Pandemic Exacerbates Health Inequities for Individuals with High Blood Pressure

Steps to minimize the spread of COVID-19 have had unintended consequences for the millions of individuals managing chronic conditions, such as high blood pressure (HBP), according to new data published in the Journal of the American Heart Association.

HBP is a leading cause of health disparities and heart disease in the United States, according to the authors of the paper.

Hypertension and other chronic conditions disproportionately affect people from ethnic and racial minorities, who are often live in under-resourced communities and face historic or systemic disadvantages. Considering these inequities is essential both for COVID-19 responses and for long-term management approaches to chronic conditions.

“Media coverage has examined how and why COVID-19 is disproportionately impacting communities of color to some degree,” lead author Adam Bress, PharmD, MS, an associate professor of population health science in the division of health system innovation and research at the University of Utah School of Medicine in Salt Lake Sity, said in a statement. “However, it is critical that we continue to examine and explain the degree to which the pandemic has widened the divide among race [or] ethnic and class groups in the US and exposed the systemic and institutional cracks in our health care system in terms of health care equity for people who are under-represented and populations that face disadvantages.”

A panel of clinicians, investigators, and leaders from diverse backgrounds recently convened to discuss how the COVID-19 pandemic widened inequities in hypertension control and to examine environmental and socioeconomic factors that contribute to disparities within the health care system. They also aimed to develop strategies to help close the gap moving forward.

One large nationwide study of more than 50,000 adults found that the number of individuals maintaining healthy blood pressure (BP) levels had been declining even before the pandemic, and a lack of access to health care and health insurance were major contributing factors. HBP in this study was defined as greater than 140/90 mm Hg, though the American Heart Association guidelines define HBP as greater than 130/80 mm Hg.

This study found that between 2017 and 2018, just 22% of uninsured individuals in the study had healthy BP levels compared with 40% to 46% of those who had some form of health insurance. Furthermore, just 8% of individuals who had not seen a health care professional in the previous year had their BP under control compared with 47% of those who reported seeing a health care professional. The results also suggest that Black adults were 12% less likely to have healthy BP levels than White adults.

The COVID-19 pandemic caused a major shift in health care, with the switch from in-person to virtual medical visits. Although virtual visits can be convenient for many patients, this also presents a challenge, because many individuals do not have access to validated home BP monitors. This lack of access to devices, as well as a lack of internet access or inadequate digital literacy to participate in virtual appointments, posed significant barriers.

Additional obstacles to achieving controlled BP are a lack of adherence to lifestyle changes and medications. Limited trips to grocery stores or physicians’ offices also resulted in limited access to counseling and healthy food, which can have a negative effect on hypertension.

The panel also noted that distrust of the health care system is a major obstacle to BP control. This distrust is fueled by decades of institutional racism and historical atrocities in medical research, such as the Tuskegee study of syphilis in Black men. To address this distrust, the panel noted that community-based interventions can help foster trust and improve health care access.

One trial illustrating the importance of community interventions was the BARBER trial, in which barbershops in primarily Black neighborhoods in Los Angeles were used to encourage people to meet with pharmacists, who were embedded in the barbershops regularly. The barbershops also promoted healthy lifestyle choices with routine care by physicians.

At 6 months, individuals who participated in the intervention achieved a 21.6 mm Hg greater reduction in systolic BP and had a 51.9% greater increase in BP control than those who did not receive any intervention. These results were sustained at 12 months.

Finally, the panel noted a lack of diversity among investigators, medical school students, and research participants. The results of 1 analysis found that among all hypertension trials registered in the United States, just 5.4% enrolled exclusively Black adults, suggesting that there are few approaches and interventions being specifically studied for this population.

“Too often, individuals are blamed for their health care conditions, without considering the multiple levels of social factors and context that contribute to persistent and pervasive health inequities,” Bress said.

“Health inequities are a social justice issue,” she said. “We need to be more direct and honest about the reasons for health disparities today and commit to structural solutions to begin to address them.”

REFERENCE

COVID-19 pandemic magnified health inequities for people with high blood pressure. News release. American Heart Association. May 19, 2021. Accessed May 21, 2021. https://newsroom.heart.org/news/covid-19-pandemic-magnified-health-inequities-for-people-with-high-blood-pressure?preview=1605