the patient-physician relationship, medication adherence, and blood pressure in urban primary care patients. Am J Hypertens. 2013;26(11):1346–52 The authors of this paper found that greater race-consciousness among blacks was associated with significantly elevated diastolic blood pressure, suggesting the role of race itself as a social determinant of health outcomes. CrossRefGoogle Scholar
  21. 21.
    Cummings DM, Wu JR, Cene C, Halladay J, Donahue KE, Hinderliter A, et al. Perceived social standing, medication nonadherence, and systolic blood pressure in the rural south. J Rural Health. 2016;32(2):156–63.CrossRefGoogle Scholar
  22. 22.
    Bell CN, Thorpe RJ, LaVeist TA. The role of social context in racial disparities in self-rated health. J Urban Health. 2018;95(1):13–20.CrossRefGoogle Scholar
  23. 23.
    LaVeist T, Pollack K, Thorpe R, Fesahazion R, Gaskin D. Place, not race: disparities dissipate in Southwest Baltimore when blacks and whites live under similar conditions. Health Aff. 2011;30(10):1880–7.CrossRefGoogle Scholar
  24. 24.
    Secretary’s Advisory Committe on Health Promotion and Disease Prevention Objectives for 2020: An opportunity to address the societal determinants of health in the United States. 2010.Google Scholar
  25. 25.
    • Allen JK, Dennison Himmelfarb CR, Szanton SL, Bone L, Hill MN, Levine DM, et al. Community Outreach and Cardiovascular Health (COACH) Trial: a randomized, controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers. 2011;4(6) Available from: This trial highlights the utility of community health workers in addressing socioeconomic barriers to blood pressure control through solutions tailored to individual patients and their environment.
  26. 26.
    Miller ER, Cooper LA, Carson KA, Wang NY, Appel LJ, Gayles D, et al. A dietary intervention in urban African Americans: results of the “five plus nuts and beans” randomized trial. Am J Prev Med. 2016;50(1):87–95.CrossRefGoogle Scholar
  27. 27.
    Ephraim PL, Hill-Briggs F, Roter DL, Bone LR, Wolff JL, Lewis-Boyer LP, et al. Improving urban African Americans’ blood pressure control through multi-level interventions in the Achieving Blood Pressure Control Together (ACT) study: a randomized clinical trial. Contemp Clin Trials. 2014;38(2):370–82.CrossRefGoogle Scholar
  28. 28.
    Buis L, Dawood K, Kadri R, Dawood R, Richardson C, Djuric Z, et al. Improving blood pressure among African Americans with hypertension using a mobile health approach (the MI-BP App): protocol for a randomized control trial. JMIR Res Protoc. 2019;8(1):e12601.CrossRefGoogle Scholar
  29. 29.
    •• Cooper LA, Purnell TS, Ibe CA, Halbert JP, Bone LR, Carson KA, et al. Reaching for health equity and social justice in Baltimore: the evolution of an academic-community partnership and conceptual framework to address hypertension disparities. Ethn Dis. 2016;26(3):369. This description of an academic-community partnership in an urban environment models a new way to address racial disparities by engaging community members in research design and sharing results.–78.CrossRefGoogle Scholar
  30. 30.
    Patient protection and affordable care act. United States of America; 2010.Google Scholar
  31. 31.
    Bipartisan Budget Act of 2018. 2018.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Shannon K. Doyle
    • 1
  • Anna Marie Chang
    • 2
  • Phillip Levy
    • 3
  • Kristin L. Rising
    • 2
    Email author
  1. 1.Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaUSA
  2. 2.Department of Emergency MedicineThomas Jefferson UniversityPhiladelphiaUSA
  3. 3.Department of Emergency Medicine and Integrative Biosciences CenterWayne State UniversityDetroitUSA

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