Hypertension Management to Reduce Racial/Ethnic Disparities: Clinical and Community-Based Interventions

Abstract

Purpose of the Review

Hypertension remains a major public health concern globally and in the United States with significant racial/ethnic disparities in prevalence, treatment, and control. Despite effective treatments, undiagnosed or uncontrolled hypertension persists, leading to an increased risk of cardiovascular disease and substantial healthcare costs. Addressing hypertension disparities requires a comprehensive approach, integrating clinical interventions with community-based strategies. This review examines the current landscape of clinic-and community-based interventions designed to improve hypertension management and reduce disparities.

Recent Findings

Clinic-based approaches highlighted include implementing evidence-based guidelines, using treatment algorithms, promoting self-management, integrating digital health technologies, and incorporating team-based care approaches. Community interventions discussed involve lifestyle modification programs, faith-based initiatives, trusted community spaces, culturally-tailored health education, engaging community health workers, and collaborative care models linking clinics and communities. This review stresses the importance of addressing SDoH, fostering community engagement, and delivering culturally competent care. Strengthening clinic-community linkages, evaluating long-term effectiveness and cost-effectiveness, leveraging technology and innovation, and addressing gaps in research for underrepresented groups are key priorities for advancing health equity in hypertension management.

Summary

To effectively close the widening gap in hypertension disparities, collaborative multi-level efforts integrating clinical excellence and community empowerment are essential to mitigate the disproportionate burden of hypertension among racial/ethnic minority populations.

Introduction

Hypertension, defined as a blood pressure (BP) reading of ≥130/80 mm Hg, is a major risk factor for cardiovascular disease (CVD).[1] In the US, approximately 122 million people have diagnosed hypertension,[1] and over 124,508 deaths were attributed to hypertension in 2021. Despite continued efforts to increase awareness and availability, over 14 million US adults remain undiagnosed. In comparison, about 92 million (75%) adults with hypertension have uncontrolled BP (≥130/80 mm Hg).[2] Of these, 34.1 million are untreated due to uninitiated prescriptions or non-adherence, while among those treated, many remain uncontrolled due to undertreatment (33.6 million) or suboptimal management (24.3 million).[2] The financial burden of hypertension in the US is substantial, with an annual average healthcare expenditure of $52.4 billion on direct and indirect costs between 2019 and 2020, including costs related to healthcare services, medications, and productivity losses due to premature mortality.[1]

Hypertension Disparities in the US

Racial and ethnic minoritized persons worldwide and in the US are disproportionately impacted by hypertension and its sequelae, and subsequently have poor cardiovascular health outcomes.[1, 3–5] Black adults (59%) have the highest hypertension prevalence followed by White (47%), Asian (45%), and Hispanic (44%) adults.[1, 4, 5] Compared to other groups, Black adults develop hypertension-related complications at earlier ages.[6] Even when diagnosed and treated, minoritized persons, especially Black and Hispanic adults, have lower BP control rates.[7–9] Consequently, Black and Hispanic adults face a higher risk of developing life-threatening hypertension-related complications. Black adults have a 30% higher risk of fatal stroke, 50% higher risk of CVD mortality, and more than fourfold higher risk of end-stage renal disease.[6] Adverse social determinants of health (SDoH) including limited access to healthcare services, lack of health insurance, limited access to healthy food options or safe spaces for physical activity, and geographical disparities in healthcare infrastructure[9] contribute to these disparities in hypertension control.[5]

SDoH include a complex interplay of individual, clinician, healthcare system, community-level, systemic, and structural factors that collectively contribute to health disparities[10, 11] and greatly influence cardiovascular health outcomes.[12, 13] Addressing disparities in hypertension among minoritized populations requires an integrated approach.[14] This approach should focus on interventions that promote health equity, improve access to healthcare, and address contextual SDoH. Furthermore, intersectoral collaboration is key to mitigating the burden of hypertension.[14] Efforts must center individuals while involving clinicians, community members, health system leaders, policymakers, and other key partners.

Considerations for Hypertension Management

Effective hypertension management is crucial for reducing the risk of cardiovascular events and improving overall health outcomes. It requires a collaborative effort to optimize patient outcomes.[15] A comprehensive approach to hypertension management involves a combination of lifestyle modifications and pharmacological interventions tailored to an individual’s needs and risk factors. Lifestyle changes, including the adoption of a healthy dietary pattern (e.g., the Dietary Approaches to Stop Hypertension [DASH]), regular physical activity, weight management, stress reduction, and limitation of alcohol consumption, form the foundation of hypertension management.[16] When lifestyle changes alone are insufficient, pharmacological treatment is initiated, typically with first-line agents such as thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs).[16, 17] The choice of medication depends on factors such as age, regular BP monitoring, and medication adherence. Additionally, treatment plan adjustments are essential to achieve and maintain optimal BP control.[18] Disparities in hypertension management may exist across various aspects of care, including treatment initiation, follow-up, and medication selection.[19, 20]

Clinical and Community-Based Interventions Approaches to Hypertension Management

The integration of clinical and community-based interventions is a crucial strategy for effectively managing hypertension and reducing health disparities. This was highlighted in the Surgeon General’s Call to Action to Control Hypertension.[21] Clinical interventions involving- direct care provided by clinicians are essential for diagnosing hypertension, initiating treatment, and monitoring patient progress. However, these interventions alone may be insufficient[22] to address the complex factors contributing to disparities in hypertension outcomes, particularly among racial and ethnic minoritized groups experiencing social marginalization.[23] Community-based interventions complement clinical care by addressing the SDoH and promoting healthy lifestyles.[22, 24] These interventions are particularly important in reducing disparities, as they can be tailored to specific communities’ unique needs, cultural beliefs, and socioeconomic circumstances.[25]

