Marginalized groups have less well controlled blood pressure – but why?

Kendra Sims, PhDEpidemiological research reveals that, for almost every disease, marginalized people have worse outcomes. As research has increasingly tried to untangle various factors potentially at play – cultural behaviors, environmental and medical racism, expanded medical options for the affluent – it seems increasingly clear that the experience of discrimination plays a significant role.

Kendra Sims, PhD, a postdoctoral fellow working with Kirsten Bibbins-Domingo, MD, PhD, and Maria Glymour, ScD, studies blood pressure, where the health stakes are high and disparities are pronounced – whether by race or ethnicity, gender, socioeconomic class or urban or rural setting.

As Sims sees it, if one can identify how social inequality causes higher blood pressure, one may be able to reduce heart disease without first having to solve all of society’s ills. One of Sims’s specific research questions involves how the social environment may interfere with marginalized patients’ ability to adhere to blood pressure medication regimes.

In a paper recently published in the American Journal of Epidemiology, Sims addressed this question using a large cohort of research participants over age 51 who reported being prescribed medication for high blood pressure. Participants were asked four years later if they were taking their blood pressure medications.

The participants also completed a battery of surveys on everyday experiences of discrimination, and economic events that play important roles in shaping opportunity, such as educational attainment, hiring and promotion, healthcare access and housing. The participants were asked how often they were treated with fear, harassment and disrespect, and how often they experienced poorer treatment in healthcare situations. They also completed to mental health surveys.

The participants were male retirees: 73% were white, 17% were non-Hispanic Black and 10% were Hispanic/Latino. The irony of analyzing the effects of discrimination on mostly white men is not lost on Sims. But if the experience of marginalization contributes to medical noncompliance, that should be as true in aging men regardless of their racial and ethnic designation.

“Our society prioritizes the young and able-bodied,” Sims said. “As people get older and accumulate age-related disabilities, they can lose some of those privileges.”

Sims and her colleagues specifically looked for mediating factors that would connect participants’ reported experiences of discrimination with nonadherence to blood pressure medication. How might experiences of unfair treatment cause some patients not to take medication reliably for this leading cause of cardiovascular disease?

“These stark health disparities should be reframed around modifiable factors to inform targets for intervention,” Sims said.

The researchers found that discrimination in day-to-day life as well as in key life events are related to reduced antihypertensive medication adherence. Lifetime discrimination appeared to lead to depressive symptoms, which contributed to reduced adherence. That means that treating depressive symptoms in older people could also improve their blood pressure management. Because hypertension is a major risk factor for heart attack and stroke, that could mean longer productive lives.

The study found that neither perceived position in society nor relatively less wealth was associated with reduced medication adherence. Because the cohort was predominantly white and fairly affluent, the impact of a complex risk factor like discrimination is likely even greater.

But Sims says the question demands further exploration among more marginalized groups.