Abstract
BACKGROUND
Social support is an important determinant of health, yet understanding of its contribution to racial disparities in hypertension is limited. Many studies have focused on the relationship between hypertension and social support, or race/ethnicity and social support, but few have examined the inter-relationship between race/ethnicity, social support, and hypertension. The objective of this study was to determine whether the relationship between race/ethnicity and hypertension varied by level of social support.
METHODS
Data from the National Health and Nutrition Examination Survey (NHANES) 2001–2006 were used to calculate the odds ratios (ORs) for the association between hypertension and race/ethnicity by levels of social support. Hypertension was defined as systolic blood pressure (BP) ≥140 mm Hg and/or diastolic BP ≥ 90 mm Hg or having been prescribed antihypertensive medication. Social support was defined by emotional and financial support, and marital status.
RESULTS
Black/white ORs of hypertension increased as social support decreased; that is, the race difference among those without social support was larger compared to those with social support. Contrarily, Mexican American/white ethnic differences were only observed among those with social support; Mexican Americans with social support had lower odds of hypertension than their white counterparts.
CONCLUSIONS
This study observed that the relationship between race (but not ethnicity) and hypertension varies by social support level. Results suggest there may be beneficial effects of social support on hypertension among blacks, however, the possible impact of social support on ethnic differences in hypertension remains unclear.
Keywords: blood pressure, hypertension, psychosocial factors, Race/ethnicity, social support
Compared to whites, blacks experience a higher prevalence of hypertension and are diagnosed at younger ages,1–3 but the sources of disparities are not well understood. Controlling for age, gender, socioeconomic status (SES), health status, and health behaviors has only partially explained disparities.4,5 A number of psychosocial measures have been associated with hypertension,5–9 including social support.5,10 Social support is the product of interpersonal relationships that may directly affect health or act as a buffer against stressors that are deleterious to health.11,12 Studies restricted to all white or all black samples have found greater levels of social support to be associated with lower blood pressure (BP) or lower incidence of hypertension.6,10,13–18
Studies of race differences in the amount and type of social support received have been conducted with conflicting results. When race differences were found, blacks were less likely to receive social support,19 more likely to have smaller social networks, and more likely to have social support come from family members as compared to whites.19,20 Other studies have found that whites and blacks give and receive similar amounts of social support,21–23 specifically among older populations, where the need for social support may be more evident, and thus may be received more frequently.
Race/ethnic differences in social support may play an important role in the association between race/ethnicity and hypertension. However, studies of the inter-relationship between race, social support, and hypertension are scarce.10,24 There is also a dearth of research on ethnicity, social support, and hypertension, particularly comparing Hispanics to non-Hispanic whites.25 Among Hispanics, Mexican Americans are the largest minority group in the United States.26 The prevalence of hypertension is lower among Mexican Americans compared to whites.27 However, studies of the effect of social support on hypertension in Mexican Americans or on ethnic differences in hypertension are few.28 In general, Mexican Americans receive more support from family than friends,29 and a higher level of social support among Mexican Americans has been proposed as a reason for a lower prevalence of hypertension compared to whites.30
Because social support may buffer against stressors that lead to hypertension, the strength of the association between race and hypertension may be weaker among those with social support as compared to those without social support. Conversely, because the prevalence of hypertension among Mexican Americans is lower compared to whites,27 ethnic differences will be greatest among those with social support; that is, the odds of hypertension should be lowest among Mexican Americans with the most social support, thus the Mexican-American/white odds ratio (OR) of hypertension should be lowest among those with the most social support and should approach one as social support decreases. Hence, the objective of this study is to determine whether the association between race (black vs. white) and hypertension, and ethnicity (Mexican American vs. white) and hypertension varies by level of social support. Specifically, it is hypothesized that the race differences in hypertension will be attenuated among those with social support as compared to those without social support, and ethnic differences will be greater among those with social support compared to those without social support.