For example, community-based interventions can improve healthcare access, provide culturally sensitive hypertension management education, and create supportive environments that encourage healthy behaviors.[26, 27] Specifically, community-based interventions for hypertension disparities can partner with trusted organizations, like faith-based institutions and health centers, to deliver culturally sensitive education and support programs.[28] Such interventions may also improve medication adherence, access to healthcare services[29] and advocate for policies that improve access to affordable, healthy food options, and create safe spaces for physical activity in underserved neighborhoods.[30]

Care Coordination Model for Hypertension Management: Integrating Clinic and Community

An interdisciplinary team, utilizing a collaborative approach, is crucial in providing comprehensive, patient-centered hypertension management.[15, 31] The team may include physicians, nurses, pharmacists, dietitians, social workers, psychologists, community health workers, and rehabilitation specialists.[32–34] This approach recognizes the importance of addressing both clinical factors and SDoH to effectively manage hypertension and reduce health disparities.[35]

SDoH and Genetic Considerations in Hypertension Management

Among minoritized populations, prolonged exposure to adverse SDoH can create environments of high chronic stress which can elevate BP, increase the risk of developing hypertension, and contribute to health inequities in hypertension.[36] Adverse SDoH that have been associated with increased BP typically arise from intermediary (e.g., increased experiences of discrimination, implicit bias, stigma, food insecurity) and structural factors, such as, structural racism, economic hardship (poverty, low income, unemployment), limited access to quality education and healthcare, lack of transportation, and unsafe neighborhoods and built environments.[14, 37] Addressing these social determinants contributing to negative health outcomes among minoritized populations is crucial.

Additionally, addressing, hypertension management requires understanding genetic predispositions influencing BP regulation. A family history of hypertension, particularly when presenting before the age of 60, is the strongest known risk factor for elevated BP in offspring.[38, 39] However, this risk is influenced by shared environments and lifestyle habits, such as physical activity levels, dietary sodium intake, and alcohol consumption.[40] Although genetic variants have been implicated in hypertension risk, including those affecting pathways involved in BP regulation (e.g., the renin-angiotensin-aldosterone system, endothelial function, and sodium homeostasis),[41] environmental and lifestyle factors often exacerbate the impact of these genetic factors. Studying the genetic basis of hypertension improves both risk prediction and identifies potential treatment targets. For instance, pharmacogenetic studies have identified genetic variants associated with differential responses to antihypertensive medications, guiding personalized treatment approaches.[42] Understanding genetic predisposition to hypertension aids in tailoring screening, prevention, and treatment strategies. However, it is important to note that while genetic factors play a role, social and environmental factors significantly contribute to disparities in hypertension outcomes, particularly among minoritized populations. Therefore, addressing the SDoH remains imperative in conjunction with genetic considerations.[14]

Integrating genetic testing and counseling into clinical and community settings can empower individuals to make informed lifestyle choices and medication-related decisions aligned with their genetic risk profile. However, this personalized approach should be implemented alongside efforts to address the social and environmental factors that contribute to hypertension disparities.[9]

Rapid Narrative Review of Current Landscape of Clinic-Based and Community-Based Interventions for Hypertension Management

Recognizing the multiple factors contributing to hypertension disparities and opportunities for clinic and community-based approaches to hypertension management, we conducted a rapid review to examine the current landscape of clinic- and community-based interventions both within and outside the United States designed to address hypertension in diverse populations. We explored a range of interventions, including approaches involving mobile Health (mHealth), lifestyle modification, and social support, among others, to identify effective and promising approaches and highlight areas for future research to address the unique needs of communities where the burden of hypertension is greatest.

Methods

Using a narrative review approach,[43] we applied a broad search strategy in PubMed to identify full-text, peer-reviewed randomized controlled trials, and observational studies published in English since 2014 (Supplemental Table 1). The search terms included medical subject headings (MeSH) and text words that related to the following concepts: hypertension, hypertension management, clinic-based interventions, and community-based interventions. Studies that clearly described clinic- or community-based interventions for adults with hypertension were included (Supplemental Table 2). We excluded systematic reviews, studies that focused on peri-natal hypertension or pediatric populations, and those that did not have BP as an outcome. To supplement our primary search, we used Medline, Google Scholar, and hand-searched the reference lists of articles we had previously identified, to further identify relevant publications that are not indexed in electronic databases.

Findings

The search yielded a substantial body of literature exploring clinic- and community-based interventions for hypertension management. Some studies examining clinic-based interventions offered specific clinical practice guidelines for managing hypertension, while others focused on community-based approaches and presented more tangible interventions. Table 1 provides a comprehensive overview of various clinic-based and community-based intervention studies, including their design, sample characteristics, and blood pressure outcomes.

Table 1.

