Abstract
Objectives:
Nearly half of US adults have hypertension. The prevalence of hypertension is higher among adults with disabilities than among those without disabilities; however, national estimates use old data and definitions, and hypertension awareness and control are understudied. This study compared hypertension prevalence, awareness, and control among adults with and without disabilities.
Methods:
We analyzed data from the National Health and Nutrition Examination Survey (August 2021–August 2023) for adults aged ≥18 years (N = 5999). To determine disability status, we used the Washington Group on Disability Statistics questionnaire, which covers the domains of seeing, hearing, walking, communication, cognition, self-care, upper-body function, and affect. Hypertension was defined as blood pressure ≥130/80 mm Hg or use of antihypertensive medication. Among adults with hypertension, awareness was defined as self-report of physician diagnosis and control as blood pressure <130/80 mm Hg. We estimated adjusted prevalence ratios (APRs) using logistic regression, adjusting for demographic and health characteristics and accounting for the complex survey design.
Results:
Hypertension prevalence was significantly higher among adults with disabilities than among those without disabilities (57.2% vs 45.1%; P < .001). Among those with hypertension, the prevalence of awareness (71.3% vs 55.0%; P < .001) and control (27.3% vs 18.4%; P < .001) was significantly higher among adults with disabilities than among those without disabilities. Adjusted analyses showed a higher prevalence of hypertension (APR = 1.12; 95% CI, 1.04-1.21), awareness (APR = 1.22; 95% CI, 1.14-1.30), and control (APR = 1.31; 95% CI, 1.12-1.54) among adults with disabilities than among those without disabilities.
Conclusions:
Primary prevention may be particularly important for adults with disabilities. Improving awareness and control remains a key public health challenge regardless of disability status.
Keywords: hypertension, hypertension awareness, hypertension control, disability
High blood pressure, or hypertension, affects 48% of US adults and is a major risk factor for stroke, heart disease, and other adverse health outcomes.1,2 Hypertension treatment involves the awareness or recognition of an individual’s condition and the effective management and control of hypertension. 3 Yet, in the United States, only 59% of adults with hypertension are aware of it and only 21% have it under control. 1 The US government’s Healthy People 2030 initiative has established targets for improving health outcomes for people in the United States. 4 Key objectives include enhancing cardiovascular health and reducing deaths from heart disease and stroke. 5 Specific goals involve decreasing the proportion of adults with hypertension and increasing the control of hypertension. 6 Additionally, Healthy People 2030 aims to improve the health and well-being of people with disabilities. 7 Adults with disabilities have a higher prevalence of smoking, obesity, diabetes, and heart disease—conditions linked to hypertension—than adults without disabilities, but the prevalence of hypertension awareness and control in this population is unclear. 8
The most recent nationally representative study of hypertension prevalence by disability status used nationally representative data from 2001 through 2010 and the previous definition of hypertension: systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. 9 That study found a higher prevalence of hypertension among adults with disabilities, defined as having severe difficulties in basic functioning domains, than among adults without disabilities, but it did not assess awareness or control. 9 The 2017 American Heart Association/American College of Cardiology (AHA/ACC) redefined hypertension as systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥80 mm Hg. 10 In 2025, the AHA/ACC reaffirmed that definition. 11 Using current, evidence-based definitions to understand hypertension prevalence, awareness, and control among people with disabilities is important to assess progress toward meeting the Healthy People 2030 goals of improving cardiovascular health, improving the health and well-being of people with disabilities, and the intersection of these 2 goals.
Prior research used various definitions of disability, adding to the complexity of comparing estimates across studies. 12 In 2008, the United Nations Washington Group on Disability Statistics (WG) developed internationally standardized measures for collecting disability data that expanded the domains of functioning limitations to include 8 domains: seeing, hearing, walking, communication, cognition, self-care, upper-body function, and affect (anxiety and depression). 13
The objective of this study was to compare the prevalence of hypertension, hypertension awareness, and hypertension control among US adults by disability status, using the WG questions and the 2017 AHA/ACC hypertension definition.
Methods
The National Health and Nutrition Examination Survey (NHANES) collects nationally representative health data for the civilian noninstitutionalized US population and is administered by the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS). NHANES conducts in-home interviews and health examinations in mobile examination centers. 14 We included participants aged ≥18 years and excluded those who were pregnant.