METHODS
The National Health and Nutrition Examination Survey (NHANES) is an ongoing nationally representative survey of the health, functional, and nutritional statuses of the US population. Each sequential series of this cross-sectional survey samples the civilian noninstitutionalized population, with an oversample of low-income individuals, participants aged between 12 and 19 years, adults over the age of 60 years, blacks, and Mexican Americans.31 This survey uses a stratified, multistage probability sampling design where data are collected in two phases. First, information regarding the participant’s health history, health behaviors, and risk factors is obtained during a home interview. Then participants are invited to take part in a medical examination where they receive a detailed physical examination.32 Social support questions were only asked of participants aged ≥40 years, therefore, data from 2001 to 2006 were combined, excluded those missing BP measurements and consisted of 5,593 non-Hispanic black, non-Hispanic white (hereafter referred to as black and white), and Mexican-American adults.
Study variables
Hypertension was defined as systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg or currently taking antihypertensive medication. Hypertension was measured following NHANES protocol by calculating average BP, excluding the first measurement.32 For whites and blacks, race was assessed by the response to the question, “What race do you consider yourself to be?” Mexican American respondents were included if they considered themselves Hispanic/Latino and being Mexican American represented their Hispanic origin or ancestry. Social support was assessed by emotional support, financial support, and marital status. Emotional support was assessed by the following: “Can you count on anyone to provide you with emotional support such as talking over problems or helping you make a difficult decision?” (responses were yes, no, “don’t need help”). Financial support was assessed by the following: “If you need some extra help financially, could you count on anyone to help you; for example, by paying any bills, housing costs, hospital visits, or providing you with food or clothes?” (responses were yes, no, “offered help but wouldn’t accept it”). A categorical variable was created to represent having both emotional and financial support (yes to both social support measures), either form of social support (yes to one, but not both measures of social support), and neither form of social support (no to both measures). Sensitivity analyses were performed to determine the effect of including those who refused to respond, were uncertain of, or did not need/would not accept support (n = 215) in the “Neither” group, and determined these persons to be meaningful. Social support was also assessed by current marital status (yes/no).
Demographic variables included age (years) and gender (1 = male; 0 = female). SES was assessed using binary variables for income categories (<$20,000, $20,000–44,999, $45,000–74,999, ≥$75,000), and education categories (less than high school graduate, high school graduate or general equivalency diploma equivalent recipient, more than high school education).
Health-related characteristics included having health insurance (1 = yes; 0 = no), diabetes (1 = yes; 0 = no), obesity (1 = body mass index (BMI) ≥ 30; 0 = BMI < 30), fair/poor health (1 = yes; 0 = no), and physical inactivity (1 = not regularly physically active; 0 = regularly physically active).
Data analysis strategy
The mean and proportional differences between race/ethnic groups for demographic, SES, and health-related characteristics were evaluated using Student’s t-tests for continuous variables and χ2-tests for categorical variables. The odds of hypertension among blacks and Mexican Americans compared to whites were calculated using logistic regression models controlling for demographic, SES, health-related characteristics (Model 1). Analyses additionally controlled for emotional and financial support (Model 2), and marital status (Model 3) to determine the effect of these social support measures on the race/ethnic ORs of hypertension. Analyses to determine whether social support modified the effect of race/ethnicity on hypertension were performed using multiplicative interaction terms.33 If interaction was detected, race and ethnic differences in odds of hypertension were determined within levels of social support, that is, among those with both, either/or and neither/nor emotional and financial support, and among married and unmarried persons. Following the procedure recommended by the National Center for Health Statistics,34 all analyses used Taylor-linearization procedures for the complex multistage sampling design and a weight variable was created to account for combining multiple years of NHANES. P values <0.05 were considered statistically significant and all t-tests were two-sided. All statistical procedures were performed using STATA statistical software, version 10 (StataCorp, College Station, TX).