Interventions

Author, Year	Design	Sample	Country	Setting	Intervention	Interdisciplinary Team members	BP Effect
Clinic-based
Lv et al., 2017[1]	Pre-post	149 persons, ages 35–75, with uncontrolled HTN diagnosis	United States	Clinic-based	Web-based HTN self-management system+ EHR integration, smartphone, Bluetooth BP monitor, pedometer	Clinic care team, including Nurse care mangers, registered dietitian (RD), and pharmacist	At 6 mo: 55.9% met office BP goal (<140/90; P<.001), 86.0% had clinically meaningful BP↓; 71.4% met home BP (<135/85 mmHg) vs 25.2% baseline (P<.001)
Kario et al., 2021[2]	Open-label RCT	390 persons with HTN.	Japan	Clinic-based	1:1 random assignment to digital therapeutics group or control group (standard lifestyle modification).	Clinical staff (not specified)	24hr ABPM, home, and office SBPs ↓ after 12 weeks. Between-group differences in SBP were −2.4 (95%CI −4.5 to −0.3), −4.3 (−6.7 to −1.9), and −3.6 (−6.2 to −1.0) mmHg, respectively.
Bobrow et al., 2016[3]	Single-blind, three-arm RCT	1372 persons with HTN aged ≥21	South Africa	Clinic-based	SMS for HTN treatment adherence; Usual care vs Interactive vs Informational messages (no interaction)	Clinical staff (not specified)	SBP↓ in all groups; no significant mean SBP change between SMS message and usual care groups
Haskell et al, 2006[4]	RCT	148 patients in Not-for-profit or free clinics/ hospitals.  Mean age: 59.3 yrs (35–80 yrs)	United States	Clinic based	Disease management program (UC+ team case management) or usual care (UC)	Team case management - physician supervisor, nurses, dietitians	SBP & DBP ↓ significantly in Intervention (UC+) arm. Significant changes in risk factors SBP & DBP were observed in the UC+ versus UC arms.
Boutin-Foster et al., 2016[5]	RCT	238 Black adults with uncontrolled BP	United States	Clinic based	Positive affect/self-affirmation intervention with motivational interviewing vs education control	Trained research assistants	No difference in BP control rates between intervention and control groups at 1 year
Ogedegbe et al., 2024[6]	RCT	450 Black and Hispanic stroke survivors with uncontrolled HTN	United States	Clinic based	Home BP telemonitoring (HBPTM) alone vs HBPTM + nurse case management (NCM)	Nurse case managers, physicians	At 12 mo: SBP ↓ 15.1 mmHg in NCM+HBPTM group vs 5.8 mmHg in HBPTM alone group (P<.001). No difference in recurrent stroke at 24 mo (4.0% in both groups).
Community-based
Pengpid et al., 2019[7]	Cluster Community RCT	443 participants, aged 35–65 years, with pre-DM and/or pre-HTN from 12 Buddhist temples.	Thailand (Nakhon Pathom)	Community-based	Six 2-hour group lifestyle counseling sessions (diet/physical activity) over 6 mo by nurses (temple/health facility)	Study Nurses	After 6 mo SBP ↓, group x time effects): −2.13 mmHg (SE: 1.26), p=.09; After 12 mo only DBP ↓.
Kundapur et al., 2023[8]	RCT	305 participants with HTN and DM; mean age of 58.8 ± 11.4 years	India (Coastal Karnataka)	Community-based	Intervention groups: 1) physical activity alone; 2) Comprehensive lifestyle modification module) & 3) control group Family cooks involved for ~2 mo.	CHWs, participants’ families	SBP and DBP significantly ↓ Physical activity arm (↓SBP: −26.32 mmHg) and comprehensive lifestyle modification arm (↓SBP: −10.27 mmHg; ↓DBP: −30.76 mmHg). Control group showed no significant reduction
Calano et al., 2019[9]	Pre-post	50 adults with HTN in a rural community	Philippines	Community-based	Participants enrolled in a 2-mo, community-based health program based on the PRECEDE-PROCEED model. Program had four strategies, which were BP monitoring, health education sessions, motivational interviews and house-to-house visits	Nursing students, community health nurses	Significant ↓ in SBP and DBP after program/intervention
Cooper et al. 2017[10]	Pre-post	109 participants Mean age	United States	Community-based	Thirty-nine faith community nurses offered a 3-month BP self-monitoring and coaching intervention in 2014 and 2015	Faith community nurses	Mean SBP and DBP significantly ↓ each month and over the 3 -mo period. SBP: 148.8 (first mo) to 127.9 in mmHg (final mo) DBP: 83.1 (first mo) to 75.9 mmHg (final mo)
Brewer et al. 2022[11]	Cluster RCT	85 African American adults	United States	Community (Churches)	Mobile health intervention (FAITH! App) promoting cardiovascular health vs delayed intervention control	Researchers, Community Steering Committee, Church liaisons	SBP and DBP ↓ in both intervention group (NSS) and control group (p=<0.05) after community-informed, mobile health intervention (FAITH! App) at 6 months
Xiao et al., 2020[12]	Community RCT	2912 rural participants, aged 18–75, with HTN; one-year trial	China	Community-based	Control group (2 communities): received standard drug therapy; Intervention group (4 communities): received drug therapy plus a lifestyle intervention	Community physicians and nurses	BP ↓ for both control and intervention groups after a year; within-group change in SBP/DBP in intervention group was significantly higher than in control group
Schoenthaler, et al. 2018[13]	Cluster RCT (32 churches)	373 Black adults, aged ≥18 years, with HTN, uncontrolled BP and DM mellitus or CKD	United States (New York)	Community based (Faith)	Evaluated the comparative effectiveness of a faith-based therapeutic lifestyle change (TLC) intervention plus motivational interviewing (MINT-TLC) vs. health education (HE) alone on blood pressure (BP) reduction among black adults with uncontrolled hypertension. MINT-TLC: 11 group + 3 individual sessions focused on strategies for adoption of healthy lifestyle behaviors incl. meal planning, stress management, medication adherence, structured goal setting, and healthy food tastings. HE:1 TLC session plus 10 sessions on general health topics.	Lay health advisors (3–4 members of each church) trained to deliver the intervention; study staff	The MINT-TLC group saw greater SBP ↓ than control group at both 6 (−16.53 mm Hg vs. −10.74 mmHg) and 9 months (−18.2 mmHg vs. -13.0 mmHg) Both groups had significant BP↓ at 6 months, but only SBP remained significant at 9 months. DBP showed no significant change at 9 months.