The NCHS Ethics Review Board approved the NHANES data collection protocol, and written consent was obtained from all participants. Per the NCHS ethics review board, this secondary data analysis of deidentified public-use data files was exempt from institutional review board review.
We used data from August 2021 through August 2023, the most recently available NHANES cycle. For this cycle, the interview response rate was 34.5% and the response rate for mobile examination centers was 25.6%. 15
Blood pressure was measured by using standardized protocols and a validated oscillometric device. 16 Hypertension was defined as an average systolic blood pressure ≥130 mm Hg or an average diastolic blood pressure ≥80 mm Hg from 3 measurements or as self-reported current use of antihypertensive medication. Among those with hypertension, awareness was defined as self-report of receiving a diagnosis from a health professional, and control was defined as an average systolic blood pressure <130 mm Hg and an average diastolic blood pressure <80 mm Hg.10,17
We defined disability status by using the WG Short Set on Functioning–Enhanced, which includes 12 questions in 8 functioning domains: seeing, hearing, walking, communication, cognition, self-care, upper-body function, and affect (anxiety and depression). All domains except anxiety and depression capture 4 levels of difficulty: “no difficulty,” “some difficulty,” “a lot of difficulty,” and “cannot do at all.” For anxiety and depression, questions capture 5 levels of frequency (“never,” “a few times a year,” “monthly,” “weekly,” and “daily”) and 3 levels of intensity (“a little,” “somewhere between a little and a lot,” and “a lot”). 18 We categorized adults as experiencing a disability if they reported at least 1 of the following: (1) having “a lot of difficulty” or “cannot do at all” for at least 1 of the first 7 domains, (2) having anxiety with “daily” frequency and “a lot” of intensity, or (3) feeling depressed with “daily” frequency and “a lot” of intensity.3,19
Covariates were age, sex, race and Hispanic origin, health insurance status, body mass index (BMI) categories, and tobacco smoking status.
Among 6337 participants examined at mobile examination centers, we excluded 5.3% for pregnancy (n = 41) and missing data (n = 297). Data were missing for the following: self-reported disability (n = 2), hypertension awareness (n = 2), health insurance status (n = 12), BMI (n = 62), tobacco smoking status (n = 7), and all 3 blood pressure measurements (n = 212). The final sample was 5999 participants.
We used SAS version 9.4 (SAS Institute Inc) and SUDAAN version 11.0 (RTI International) to account for the complex survey design. We estimated prevalence ratios and adjusted prevalence ratios (APRs) by using multivariable logistic regression and mobile examination center weights. We calculated population counts by multiplying weighted NHANES estimates by population totals. 15 We conducted estimation of crude and adjusted risk ratios in SUDAAN by using the predictive margins functions PREDMARG/ADJRR and PRED_EFF in PROC RLOGIST. 20 We assessed comparisons by disability status by using Satterthwaite-adjusted χ² tests. We set statistical significance at P < .05. Estimates include 95% CIs and met NCHS presentation standards for proportions unless otherwise noted. 21
Results
We estimated that 20.7% of US adults (approximately 52.5 million) experienced a disability during August 2021–August 2023. Disability prevalence by functioning domain was 3.4% for seeing, 2.5% for hearing, 6.7% for mobility, 1.2% for communication, 6.6% for cognition, 0.7% for self-care, 3.5% for upper-body function, 5.7% for anxiety, and 2.4% for depression. These domain-specific prevalences are not mutually exclusive.
When compared with adults without disabilities, adults with disabilities tended to be older and female, to have obesity, and to be current tobacco smokers (all P < .05). For example, 59.5% of women had a disability versus 40.5% of men. We observed no significant associations for race and Hispanic origin or health insurance coverage (Table 1).
Table 1.
