Johns Hopkins University School of Nursing, Baltimore, MD.
Johns Hopkins Center for Health Equity, Baltimore, MD.
Ethn Dis. 2021 Jan 21;31(1):97-108. doi: 10.18865/ed.31.1.97. eCollection 2021 Winter.
Uncontrolled hypertension is a significant risk factor for cardiovascular morbidity and mortality. In the United States, many patients remain uncontrolled, in part, due to poor medication adherence. Efforts to improve hypertension control include not only attending to medical management of the disease but also the social determinants of health, which impact medication adherence, and ultimately blood pressure control.
To determine which social determinants - health care access or community and social stressors - explain medication adherence.
In this cross-sectional analysis, we used baseline data (N=1820, collected August 2017 to October 2019) from a pragmatic trial, which compares the effectiveness of a multi-level intervention including collaborative care and a stepped approach with enhanced standard of care for improving blood pressure. We used logistic regression analyses to examine the association between patient experiences of care and community and social stressors with medication adherence.
The participants represented a diverse sample: mean age of 60 years; 59% female; 57.3% Black, 9.6% Hispanic, and 33.2% White. All participants had a blood pressure reading ≥140/90 mm Hg (mean blood pressure - 152/85 mm Hg). Half of the participants reported some level of non-adherence to medication. Regression analysis showed that, compared with Whites, Blacks (AOR .47; 95% CIs: .37-.60, P<.001) and Hispanics (AOR .48; 95% CIs: .32- .73, P<.001) were less likely to report medication adherence. Also part-time workers (AOR .57; 95% CIs: .38-.86, P<.05), and those who reported greater perceived stress (AOR .94; 95% CIs: .91 - .98, P<.001) and everyday discrimination (AOR .73; 95% CIs: .59 - .89; P<.001) had lower odds of medication adherence. Among Blacks, greater perceived stress (AOR .93; 95% CIs: .88-.98, P<.001) and everyday discrimination (AOR .63; 95% CIs: .49 - .82, P<.005) were negatively associated with medication adherence. Among Hispanics, greater report of everyday discrimination (AOR .36; 95% CIs: .14 - .89, P<.005) was associated with lower odds of medication adherence. Among Whites, the negative effect of perceived stress on medication adherence was attenuated by emotional support.
Using the social determinants of health framework, we identified associations between stress, everyday discrimination and medication adherence among non-Hispanic Blacks and Hispanics that were independent of health status and other social determinants. Programs to enhance self-management for African American and Hispanic patients with uncontrolled blood pressure should include a specific focus on addressing social stressors.
未得到控制的高血压是心血管发病率和死亡率的一个重要危险因素。在美国，许多患者的血压仍然得不到控制，部分原因是药物治疗的依从性较差。为了改善高血压的控制，除了关注疾病的医疗管理外，还需要关注影响药物治疗依从性进而影响血压控制的健康社会决定因素。
确定健康保健可及性或社区和社会压力源是哪些社会决定因素解释了药物治疗的依从性。
在这项横断面分析中，我们使用了一项实用试验的基线数据（N=1820，收集于 2017 年 8 月至 2019 年 10 月），该试验比较了包括协作护理和强化标准护理在内的多层次干预措施与增强标准护理相比，对改善血压的有效性。我们使用逻辑回归分析来检查患者对护理的体验以及社区和社会压力源与药物治疗依从性之间的关联。
参与者代表了一个多样化的样本：平均年龄 60 岁；59%为女性；57.3%为黑人，9.6%为西班牙裔，33.2%为白人。所有参与者的血压读数≥140/90mmHg（平均血压为 152/85mmHg）。一半的参与者报告了某种程度的药物治疗不依从。回归分析显示，与白人相比，黑人（OR.47；95%置信区间：.37-.60，P<.001）和西班牙裔（OR.48；95%置信区间：.32-.73，P<.001）更不可能报告药物治疗依从性。此外，兼职工作者（OR.57；95%置信区间：.38-.86，P<.05），以及报告压力较大（OR.94；95%置信区间：.91 -.98，P<.001）和日常歧视（OR.73；95%置信区间：.59 -.89；P<.001）的患者，药物治疗依从性较低。在黑人中，更大的压力感知（OR.93；95%置信区间：.88-.98，P<.001）和日常歧视（OR.63；95%置信区间：.49 -.82，P<.005）与药物治疗不依从性呈负相关。在西班牙裔中，更大的日常歧视报告（OR.36；95%置信区间：.14 -.89，P<.005）与药物治疗依从性较低有关。在白人中，压力对药物治疗依从性的负面影响通过情感支持而减弱。
使用健康社会决定因素框架，我们确定了非西班牙裔黑人和西班牙裔人群中压力、日常歧视与药物治疗依从性之间的关联，这些关联独立于健康状况和其他社会决定因素。为控制血压的非西班牙裔黑人和西班牙裔患者增强自我管理的计划应特别注重解决社会压力源。