Valdés González et al, 2020[14]	Community demonstration – Pragmatic design	20,344 community residents aged 18 – 85 yrs (3587 registry patients with diagnosed HTN).	Cuba Carlos Verdugo Martínez Polyclinic	Community-based	Standardized clinical training program with certification for BP measurement, routine screening for HTN in clinics & community, simple directive pharmacologic treatment algorithm, registry with performance reporting & feedback.	Ministry of Public Health, CHW, non-healthcare workers in community clinics & polyclinics (epidemiologists, nutritionists, rehabilitation team, optometrists)	↑ proportion of patients treated before and after program implementation (87.5% vs. 94%, P<0.001). ↑ HTN control before and after program implementation (29.1% vs. 57.9%, P<0.05)
Bangurah, Vardaman, & Cleveland, 2017[15]	Pre-post	16 Black adults aged 55 & older, diagnosed with, or taking oral medications for HTN.	United States	Community-based (Faith)	Behavioral + lifestyle interventions (sodium restriction & ↑ physical activity). Nurse-led diet & exercise teaching with BP monitoring led to lower BP readings over 4 weeks.	Nurse	BP readings ↓ by >10 mmHg postintervention among 50% of participants (n = 8), all participants attained BP readings <140/90 mmHg postintervention
Khetan et al., 2019[16]	Cluster RCT	3,556 adults aged 35–70 yrs screened for HTN, DM, & smoking.	India (Dalkhola)	Community-based	CHW behavioral change counseling (HTN, DM, Smoking) via home-based visit vs. handout + brief advice (yearly).	CHW, their supervisors, field workers, study investigators.	↓ SBP from baseline to post-intervention (diff: −8.9; 95% CI: −3.5 to −14.4 mmHg; p<0.05).
West-Pollak et al., 2014[17]	Pre-post	59 adults with pre-DM or DM	Dominican Republic	Community-based	Lifestyle modification program for a year	Nurse practitioner & dietitian/DM educator, doctors	Average ↓ in SBP: 11.9 mmHg and 11.8 mmHg ↓ DBP at 6 mo (P<0.05). At 1 year, ↓ SBP to 5 mmHg (NSS).
Islam et al. 2023[18]	RCT	303 South Asian patients aged 18–85 with diagnosed HTN and uncontrolled BP (SBP ≥140 mm Hg or DBP ≥90 mm Hg) within the previous 6 months, between 2017–2019	United States (New York)	Community-based	Intervention: CHWs delivered a culturally adapted HTN management curriculum, with follow up every 2 weeks + goal setting on HTN control. Control group: received usual care.	CHW	Intervention group had ↓ SBP and DBP compared to control group at 6 mo (SBP: 133.6±12.6 vs.141.1±16.6 mmHg; DBP: 82.4±7.4 vs.87.5±9.0 mmHg) Intervention group had ↑ controlled BP (68.2% vs. 41.6%), were 3.7 times more likely to achieve controlled BP at follow up compared to control group.
Ursua et al. 2018[19]	RCT	240 Filipino American individuals with uncontrolled HTN (SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg).	New York, United States	Community-based	4-mo CHW intervention. Intervention Group: received 4 educational workshops, 4 individual visits with Filipino CHWs, monthly CHW follow-up to develop personalized goal plans. Control group: received only 1 educational workshop	CHW	At 8-mo, BP was controlled among a greater % of treatment group participants (83.3%) compared to control group (42.7%). Adjusted odds of controlled BP for treatment group was 3.2 times odds of control group (P < 0.01).
Lynch et al 2023[20]	Pre-post	79 African American adults with poorly controlled BP	Chicago, IL, United States	Community-based	CHWs met participants biweekly (6 mo, home/church) to coach on BP, meds, diet & goals.	Trained church members serving as CHW	At 6-mo, mean change in SBP across participants was − 5 mmHg (p = 0.029). Change was greater among participants (n = 45) with higher baseline BP (− 9.2 mmHg, p = 0.009).
Victor et al. (2018)[21]	Cluster RCT	319 Black men with uncontrolled HTN	United States	Community-based (Barbershops)	Pharmacist-led intervention with medication management vs. active control promoting lifestyle changes	Barbers, pharmacists, physicians, field interviewers	Mean ↓ in SBP was 21.6 mmHg greater in intervention group than control at 6 months (95% CI 14.7–28.4 mmHg, p<0.001)
Community and Clinic-Based
Jafar et al., 2020[22]	Cluster RCT	Total of 2645 adults with HTN	Bangladesh, Pakistan, & Sri Lanka	Community- & clinic-based.	30 communities randomly assigned to an intervention (home visits for BP monitoring by government CHWs, physician training, and public sector care coordination) group or usual care	CHWs and physicians	Mean ↓ in SBP for intervention group (−9.0 mmHg) was 5.2 mm Hg greater than in control group (−3.9 mmHg) (95% confidence interval [CI], 3.2 to 7.1; P<0.001), at 24 mo. Mean ↓ in DBP for intervention group was 2.8 mmHg more than for control group (95% CI, 1.7 to 3.9). BP control was achieved for 53.2% of intervention group compared with 43.7% of control group.
Hauspurg et al., 2023[23]	RCT	148 postpartum persons with overweight/obesity and hypertensive disorders of pregnancy	United States	Hospital & community-based	Feasibility of a RCT of home BP monitoring (HBPM) alone, HBPM + a lifestyle intervention (Heart Health 4 New Moms, HH4NM), and a control group postpartum individuals with overweight and obesity a history of gestational HTN or preeclampsia.	Physicians, nurses, dietitians, CHW	SBP and DBP↓ (NSS) in HBPM +HH4NM group, but not in the HBPM alone group, compared to control.
Cooper et al., 2024[24]	Cluster RCT	1820 adults with uncontrolled hypertension and ≥1 other CVD risk factors; 57.4% Black, 33.2% White, 9.4% Hispanic	United States	Clinic and community-based	Standard of care plus (SCP) vs collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs.	Physicians, nurses, care managers, community health workers, specialist consultants	At 12 mo: No significant difference in BP control between CC/SC (57.3%) and SCP (56.7%) arms. Both arms achieved significant BP reductions (SBP: CC/SC −13.8 mmHg, SCP −14.6 mmHg; DBP: CC/SC −6.9 mmHg, SCP −5.5 mmHg). CC/SC showed greater improvements in patient ratings of chronic illness care.