Demographic and health behavior characteristics among adults aged ≥18 years, by disability status, United States, August 2021–August 2023 a
| Characteristic | Overall | With disabilities b | Without disabilities | P value c |
|---|---|---|---|---|
| No. (%) | 5999 (100.0) | 1359 (20.7) | 4640 (79.3) | — |
| Demographic | ||||
| Age, y | <.001 | |||
| 18-39 | 36.5 (33.7-39.4) | 28.8 (23.9-34.1) | 38.5 (36.1-41.0) | |
| 40-59 | 33.0 (30.9-35.1) | 32.7 (29.4-36.2) | 33.1 (31.0-35.2) | |
| ≥60 | 30.5 (28.2-32.8) | 38.4 (34.6-42.4) | 28.4 (26.4-30.4) | |
| Sex | <.001 | |||
| Male | 49.2 (47.8-50.7) | 40.5 (36.0-45.2) | 51.5 (50.0-52.9) | |
| Female | 50.8 (49.3-52.2) | 59.5 (54.8-64.0) | 48.5 (47.1-50.0) | |
| Race and Hispanic origin | .71 | |||
| Hispanic | 16.5 (11.2-23.1) | 16.5 (10.7-23.8) | 16.5 (11.2-23.2) | |
| Non-Hispanic Black | 10.6 (7.9-13.7) | 9.6 (6.8-13.0) | 10.8 (8.2-14.0) | |
| Non-Hispanic White | 60.5 (56.2-64.7) | 61.3 (55.8-66.7) | 60.3 (55.9-64.5) | |
| Other d | 12.4 (10.2-14.9) | 12.6 (9.8-16.0) | 12.3 (9.9-15.2) | |
| Health insurance coverage e | .68 | |||
| Yes | 90.7 (88.5-92.6) | 90.2 (86.2-93.4) | 90.8 (88.6-92.8) | |
| No | 9.3 (7.4-11.5) | 9.8 (6.6-13.8) | 9.2 (7.2-11.4) | |
| Health | ||||
| BMI category f | <.001 | |||
| Underweight/normal | 28.8 (25.6-32.1) | 24.9 (22.6-27.3) | 29.8 (26.1-33.8) | |
| Overweight | 31.7 (29.9-33.5) | 27.0 (24.4-29.7) | 32.9 (31.0-34.8) | |
| Obesity | 39.5 (35.6-43.5) | 48.1 (45.0-51.2) | 37.3 (33.1-41.6) | |
| Tobacco smoking status g | <.001 | |||
| Current | 14.2 (11.9-16.8) | 24.6 (19.9-29.9) | 11.5 (9.6-13.6) | |
| Former | 22.9 (21.0-24.9) | 26.4 (23.1-29.9) | 22.0 (19.8-24.3) | |
| Never | 62.9 (58.9-66.7) | 49.0 (43.7-54.2) | 66.5 (63.0-69.9) |
Abbreviations: —, not applicable; BMI, body mass index.
Data source: National Health and Nutrition Examination Survey. 14 All values are percentage (95% CI) unless otherwise noted; percentages may not add to 100 because of rounding. All estimates except sample size are weighted.
Defined as highest level of difficulty (“a lot of difficulty” or “cannot do at all”) for seeing, hearing, walking, communication, cognition, self-care, and upper-body functioning. For anxiety and depression, defined as the highest level of difficulty: (1) having anxiety with “daily” frequency and “a lot” of intensity or (2) feeling depressed with “daily” frequency and “a lot” of intensity.
Satterthwaite-adjusted χ² tests were performed to compare distribution of characteristics by disability status; significance set at P < .05.
Includes non-Hispanic Asian, Native Hawaiian, Pacific Islander, Native American, Alaska Native, other race, and multiracial.
Defined by response to “Are you covered by health insurance or some other kind of health care plan?”
Calculated as weight in kilograms divided by height in meters squared (underweight/normal, <25; overweight, 25 to <30; obesity, ≥30). Among participants aged 18 or 19 years, BMI was categorized by using the 2000 Centers for Disease Control and Prevention Growth Charts age- and sex-specific percentiles: underweight/normal, <85th percentile; overweight, 85th to <95th percentile; obesity, ≥95th percentile. 22
Defined by responses to “Have you smoked at least 100 cigarettes in your entire life?” and “Do you now smoke cigarettes?”
Hypertension was more prevalent among adults with disabilities (57.2%; approximately 30 million) than among those without disabilities (45.1%; approximately 90 million; P < .001). Hypertension prevalence differed significantly between those with and without disabilities by age group, sex, BMI category, and tobacco smoking status (Table 2). For example, we found a significantly higher prevalence of hypertension among those with disabilities than among those without disabilities among men (60.5% vs 48.9%) and women (54.9% vs 41.2%) and among those with underweight/normal weight (37.1% vs 29.1%) and obesity (69.9% vs 60.6%).