RESULTS
Table 1 displays the distribution of select demographics and health-related characteristics by race/ethnicity. Compared with whites, blacks and Mexican Americans were younger, and had worse SES profiles than whites. Blacks and Mexican Americans were less likely to be insured, and more likely to report fair/poor health, and be diabetic and physically inactive compared to whites. Blacks were less likely to be male and more likely to be obese than whites. Compared to whites, a greater percentage of blacks were hypertensive (60.1% vs. 45.7%, P < 0.001), whereas Mexican Americans were less likely to be hypertensive (60.1% vs. 33.5%, P < 0.001). Blacks and whites had a similar distribution of emotional and financial support, whereas Mexican Americans were less likely to have both emotional and financial support than whites (P < 0.001). Similar percentages of Mexican Americans were not married when compared to whites (29.1% vs. 29.5%, P = 0.852), while blacks were more likely to not be married (51.6%, P < 0.001).
Table 1.
Distribution of select demographics, SES, and health-related characteristics by race/ethnicity among adults aged ≥40 years, NHANES 2001–2006
| White (n = 3,213) | Black (n = 1,067) | Mexican American (n = 994) | P value | ||
|---|---|---|---|---|---|
| White vs. black | White vs. Mexican American | ||||
| Age, mean ± s.e. | 59.2 ± 0.5 | 56.2 ± 0.5 | 53.9 ± 0.7 | <0.001 | <0.001 |
| Male, % | 48.6 | 44.0 | 52.8 | 0.008 | 0.068 |
| Income, % | |||||
| <$20,000 | 14.7 | 25.1 | 28.6 | <0.001 | <0.001 |
| $20,000–44,999 | 28.6 | 34.2 | 38.7 | ||
| $45,000–74,999 | 24.9 | 21.2 | 19.8 | ||
| ≥$75,000 | 31.9 | 19.4 | 12.9 | ||
| Education, % | |||||
| Less than a high-school graduate | 14.5 | 32.3 | 59.1 | <0.001 | <0.001 |
| High-school graduate/GED equiv. | 29.3 | 22.3 | 15.8 | ||
| More than high school | 56.1 | 45.4 | 25.1 | ||
| Insured, % | 91.9 | 83.3 | 67.5 | <0.001 | <0.001 |
| Fair/poor health, % | 17.7 | 29.9 | 38.5 | <0.001 | <0.001 |
| Diabetes, % | 11.5 | 20.9 | 19.1 | <0.001 | <0.001 |
| Obese, % | 35.0 | 44.0 | 35.5 | <0.001 | 0.812 |
| Physically inactive, % | 34.8 | 46.4 | 56.1 | <0.001 | <0.001 |
| Hypertensive, % | 45.7 | 60.1 | 33.5 | <0.001 | <0.001 |
| Emotional and financial support, % | |||||
| Both | 76.2 | 74.7 | 65.2 | 0.662 | <0.001 |
| Either | 18.3 | 19.7 | 22.5 | ||
| Neither | 5.6 | 5.6 | 12.3 | ||
| Unmarried, % | 29.5 | 51.6 | 29.1 | <0.001 | 0.852 |
GED, general equivalency diploma; SES, socioeconomic status.
Table 2 presents the association between race/ethnicity, social support, and hypertension for adults aged ≥40 years. In Model 1, controlling for demographics, SES, and health-related characteristics, blacks had higher odds of hypertension than whites (OR = 1.99, 95% CI = 1.68–2.36), and Mexican Americans had lower odds (OR = 0.69, 95% CI = 0.52–0.92). Model 2 adjusts for covariates in Model 1 plus emotional and financial support. Emotional and financial support were not predictive of hypertension. In Model 3, which adjusts for marital status as well as covariates in Model 1, marital status is not predictive of hypertension. Neither emotional and financial support nor marital status affected the race/ethnicity ORs of hypertension.
Table 2.