mo: months; RCT: randomized controlled trial; HTN: Hypertension; DM: Diabetes; EHR: Electronic Health Record; CHW: Community Health Workers; RD: Registered Dietitian; RN: Registered Nurses; BP: Blood Pressure; SBP: Systolic BP; DBP: Diastolic BP; ↓: decrease: ↑: increase; RCT, Randomized Controlled Trial; CI: Confidence Interval; CKD: Chronic Kidney Disease; NSS: Not Statistically Significant

Clinic-Based Interventions

Clinic-based interventions for hypertension management typically focus on implementing evidence-based guidelines, improving patient-provider communication, and tailoring treatment plans to individual needs. The American College of Cardiology/American Heart Association (ACC/AHA) provides specific clinical practice guidelines to inform effective practices for the prevention and treatment of hypertension, including hypertension self-management, BP monitoring, medication adherence, and the use of collaborative patient-provider communication strategies.[16, 44]

Several studies have demonstrated the effectiveness of clinic-based interventions to improve BP control.[45–48] The range and effectiveness of these clinic-based approaches to hypertension management are depicted in Table 1. In one study, a clinic integrated a web-based hypertension self-management system into the electronic health records (EHR) and found clinically meaningful BP reductions at 6 months.[45] The intervention included the use of a smartphone, Bluetooth^® BP monitor, and pedometer. Similarly, Kario et al.[46] assessed the efficacy of a digital therapeutics intervention in a clinic-based setting in Japan and found significant reductions in ambulatory, home, and office systolic blood pressure (SBP) in the intervention group compared to the control group at 12 weeks.[46]

The use of treatment algorithms is another important aspect of clinic-based interventions. These algorithms provide a structured approach to hypertension management, guiding clinicians in selecting appropriate medications and adjusting treatment based on patient response.[49] The integration of treatment algorithms into EHR systems can further streamline the management process and ensure adherence to evidence-based guidelines.[50]

Patient self-management is a key component of successful clinic-based interventions. This includes BP self-monitoring, weight management, adherence to a heart-healthy diet, increased physical activity, improved hypertension knowledge, and stress reduction techniques.[16] While some studies have explored the use of SMS messages to support treatment adherence in a clinic-based setting, the results have been mixed,[47] highlighting the need for further research on the effectiveness of mobile health (mHealth) interventions.

The integration of digital health and wearable devices, smartwatches, and smartphones, and patient-generated health data (e.g., home BP measurements via Bluetooth-enabled BP devices) into EHR systems is an emerging multifaceted approach in clinic-based hypertension management.[51] This allows patients to upload BP readings into the EHR, informing providers in real-time of any abnormalities and providing opportunities for timely interventions to prevent complications.[52] The use of digital health devices has been associated with increased patient-provider communication, individualized treatment plans, and improved home and clinic BP readings in patients with hypertension.[53]

Team-based care is another important aspect of clinic-based interventions. Haskell and colleagues[48] observed significant improvements in SBP and diastolic blood pressure (DBP) among patients who received the intervention compared to those receiving usual care when evaluating a team-based disease management program delivered by physicians, nurses, and dietitians in a clinic setting. However, not all clinic-based interventions have demonstrated significant effects on BP control. For example, in the Trial Using Motivational Interviewing, Positive Affect, and Self-Affirmation in African Americans with Hypertension (TRIUMPH)[54] did not find an effect on BP control, highlighting the need for further research to identify effective strategies for specific populations.

Clinic-based interventions for hypertension management involve a multifaceted approach, including the implementation of evidence-based guidelines, the use of treatment algorithms, patient self-management, the integration of digital health technologies, and team-based care. While many studies have shown the effectiveness of these interventions in improving BP control, there is still a need for further research to optimize hypertension management in clinical settings and address the unique needs of minoritized populations.