Table 2.
Prevalence of hypertension, awareness of hypertension, and controlled hypertension, by demographic and health behavior characteristics among adults aged ≥18 years, by disability status, United States, August 2021–August 2023 a
| Hypertension
b
|
Awareness of hypertension
c
|
Controlled hypertension
d
|
||||
|---|---|---|---|---|---|---|
| Characteristic | With disabilities
e
(n = 1359) |
Without disabilities (n = 4640) |
With disabilities
e
(n = 848) |
Without disabilities (n = 2343) |
With disabilities
e
(n = 848) |
Without disabilities (n = 2343) |
| Overall | 57.2 (53.6-60.6) | 45.1 (42.8-47.5) | 71.3 (67.3-75.1) | 55.0 (51.9-57.9) | 27.3 (23.7-31.1) | 18.4 (16.5-20.3) |
| Demographic | ||||||
| Age, y | ||||||
| 18-39 | 25.0 (17.2-34.1) | 23.2 (20.2-26.5) | 42.1 (29.2-55.9) | 24.0 (17.5-31.5) | 6.8 (2.3-15.1) | 4.1 (2.2-6.9) f |
| 40-59 | 62.3 (57.1-67.3) | 49.8 (46.9-52.7) | 67.7 (56.7-77.4) | 53.0 (47.0-58.9) | 25.4 (19.3-32.4) | 15.6 (12.5-19.0) |
| ≥60 | 76.9 (73.6-80.0) | 69.5 (66.0-72.9) | 80.9 (76.3-84.9) | 70.7 (67.8-73.4) | 33.5 (28.1-39.4) | 27.2 (23.1-31.5) |
| Sex | ||||||
| Male | 60.5 (53.0-67.6) | 48.9 (46.3-51.4) | 66.7 (58.9-73.8) | 52.1 (48.5-55.6) | 25.9 (19.4-33.4) | 17.0 (14.9-19.2) |
| Female | 54.9 (49.7-60.0) | 41.2 (37.9-44.5) | 74.8 (70.7-78.5) | 58.6 (54.8-62.3) | 28.3 (23.9-33.1) | 20.1 (16.7-23.9) |
| Race and Hispanic origin | ||||||
| Hispanic | 43.4 (32.0-55.2) | 38.4 (31.0-46.2) | 68.4 (55.4-79.5) | 52.7 (45.7-59.6) | 28.2 (18.3-40.0) | 15.9 (12.0-20.4) |
| Non-Hispanic Black | 71.5 (57.9-82.7) | 56.7 (51.9-61.3) | 79.4 (70.8-86.5) | 63.9 (54.1-73.0) | 25.5 (17.8-34.5) | 18.2 (14.1-23.0) |
| Non-Hispanic White | 58.9 (53.9-63.8) | 45.9 (42.8-49.0) | 70.3 (63.8-76.3) | 53.8 (49.7-57.9) | 29.0 (23.4-35.1) | 18.1 (15.0-21.6) |
| Other g | 55.9 (48.3-63.4) | 40.5 (34.6-46.7) | 71.3 (58.3-82.2) | 53.1 (46.9-59.3) | 19.3 (12.3-28.0) | 22.8 (15.6-31.3) |
| Health insurance coverage h | ||||||
| Yes | 58.2 (53.9-62.4) | 45.9 (43.2-48.6) | 73.5 (69.0-77.7) | 56.7 (53.6-59.7) | 27.9 (24.1-32.1) | 19.4 (17.4-21.5) |
| No | 47.6 (32.2-63.4) f | 37.4 (30.7-44.5) | 46.5 (25.6-68.3) f | 34.1 (23.6-45.8) | 20.1 (10.0-34.1) | 5.8 (1.7-13.8) f |
| Health | ||||||
| BMI category i | ||||||
| Underweight/normal | 37.1 (30.7-43.8) | 29.1 (25.7-32.7) | 63.4 (54.3-71.8) | 46.8 (41.2-52.5) | 20.6 (12.1-31.5) | 14.0 (10.0-18.8) |
| Overweight | 52.9 (43.2-62.4) | 42.1 (38.4-46.0) | 64.0 (54.1-73.1) | 56.0 (50.8-61.2) | 23.1 (16.4-30.9) | 18.6 (15.4-22.3) |
| Obesity | 69.9 (65.6-74.0) | 60.6 (56.4-64.8) | 76.5 (71.0-81.5) | 57.4 (54.0-60.8) | 30.9 (26.4-35.7) | 19.8 (17.5-22.3) |
| Tobacco smoking status j | ||||||
| Current | 55.7 (47.2-64.0) | 48.2 (42.5-53.9) | 60.7 (49.7-71.1) | 53.0 (47.1-58.8) | 27.1 (20.0-35.2) | 13.8 (9.0-20.0) |
| Former | 69.1 (62.5-75.3) | 56.1 (51.7-60.4) | 77.5 (69.8-84.0) | 60.8 (55.8-65.6) | 28.3 (21.5-35.8) | 21.0 (17.7-24.5) |
| Never | 51.4 (46.9-55.9) | 41.0 (38.1-44.0) | 72.5 (66.6-77.9) | 52.7 (48.5-57.0) | 26.7 (22.2-31.5) | 18.1 (15.5-21.0) |
Abbreviation: BMI, body mass index.
Data source: National Health and Nutrition Examination Survey. 14 All values are percentage (95% CI) unless otherwise noted. All estimates except sample size are weighted.
