Moving Beyond the Individual: Multilevel Solutions for Equitable Hypertension Control

Approximately 122 million adults in the United States aged 20 years have hypertension, but less than half have controlled blood pressure. 1Control is even lower in non-Hispanic Black and low-income adults compared with their non-Hispanic White and higher-income counterparts.Although the cardiovascular risks of uncontrolled blood pressure are wellestablished, achieving optimal blood pressure control can be challenging and include a variety of individual-, health system-, and structural-level factors.First, awareness that blood pressure is elevated requires access to routine primary care.Yet, fewer than 64% of all Americans in their 30s had primary care in 2015 according to a study by the Medical Expenditure Panel Survey. 2 Second, healthy lifestyle behaviors targeting diet and physical activity are an integral part of hypertension treatment and prevention but significant barriers, such as income, time to prepare healthy meals or exercise, and geographic access to healthy foods and safe spaces to exercise may make adherence challenging.Third, optimizing blood pressure control often requires multiple follow-up visits with a primary care clinician.A recent study in a safety-net county-based health system found that missed visits and treatment intensification accounted for 14% and 21% of the higher probability of uncontrolled hypertension seen in Black patients compared with other race and ethnic groups. 3Thus, barriers to accessing regular care may uniquely contribute to the racial and socioeconomic inequities seen in blood pressure control.