Community-Based Interventions

Collaborative community partnerships are essential for facilitating better health and well-being. These partnerships are often established through investments from funding agencies and philanthropic organizations.[55, 56] They typically involve local organizations with varying levels of expertise and infrastructure, as well as state and federal agencies, including health departments. Evidence suggests that such partnerships have been critical for promoting widespread behavioral and environmental changes, although the magnitude and longevity of these changes can be difficult to evaluate.[55]

Community-based interventions designed to address hypertension often include health education, culturally sensitive outreach programs and leveraging trusted community figures for BP screening and medication adherence support. Specific examples include lifestyle modification programs, faith-based interventions, culturally adapted health education, community health worker (CHW) interventions, and collaborative care models, which have shown promise in improving hypertension control.[23, 57–60] (Table 1)

Lifestyle Modification Programs

Interventions involving lifestyle modification programs typically include counseling or educational sessions, motivational interviews, home visits, SMS text messaging, interventions facilitated by trained CHWs, and engagement of family members and providers. Effective programs typically address a range of factors including diet, physical activity, and weight loss.[57, 58] For example, a community-based trial in coastal India demonstrated the efficacy of such interventions. In this study, trained workers delivered a comprehensive lifestyle modification program focusing on diet and physical activity to participants and their families. The intervention resulted in significant reductions in DBP and glycated hemoglobin levels.[57] Similarly, in the Dominican Republic,[58] a year-long lifestyle modification program resulted in significant decreases in SBP and DBP at 6 months. After initial BP reduction, long-term (i.e., ≥ 6 months) intervention effects on BP were attenuated[58] or no longer significant,[57] highlighting the challenge of sustaining the impact of lifestyle modification programs over time.

Interventions in Faith-Based Settings

Collaborations with faith-based organizations that involve health ministries and community health providers have demonstrated success in reaching and engaging communities experiencing social marginalization in hypertension prevention and control efforts and decreases in BP.[23, 59, 60] For example, in a cluster-randomized trial[60] that compared a faith-based therapeutic lifestyle change (TLC) intervention with motivational interviewing to health education (HE) alone in African American churches in New York, there was a significantly greater reduction in SBP in the TLC group compared to the HE group at 6 months, and both groups maintained significant, but attenuated reductions in BP at 9 months. In another faith-based intervention,[23] where 39 faith community nurses offered a BP self-monitoring and coaching intervention over 3 months, mean SBP and DBP significantly decreased each month and over the 3-month period, demonstrating the potential of faith-based partnerships in hypertension management. Similar results were observed in the FAITH! (Fostering African American Improvement in Total Health!) Trial,[59] a community-based, cluster-randomized controlled trial assessing the feasibility and preliminary efficacy of a mobile health intervention promoting cardiovascular health among African Americans in faith communities. Here, after 6 months, the intervention group had reductions in BP and significant improvements in other cardiovascular health metrics including diet and physical activity, compared to the control group.[59]

Faith-based interventions leveraging the trust and influence of religious institutions, coupled with the expertise of community health providers, offer a promising approach to address hypertension disparities. These collaborations can effectively engage and empower individuals to adopt healthy lifestyle behaviors and improve their cardiovascular health.

Interventions in Trusted Spaces

Delivering health interventions in trusted community spaces, such as barbershops, hair salons, and recreational centers, has shown promise in improving hypertension control and reducing disparities.[61–63] These settings provide a comfortable and familiar environment where community members regularly gather, offering an opportunity to reach individuals who may not frequently access traditional healthcare settings.[61] In a cluster-randomized trial in Black-owned barbershops in Los Angeles[62] a pharmacist-led intervention (involving medication management and lifestyle modifications) achieved greater SBP reduction compared to the control group (27.0 mm Hg vs. 9.3 mm Hg, p<0.001) at 6 months. Similar interventions have been found effective in hair salons.[63] Recreational centers have also been used as trusted spaces for hypertension interventions. In Detroit, a community-based research project partnered with a Latino recreational center to implement culturally-tailored health education, cooking demonstrations, and group physical activity classes, resulting in significant improvements in BP, diet quality, and physical activity levels at 6 months.[64]

Interventions in trusted spaces leverage existing social networks and community resources to promote hypertension prevention and control among populations that may face barriers to accessing traditional healthcare services. Partnering with community leaders and delivering interventions in comfortable, familiar settings, these approaches can effectively reach and engage individuals, and communities where the burden of hypertension is greatest.

Culturally Adapted Health Education

Developing and delivering culturally appropriate health education materials and programs, co-designed in partnership with community members, can improve knowledge, attitudes, and behaviors related to hypertension among racial and ethnic minoritized populations. A community-based health program among marginalized rural persons in the Philippines using culturally adapted strategies such as BP monitoring, health education, motivational interviews, and house-to-house visits, significantly reduced SBP and DBP after two months.[65] LowSalt4Life is an adaptive mobile app intervention that provides resources including educational materials, meal planning tools, and community support networks for individuals adopting low-sodium diets to manage hypertension, empowering them to make sustainable dietary changes and improve BP control.[66] This type of targeted intervention can be particularly beneficial for addressing disparities in hypertension management, as dietary sodium intake patterns may vary across different racial and ethnic groups.

Community Health Worker (CHW) Interventions

Trusted community partners, such as CHWs, can provide culturally sensitive education, support, and navigation services and have shown effectiveness in assisting underserved populations in managing hypertension and accessing appropriate care.[67–72] In the US, several studies have demonstrated the positive impact of CHW interventions on hypertension control among African American and Latino communities.[67–72] A CHW-led RCT intervention in New York City that included group education sessions and individualized health coaching led to 68% of South Asian patients achieving BP control after 6 months vs. 42% of those in the control group, demonstrating significant health improvements.[67] Again in New York City, a CHW intervention among Filipino Americans with hypertension involving monthly group sessions and home visits led to controlled BP in 83% of the treatment group compared to 43% of the control group at 8 months.[68] Through home BP monitoring, medication adherence strategies, and dietary education in the Heart 2 Heart pilot study, a church-based intervention, CHWs reduced SBP by 9.2 mm Hg among African Americans with uncontrolled hypertension, demonstrating a clinically significant reduction in BP levels through a 6-month program.[69] Globally, the effectiveness of the CHW model has been demonstrated in India, Pakistan, Bangladesh, and Sri Lanka where trained CHWs conducted routine home visits for BP monitoring and counseling in rural and semi-urban communities, consequently leading to significant reductions in BP.[70, 71]