Defined as an average blood pressure ≥130/80 mm Hg or a yes response to “Are you now taking any medication prescribed by a doctor for your high blood pressure?” Adults without disabilities significantly differed from adults with disabilities by age, sex, BMI category, and smoking status (P < .05) based on Satterthwaite-adjusted χ² tests.
Defined by the response to “Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?” among those with hypertension. Adults without disabilities significantly differed from adults with disabilities by sex, BMI category, and tobacco smoking status (P < .05) based on Satterthwaite-adjusted χ² tests.
Defined as average blood pressure <130/80 mm Hg among those with hypertension. Adults without disabilities significantly differed from adults with disabilities by sex, BMI category, and tobacco smoking status (P < .05) based on Satterthwaite-adjusted χ² tests.
Defined as highest level of difficulty (“a lot of difficulty” or “cannot do at all”) for seeing, hearing, walking, communication, cognition, self-care, and upper-body functioning. For anxiety and depression, defined as the highest level of difficulty: (1) having anxiety with “daily” frequency and “a lot” of intensity or (2) feeling depressed with “daily” frequency and “a lot” of intensity.
Estimate is unreliable and did not meet National Center for Health Statistics data presentation standards for proportions.
Includes non-Hispanic Asian, Native Hawaiian, Pacific Islander, Native American, Alaska Native, other race, and multiracial.
Defined by the response to “Are you covered by health insurance or some other kind of health care plan?”
Calculated as weight in kilograms divided by height in meters squared (underweight/normal, <25; overweight, 25 to <30; obesity, ≥30). Among participants aged 18 or 19 years, BMI was categorized by using the 2000 Centers for Disease Control and Prevention Growth Charts age- and sex-specific percentiles: underweight/normal, <85th percentile; overweight, 85th to <95th percentile; obesity, ≥95th percentile. 22
Defined by responses to “Have you smoked at least 100 cigarettes in your entire life?” and “Do you now smoke cigarettes?”
Among adults with hypertension, the prevalence of awareness was higher among those with disabilities than among those without disabilities (71.3% vs 55.0%; P < .001). Hypertension awareness prevalence differed significantly between those with and without disabilities by sex, BMI category, and tobacco smoking status. For example, we observed a significantly higher prevalence of hypertension awareness among those with disabilities versus those without disabilities among men (66.7% vs 52.1%) and women (74.8% vs 58.6%) and among those with underweight/normal weight (63.4% vs 46.5%) and obesity (76.5% vs 57.4%).
Similarly, among adults with hypertension, the prevalence of control was higher among adults with disabilities than among those without disabilities (27.3% vs 18.4%; P < .001). The prevalence of hypertension control differed significantly between those with and without disabilities by sex, BMI category, and tobacco smoking status. For example, the prevalence of hypertension control was significantly higher among adults with disabilities than among those without disabilities for men (25.9% vs 17.0%) and women (28.3% vs 20.1%) and among those with underweight/normal weight (20.6% vs 14.0%), overweight (23.1% vs 18.6%), and obesity (30.9% vs 19.8%).