Association between race/ethnicity, social support and hypertension among adults aged ≥40 years, NHANES 2001–2006
| Model 1 | Model 2 | Model 3 | ||||
|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| Race/ethnicity | ||||||
| White | 1.00 | 1.00 | 1.00 | |||
| Black | 1.99 | 1.68–2.36 | 1.99 | 1.67–2.36 | 1.97 | 1.66–2.34 |
| Mexican American | 0.69 | 0.53–0.92 | 0.70 | 0.53–0.93 | 0.70 | 0.52–0.92 |
| Age | 1.07 | 1.06–1.07 | 1.07 | 1.06–1.07 | 1.07 | 1.06–1.07 |
| Male | 0.90 | 0.76–1.07 | 0.91 | 0.76–1.08 | 0.91 | 0.76–1.08 |
| Income | ||||||
| <$20,000 | 1.00 | 1.00 | 1.00 | |||
| $20,000–44,999 | 0.91 | 0.71–1.17 | 0.90 | 0.71–1.15 | 0.92 | 0.71–1.20 |
| $45,000–74,999 | 1.04 | 0.81–1.32 | 1.02 | 0.80–1.31 | 1.06 | 0.81–1.38 |
| ≥$75,000 | 0.77 | 0.58–1.01 | 0.75 | 0.57–0.99 | 0.79 | 0.59–1.06 |
| Education | ||||||
| Less than high-school graduate | 1.00 | 1.00 | 1.00 | |||
| High-school graduate/GED equiv. | 1.10 | 0.89–1.36 | 1.10 | 0.89–1.36 | 1.10 | 0.89–1.35 |
| More than high school | 1.01 | 0.83–1.23 | 1.01 | 0.82–1.23 | 1.00 | 0.82–1.23 |
| Insured | 1.65 | 1.30–2.09 | 1.64 | 1.29–2.09 | 1.64 | 1.29–2.08 |
| Fair/poor health | 1.59 | 1.22–2.06 | 1.59 | 1.22–2.08 | 1.59 | 1.22–2.06 |
| Diabetes | 1.73 | 1.33–2.26 | 1.74 | 1.34–2.26 | 1.73 | 1.33–2.26 |
| Obese | 1.96 | 1.64–2.34 | 1.96 | 1.65–2.34 | 1.96 | 1.65–2.34 |
| Physically inactive | 1.04 | 0.83–1.31 | 1.04 | 0.83–1.31 | 1.04 | 0.83–1.31 |
| Emotional and financial support | ||||||
| Both | 1.00 | |||||
| Either | 0.94 | 0.75–1.17 | ||||
| Neither | 0.80 | 0.62–1.02 | ||||
| Unmarried | 1.06 | 0.88–1.28 | ||||
CI, confidence interval; GED, general equivalency diploma; OR, odds ratio.
Interaction between race/ethnicity and each social support measure is evaluated in Table 3. Only the interaction between race and having emotional and financial support was significant. The black/white OR in those who have neither emotional nor financial support is more than two times greater than in those with both forms of support (OR = 2.21, 95% CI = 1.04–4.69).
Table 3.
Interaction between measures of social support and race/ethnicity on odds of hypertension, NHANES 2001–2006
| Emotional and financial support | Marital status | |||
|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | |
| Model 1 | ||||
| Black race | 1.89 | 1.65–2.16 | ||
| Social support | ||||
| Both | — | — | ||
| Either | 0.93 | 0.73–1.19 | ||
| Neither | 0.72 | 0.53–0.96 | ||
| Black race × social support | ||||
| Black race × both | — | — | ||
| Black race × either | 1.04 | 0.61–1.78 | ||
| Black race × neither | 2.21 | 1.04–4.69 | ||
| Model 2 | ||||
| Black race | 1.83 | 1.46–2.30 | ||
| Unmarried | 1.04 | 0.83–1.30 | ||
| Black race × unmarried | 1.15 | 0.83–1.59 | ||
| Model 3 | ||||
| Mexican-American ethnicity | 0.69 | 0.50–0.95 | ||
| Social support | ||||
| Both | — | — | ||
| Either | 0.93 | 0.73–1.19 | ||
| Neither | 0.72 | 0.53–0.97 | ||
| Mexican-American ethnicity × social support | ||||
| Mexican-American ethnicity × both | — | — | ||
| Mexican-American ethnicity × either | 0.98 | 0.67–1.41 | ||
| Mexican-American ethnicity × neither | 1.54 | 0.74–3.19 | ||
| Model 4 | ||||
| Mexican-American ethnicity | 0.69 | 0.51–0.93 | ||
| Unmarried | 1.05 | 0.83–1.31 | ||
| Mexican-American ethnicity × unmarried | 1.13 | 0.78–1.63 | ||
Adjusted for age, gender, income, education, insurance, self-rated health, diabetes, obesity, and physical inactivity. OR, odds ratio; CI, confidence interval.