CHWs are instrumental in reducing care barriers between health systems, clinicians, and communities as well as facilitating hypertension-related health literacy, which can improve self-management activities.[73] Key aspects of CHW interventions include delivering the intervention in trusted community settings, employing CHWs from similar racial and ethnic backgrounds, and incorporating strategies to address linguistic, cultural, and socioeconomic factors influencing hypertension self-management.[73]

Collaborative Care Models

Hypertension is a complex condition that requires a multidisciplinary approach and healthcare professionals play a crucial role.[15] A team-based approach with both physicians and non-physician titration is successful in managing hypertension and decreasing hypertension-related morbidity and mortality.[29] Physicians and advanced practice clinicians can diagnose hypertension, prescribe and titrate medications, and order necessary procedures. Nurses educate patients, monitor symptoms, and coordinate care.[74] Pharmacists ensure medication safety and prescribe appropriate medications.[15] A team-based approach with both physicians and non-physician titration has been successful in managing hypertension and decreasing hypertension-related morbidity and mortality.[29] Dietitians develop personalized nutritional plans to improve cardiovascular risk factors. Social workers assess SDoH barriers and connect patients with community resources.[33] Psychologists help patients address health behavior barriers associated with suboptimal hypertension management. Rehabilitation specialists guide patients in exercise programs and develop strategies to improve functional capacity.[75] CHWs play a critical role in maximizing the efficiency and effectiveness of the interdisciplinary care team by acting as liaisons between the healthcare system and the community, advocating for health equity and facilitating culturally sensitive care.[67, 73, 76] They bridge the gap between clinical care and patients’ daily routines, improve access to services, facilitate communication, support medication adherence, and enable community-based care plans.[77–79]

Patient-centered, team-based care models that integrate primary care, behavioral health, and community resources, along with culturally concordant training for healthcare providers, can enhance hypertension care delivery for minoritized populations.[80] A study in rural China employing a collaborative team-based approach, involving community physicians, nurses, and workers, significantly improved BP control compared to usual care through antihypertensive medications and lifestyle counseling.[81] Similarly, significant improvements in hypertension control in Cuba were achieved through a comprehensive hypertension control program engaging healthcare workers and non-healthcare workers and involving standardized clinical training, routine screening, a simple pharmacologic treatment algorithm, and performance reporting registry.[82] The RICH LIFE Project, compared a collaborative care/stepped care (CC/SC) model to an enhanced standard of care (SCP) approach among 1820 adults with uncontrolled hypertension and other cardiovascular risk factors.[83] The CC/SC intervention did not significantly improve BP control rates compared to SCP at 12 months (CC/SC: 57.3%, SCP: 56.7%). However, both arms achieved clinically significant reductions in blood pressure. The CC/SC arm showed greater improvements in patient ratings of chronic illness care. Another large RCT compared home BP monitoring alone (HBPM) to HBPM plus nurse case management (NCM) among 450 predominantly low-income Black and Hispanic stroke survivors with uncontrolled hypertension.[84] Adding NCM to HBPM led to a significantly greater reduction in systolic BP at 12 months compared to HBPM alone (−15.1 mmHg vs −5.8 mmHg, P<.001). This study highlights the potential of combining technology-based interventions with personalized case management to improve BP control in high-risk, underserved populations.

Effective communication and collaboration among team members are crucial for delivering integrated, patient-centered care to improve hypertension outcomes. This approach addresses multifaceted aspects of hypertension management, ensuring strong coordination and bidirectional communication among interdisciplinary team members.[15]

Clinic-Community Linked Interventions

Successful hypertension management requires a comprehensive approach that extends beyond the walls of clinical settings. Linking clinical interventions with community-based strategies can enhance the effectiveness and reach of hypertension control efforts. Clinic-community linked interventions offer a promising approach for improving hypertension control by bridging the gap between clinical settings and communities.[70, 85] A cluster RCT in Pakistan found a multicomponent intervention delivered by CHWs and physicians reduced SBP compared to usual care.[70]

Role of Community Pharmacists

Community pharmacists also play a crucial role in hypertension management by enhancing access to care and improving medication adherence.[86, 87] Engaging pharmacists in BP monitoring, medication counseling, and lifestyle advice has shown feasibility and effectiveness in community-based settings.[88, 89] Pharmacist-led interventions are associated with significant reductions in SBP and DBP. This evidence supports the integration of pharmacists into clinic-community-linked interventions for hypertension control.[89]

The success of clinic-community-linkage interventions relies on strong partnerships and collaboration between healthcare systems and community stakeholders. Engaging community members in the planning, implementation, and evaluation of these interventions can help ensure their cultural relevance, acceptability, and sustainability. Additionally, addressing SDoH, such as access to healthy food, safe physical activity environments, and social support, is crucial for the effectiveness of clinic-community-linked interventions in improving hypertension control and reducing disparities.

Future Directions

Building on the insights of this review, we provide a comprehensive framework for addressing racial and ethnic disparities in hypertension management for the future in this section. Figure 1 outlines the key components necessary for improving health outcomes through comprehensive, patient-centered care. These components include establishing clinic-community linkages, implementing collaborative care models, evaluating long-term effectiveness of interventions, leveraging technology and innovation, addressing gaps in research, and focusing on minoritized populations. By addressing these areas, we can strive to reduce disparities in hypertension management, improve health outcomes, and empower individuals to manage their hypertension effectively.

Figure 1.