We observed no significant associations between race and Hispanic origin or health insurance coverage and disability status for the prevalence of hypertension, awareness, or control. Additionally, we observed no significant associations between age group and disability status for hypertension awareness or control.
After adjusting for age, sex, race and Hispanic origin, health insurance coverage, BMI category, and tobacco smoking status, adults with disabilities had a higher prevalence of hypertension (APR = 1.12; 95% CI, 1.04-1.21; P = .005), awareness (APR = 1.22; 95% CI, 1.14-1.30; P < .001), and control (APR = 1.31; 95% CI, 1.12-1.54; P = .004) than among adults without disabilities (Table 3). Although adjusted estimates were lower than unadjusted estimates, the direction and statistical significance of the associations remained consistent.
Table 3.
Unadjusted and adjusted prevalence ratios for hypertension outcomes, by disability status, among adults aged ≥18 years, United States, August 2021–August 2023 a
| Outcome | Unadjusted PR b (95% CI) | P value c | Adjusted PRb,d (95% CI) | P value c |
|---|---|---|---|---|
| Hypertension e | 1.27 (1.17-1.37) | <.001 | 1.12 (1.04-1.21) | .005 |
| Awareness of hypertension f | 1.30 (1.20-1.40) | <.001 | 1.22 (1.14-1.30) | <.001 |
| Controlled hypertension g | 1.49 (1.29-1.72) | <.001 | 1.31 (1.12-1.54) | .004 |
Abbreviation: PR, prevalence ratio.
Data source: National Health and Nutrition Examination Survey. 14 All estimates are weighted.
Reference group is no disabilities. Disabilities defined as highest level of difficulty (“a lot of difficulty” or “cannot do at all”) for seeing, hearing, walking, communication, cognition, self-care, and upper-body functioning. For anxiety and depression, defined as the highest level of difficulty: (1) having anxiety with “daily” frequency and “a lot” of intensity or (2) feeling depressed with “daily” frequency and “a lot” of intensity. Estimation of PRs was conducted in SUDAAN by using the predictive margins functions PREDMARG/ADJRR and PRED_EFF in PROC RLOGIST. 20
Determined by logistic regression; significance set at P < .05.
Models adjusted for age group, sex, race and Hispanic origin, health insurance coverage, body mass index category, and smoking status.
Defined as an average blood pressure ≥130/80 mm Hg or a yes response to “Are you now taking any medication prescribed by a doctor for your high blood pressure?”
Defined by the response to “Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?” among those with hypertension.
Defined as average blood pressure <130/80 mm Hg among those with hypertension.
Discussion
During August 2021–August 2023, 20.7% of US adults reported experiencing a disability. Among these, 57.2% had hypertension. In comparison, 45.1% of adults without disabilities had hypertension. Adults with disabilities had a higher prevalence of hypertension, even after adjusting for demographic characteristics, health insurance coverage, and health characteristics. Our results also suggest that among adults with hypertension, those with disabilities have a higher prevalence of hypertension awareness and control.
Our study’s estimated APR for hypertension (APR = 1.12) was similar to that for the 2001-2010 NHANES, which used the previous, higher blood pressure threshold for hypertension and a less comprehensive disability definition (APR = 1.13), 9 suggesting that differences persist in hypertension prevalence among people with and without disabilities, regardless of definitions of hypertension or disability. Hypertension is a treatable condition, and becoming aware of it is the first step in controlling it to reduce the risk of adverse health outcomes. 11 While the prevalence of hypertension control was higher among adults with disabilities (vs those without diabilities), even after accounting for observed differences, the prevalence of hypertension control remained low among adults with hypertension regardless of disability status.