Adjusted race ORs of hypertension stratified by social support are presented in Table 4. Black/white ORs are greatest in those with neither emotional nor financial support (OR = 5.82, 95% CI = 2.41–14.0), and odds ratios decrease as social support increases. Among those with either emotional or financial support, blacks had more than two times the odds of being hypertensive compared to whites (OR = 2.28, 95% CI = 1.23–4.22). Blacks with both emotional and financial support had almost two times the odds of being hypertensive than their white counterparts (OR = 1.82, 95% CI = 1.58–2.10). A similar trend is observed comparing the black/white OR among unmarried persons vs. married persons. However, race differences did not vary by marital status.
Table 4.
Fully adjusted race/ethnicity odds ratios of hypertension by level social support among those aged ≥40 years, NHANES 2001–2006
| Black/white | Mexican American/white | |||
|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | |
| Emotional and financial support | ||||
| Both | 1.82 | 1.58–2.10 | 0.66 | 0.48–0.91 |
| Either | 2.28 | 1.23–4.22 | 0.85 | 0.53–1.35 |
| Neither | 5.82 | 2.41–14.0 | 0.98 | 0.40–2.41 |
| Marital status | ||||
| Married | 1.87 | 1.49–2.35 | 0.71 | 0.52–0.96 |
| Unmarried | 2.07 | 1.61–2.66 | 0.72 | 0.46–1.13 |
Adjusted for age, gender, income, education, insurance, self-rated health, diabetes, obesity, and physical inactivity. OR, odds ratio; CI, confidence interval.
Among Mexican Americans, ethnic differences in hypertension were only observed among those with the most social support. Mexican Americans with both emotional and financial support were less likely to be hypertensive than their white counterparts (OR = 0.66, 95% CI = 0.48–0.91). Among other groups, the Mexican-American/white OR of hypertension was not significant, but there seems to be a downward trend. The ethnic OR of hypertension was significant among married persons but not among unmarried persons.
DISCUSSION
There is abundant evidence demonstrating race/ethnic differences in hypertension.1–3,27 Social support is also a well-documented determinant of hypertension.5,10,14–18 However, the inter-relationships among race/ethnicity, hypertension, and social support have not been clearly explicated. It was hypothesized that race differences in the odds of hypertension would decrease as social support increased, and ethnic differences would increase as social support increased. The findings of this study indicate that race differences in hypertension were reduced among those who received both emotional and financial support compared to those who received neither of these, consistent with the study hypothesis. However, race differences did not vary by marital status. As hypothesized, Mexican Americans with both forms of social support had lower odds of hypertension than their white counterparts, whereas ethnic differences were not observed among those with either emotional or financial support or those with neither emotional nor financial support. Ethnic differences were observed among married but not unmarried persons. However, the interactions between neither social support and ethnicity nor marital status and ethnicity were significant.
Other studies examining the inter-relationship of race, hypertension, and social support are few. One study examined race differences in self-reported hypertension controlling for social support and found that social support explained only 3% of the effect of race on hypertension,24 as in the present study (Table 2); however, they did not stratify by social support. In contrast, another study found that the unadjusted odds of hypertension were significantly greater among persons without social support compared to persons with social support in black and white adults.10 After adjusting for covariates, there was no relationship between social support and hypertension for whites, but social support remained a significant predictor among blacks. Though the methodology between this study and the present study differ, they both demonstrate that social support is an important factor in the relationship between race and hypertension.
When examining race differences by social support, the black/white OR decreased as emotional and financial support increased. The larger race OR among those with neither form of social support is likely due to the decreased odds of hypertension among whites with neither emotional nor financial support. Whites in the neither group had decreased odds of hypertension (Table 3) only when whites who responded that they did not need emotional support or would not accept financial support were included in the neither group. Thus, whites who responded that they did not need or would not accept support had lower odds of hypertension than whites who reported having both forms of support. The literature finds little evidence for a negative effect of social support on health,12 but there is no research on possible positive effects of not needing or wanting social support. To further complicate these results, it is unknown whether those persons who responded that they did not need or would not accept social support actually have those resources, but do not acknowledge them.