Key components for improving health outcomes to advance health equity

Advancing Health Equity through Clinic-Community Linkages

Future efforts should strive toward achieving significant reductions in racial and ethnic disparities in hypertension management. This comprehensive approach requires going beyond traditional clinical settings and forging strong partnerships with community-based organizations. These crucial clinic-community linkages help clinicians address complex SDoH that disproportionately impact minoritized populations such as expanding access to healthy foods, physical activity programs, and culturally sensitive resources.[80] These partnerships can also help overcome logistical and language barriers, creating a more equitable healthcare system that empowers individuals to manage their hypertension and achieve optimal health outcomes.

Strengthening and expanding clinic-community partnerships to enhance the reach and effectiveness of hypertension management interventions are essential. Collaborative care models that engage healthcare providers, CHW, and community-based organizations can facilitate the delivery of culturally tailored, patient-centered care. These partnerships can also help address the unique needs and challenges faced by underserved communities, such as limited access to healthy food options, safe spaces for physical activity, and social support networks.[90]

Evaluating Long-Term Effectiveness and Sustainability

Future efforts should focus on evaluating the long-term effectiveness and sustainability of clinic and community interventions for hypertension management. While many studies have demonstrated the short-term benefits of these interventions, there is a need for longitudinal studies that assess the durability of these effects over time.[18]

Intervention Cost-Effectiveness

Another important area for focus is the cost-effectiveness of clinics and community-based interventions for hypertension management. Conducting economic evaluations alongside clinical trials can provide valuable insights into the cost-benefit ratio of these interventions and inform decisions for resource allocation. Assessing the cost-effectiveness of these interventions is particularly relevant for underserved communities, where limited resources and competing priorities can pose challenges to the implementation and sustainability of health interventions.

Leveraging Technology and Innovation

Innovative technologies, such as telemedicine, mobile health applications, and remote monitoring devices, offer promising opportunities to improve access to hypertension care and support clinic-community linkages. Remote BP monitoring, especially when linked to EMRs, offers a promising avenue for supporting hypertension management efforts among diverse populations.[51] If scaled, healthcare providers can remotely track patients’ BP readings, identify trends, and adjust treatment plans as needed, thereby facilitating proactive management and reducing the risk of complications.[91, 92] Artificial intelligence (AI) and machine learning (ML) also hold great potential for advancing hypertension management and reducing disparities. AI-powered algorithms can analyze large datasets, including EMR data, to identify patients at high risk for uncontrolled hypertension or complications, enabling targeted interventions and personalized care.[93] ML models can also be trained to predict patient adherence to treatment plans, allowing providers to proactively address potential barriers and optimize care delivery.[94] Furthermore, AI-based chatbots and virtual assistants can provide culturally tailored patient education, support self-management, and facilitate communication between patients and healthcare teams, thereby improving access to care.[95]

Addressing Gaps in the Literature

While this review provides a comprehensive overview of clinic-based and community-based interventions for hypertension management, there are still gaps in the literature that warrant further investigation. (Figure 1.) For example, there is a need for more research on the effectiveness of these interventions in minoritized populations, particularly groups that are underrepresented in clinical trials, such as Asian Americans, Native Americans, and Pacific Islanders. Additionally, future studies should explore the potential synergistic effects of combining multiple intervention strategies, such as integrating CHW-led interventions with technology-based tools.

In addition to addressing health inequities, clinicians should consider culturally appropriate communication to foster trusting relationships with their patients. Often, communication barriers between providers and patients are attributed to a lack of cultural knowledge and sensitivity toward patients’ health beliefs and health-seeking behaviors. The acknowledgment of cultural differences is the first step toward establishing cultural safety within the patient-provider relationship, thus cultivating effective communication that is needed to achieve positive health outcomes.[96]

In healthcare settings, experiences of discrimination can lead to distrust of the medical system and reluctance to seek care or adhere to treatment plans.[97] When providing treatment, it is imperative that healthcare providers consider SDoH that impact adequate control of hypertension and develop culturally tailored interventions to meet the needs of patients experiencing health inequities.[96]

This review suggests that significant improvements in hypertension management have been associated with both clinic-based and community-based interventions many of which have been strategically designed to address common SDoH that negatively impact hypertension and contribute to hypertension-related disparities.

However, there remains a need for studies that examine the potential impact of public policy interventions implemented at either the state or national level (e.g., sodium restriction in packaged foods) on hypertension management. The potential benefits of a combined approach to hypertension management; one that includes both widespread public health interventions and smaller scale interventions such as those implemented at the clinic and community level may result in substantial reductions in disparities in hypertension outcomes and should be explored further.

Conclusion

Hypertension remains a critical public health issue worldwide and in the US despite the availability of effective treatments and increased awareness, with many racial and ethnic groups having undiagnosed or poorly controlled hypertension, leading to considerable health and economic burdens. Effective hypertension management requires collaborative efforts between clinical and community-based partnerships to provide comprehensive, patient-centered care. These partnerships have demonstrated effectiveness in driving behavioral and environmental changes conducive to improved health outcomes. Addressing disparities at the individual and systemic level and SDoH through integrated, culturally sensitive approaches, lifestyle modification programs, and faith-based initiatives have enhanced hypertension management efforts. Furthermore, leveraging innovative technologies and linking clinical and community-based interventions through collaborative care models provides support for hypertension management and reduces disparities.

Moving forward, we must strengthen and expand clinic-community linkages, evaluate long-term effectiveness and cost-effectiveness, and address gaps in research for underrepresented populations. Comprehensive strategies involving healthcare providers, policymakers and community organizations, fostering strong partnerships, leveraging technology, addressing SDoH, can move us towards equitable health outcomes for all populations.