A higher prevalence of hypertension awareness and control among adults with disabilities (vs without disabilities) persisted even among adults with health insurance, indicating that this aspect of health care access may not explain differences. Adults with disabilities may have more frequent health care contact than adults without disabilities because of co-occurring conditions. A study that used nationally representative Medical Expenditure Panel Survey data (2013-2021) found that a significantly higher percentage of adults with disabilities than adults without disabilities had outpatient visits (86.2% for severe and 85.8% for moderate disabilities vs 74.9% for no disabilities). 23 In that study, people with severe disabilities averaged 17.5 visits per year, as compared with 14.0 visits per year for those with moderate disabilities and 8.6 visits per year for those with none. When compared with adults without disabilities, adults with moderate and severe disabilities also reported a higher prevalence of blood pressure measurement within the past 2 years (3.4 and 3.6 percentage points higher, respectively). 23 More frequent health care visits and blood pressure screenings could increase the likelihood of detecting elevated blood pressure and thereby the likelihood of control.
A study using 1999-2010 NHANES data reported that adults with disabilities were more than twice as likely to be told by a physician that they had high blood pressure as compared with adults without disabilities (49.7% vs 20.2%) and, among those with hypertension, 3 times as likely to be prescribed medication for high blood pressure (44.6% vs 14.8%). 24 That analysis did not ascertain hypertension prevalence by using measured blood pressure, but it does highlight the persistently higher likelihood of adults with disabilities to have hypertension diagnosed and treated as compared with those without disabilities. These differences likely underlie the differences seen for awareness and control among those with hypertension. Other studies have highlighted additional steps in achieving blood pressure control, including increasing the frequency of health care visits and increasing treatment intensification, such as the addition of home blood pressure monitoring to inform medication adjustments.25,26
Strengths and Limitations
A key strength of our study was the use of objectively measured blood pressure in a nationally representative sample. To our knowledge, this is the first study to assess the prevalence of hypertension, hypertension awareness, and hypertension control among US adults by disability status using the 2017 AHA/ACC hypertension definition and international disability data standards.
This study also had several limitations. First, the disability measure summarized difficulties experienced across various functioning domains, which can mask differences in prevalence, awareness, and control of hypertension by each type of disability included in the disability measure. Due to small sample sizes, assessing each disability domain was not possible. Comparisons between our study and studies that use different disability definitions and measures should be made with caution. Second, the cross-sectional survey design limited causal interpretation. Third, responses may have been affected by recall bias. Fourth, our analyses may have been subject to uncontrolled confounding. For example, we could not assess the effects of health care visit frequency or access to specialty care. Factors related to antihypertensive medication adherence, cost, and access were not available and, therefore, were not assessed. Finally, NHANES excludes institutionalized populations, whose health profiles may differ from those of noninstitutionalized populations. As such, our findings cannot be generalized to populations in institutionalized settings. However, NHANES accommodates participants through accessible facilities, trained staff, and transportation to the mobile examination centers to facilitate survey participation among community-dwelling adults with disabilities. 14 NHANES interview and response rates at the mobile examination centers for the August 2021–August 2023 cycle were lower than the 2017–March 2020 response rates (51.0% and 46.9%, respectively). 27 An assessment of response rates and nonresponse bias found no evidence that the randomly sampled counties did not adequately represent the US civilian noninstitutionalized population. Despite the decline in response rate and adjustments of sampling methods at the household level to accommodate safety requirements during the COVID-19 pandemic, 28 no major sources of bias were found that were not adequately addressed with weighting methods. 27
Conclusions
Nationally representative data suggest that primary prevention of hypertension may be particularly important for adults with disabilities, while improving hypertension awareness and control remains a public health challenge among adults with and without disabilities. This study is the first step in understanding hypertension prevalence, awareness, and control among US adults by disability status using current definitions and highlights findings that are relevant to Healthy People 2030 objectives, including reducing the proportion of adults with hypertension, 5 increasing control of hypertension among adults, 6 and improving the health and well-being of people with disabilities. 7 Although evidence gaps exist in addressing hypertension management among people with and without disabilities, adults with disabilities may have a higher prevalence of hypertension awareness and control due to more frequent health care contact and health screenings. Further research could examine whether factors such as hypertension treatment, comorbidities, specific disabilities, increased clinical contact, health care visit frequency, or differences in quality of care contribute to these patterns observed for hypertension prevalence, awareness, and control.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Nimit N. Shah, PhD, MPH 
https://orcid.org/0000-0002-7540-8444
Lara J. Akinbami, MD
https://orcid.org/0000-0001-6876-6262
References
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