Two theories, main effects and buffering effects, have been used to describe how social support is related to health. The main effects of social support find a direct beneficial effect on health by lowering BP or influencing health behaviors such as exercise, and sleep or eating habits.11,12 The buffering hypothesis finds that social support is beneficial to health only when stress threatens health, that is, social support buffers against the deleterious effects of stress on health.11,12 Because lower odds of hypertension were associated with not needing or wanting social support among whites, this may suggest buffering effects of social support rather than main effects. The main effects theory of social support intrinsically relies on the notion that health and social support are positively related. It is only within the paradigm of the buffering hypothesis of social support that the results of this study can be interpreted; however, because stress was not included in this study, testing the buffering hypothesis could not be done.
Even more paradoxical is the relationship between social support and hypertension among blacks. Because the interaction between social support and race was likely due to whites with neither form of social support, it is possible that the odds of hypertension do not vary by social support among blacks. Though this is contrary to some studies,10 it may give some insight into social support mechanisms. Blacks are disproportionately represented in lower SES groups and are more likely to experience discrimination, be exposed to stressful situations and live under adverse conditions.35,36 These may lead to experiences of chronic stress among blacks.35,36 Indeed, studies have found that blacks exhibit higher levels of physiologic response to stress than whites.37 If blacks experience stressors constantly, the buffering effects of social support may be ineffective.
Contrary to other studies, Mexican Americans received less social support than whites, thus the effects of social support on ethnic differences may be masked. Also, other factors such as support from family vs. friends may have yielded results more similar to the literature. 29 In light of this, the relationship between ethnicity and hypertension appears not to differ by level of social support. Studies have shown that discrimination stress is associated with health only among Mexican Americans with low levels of social support,30 indicating a protective effect. Though Mexican Americans may experience constant stressors such as lower SES environments and acculturative stress,30 the mechanism by which Mexican Americans interpret and deal with stressors (here, by social support) may differ from blacks and may not differ from whites.
This study advances our understanding of race/ethnic differences in hypertension by highlighting the importance of social support on the relationship between race/ethnicity and hypertension. By combining emotional and financial support, and assessing the influence of marital status, the study uses more than one measure of social support which is consistent with theory that suggests that social support is obtained from a number of sources, in a number of ways.38 Moreover, this study is one of few that uses marital status to assess the race/ethnic differences in hypertension in a nationally representative sample.25 The results of this study should be considered within the context of some limitations. In NHANES 2001–2006, only persons >40 years were administered questions on social support. Social support has been found to be related to hypertension/BP in studies including persons <age 40.10,13,14 Future studies that include these persons in surveys that assess social support would be useful. Although both emotional and financial support were assessed, satisfaction with social support (such as marital quality), which has been linked to health as well,12 could not be assessed. Family vs. friend support could not be assessed using this data set, which may be important because race and ethnic differences in sources of support have been cited in the literature.19,20,29,30,39,40 Including alcohol use and smoking status rendered interaction analyses insignificant. However, because alcohol use and smoking status were not related to hypertension or social support, these variables were not included in the analyses. Furthermore, NHANES oversamples only Mexican Americans among Hispanics, and data on other Hispanic subgroups is not publicly available. It is unknown whether these relationships are true for other Hispanic subgroups.
This study observed that the relationship between race and hypertension varies by social support level, although this variation was not seen for ethnicity. The results of this study suggest there may be beneficial effects of social support on hypertension among blacks, but the observed decrease in black/white ORs with an increase in social support may be due to the relationship between social support and hypertension among whites, rather than among blacks. The study was unable to determine the mechanism by which social support may beneficially affect health.
Acknowledgments
This research was supported by grant #P60MD000214-01 from the National Center on Minority Health and Health Disparities (NCMHD) of the National Institutes of Health (NIH).
Footnotes
Disclosure: The authors declared no conflict of interest.
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