Crimson Publishers Publish With Us Reprints e-Books Video articles

Full Text

Gerontology & Geriatrics Studies

Social Determinants of Health and Psychosocial Stressors in the Control of Arterial Hypertension in the Elderly in Countries with Medium and Low Economic Income

Sebastian Galvis Acevedo*

Department of Family Medicine, Faculty of Health, Universidad del Valle, Colombia

*Corresponding author:Sebastian Galvis-Acevedo, Department of Family Medicine, Faculty of Health, Universidad del Valle, Colombia

Submission: July 21, 2022; Published: August 24, 2022

DOI: 10.31031/GGS.2022.08.000676

ISSN 2578-0093
Volume8 Issue1


We recently published a secondary analysis of a population survey conducted among the elderly population in Colombia between 2015 and 2016, in which we found that age over 74 years and residence in a rural area were variables associated with poorer control of diabetes. blood pressure in non-institutionalized older adults in Colombia [1], a low- to middle-income country located in South America.

Life expectancy is increasing in the world and demographic data shows that about 11% of the world population is over 60 years old, with a projected increase, by 2050, to 22% of the population [2]. Similarly, the prevalence of chronic non-communicable diseases is increasing worldwide, and cardiovascular disease continues to be the leading cause of death worldwide, with high blood pressure being its main risk factor [3]. Cardiovascular Disease (CVD) is responsible for the main cause of loss of Disability-Adjusted Life Years (DALYS) and this carries great costs for health systems worldwide [4].

In Colombia, the differences in blood pressure control in its older adult population could be explained, in part, by the gap that exists between the countryside and the city and by the age of older adults (those >75 years who are worse controlled). The final report of the Commission on Social Determinants of Health of the World Health Organization in 2008 invites governments and institutions to promote research on the incidence of social determinants in the health of populations [5]. In accordance with this, the medical literature that shows the participation of social determinants of health and psychosocial factors in the control of arterial hypertension is growing.

The prevalence of depression in adults between 55 and 74 years old is 13% (men 5.5% and women 7.5%) [6]. There are studies that have shown that hypertensive patients who are depressed are less well controlled [7,8]. In contrast, other studies show that depressive patients have better control of hypertension, probably attributed to the increased use of health services [9]. The scientific evidence is not yet conclusive regarding the direction of this association, although it seems to be more the association between depression and uncontrolled hypertension. Depression has been associated with increased ACTH, serum cortisol, stress-mediated sympathetic tone, decreased parasympathetic activity [8,10] and, furthermore, has been associated with changes in behavioral factors that affect blood pressure control [11,12].

On the other hand, there are studies that relate social participation with the control of hypertension. According to the theory of social capital in health [13], community participation leads to a greater perception of social cohesion and, in turn, favors greater available social support. The more an older adult participates, the more likely he is to perceive that people in his community can be trusted and that they could help him if needed, which would ultimately be associated with better health outcomes. As with depression, the scientific evidence regarding the association of social support with adequate control of hypertension is still inconclusive. In the study we carried out in Colombia [1], we did not find an association between social support and better blood pressure control, which is consistent with that reported by other authors Bahari G et al. [14] Poblete F et al. [15] Thuy LQ et al. [16]. However, other previous studies have observed that low social support is associated with uncontrolled high blood pressure [17,18] and lower risk of arterial hypertension in older adults who provide social support (volunteers) [18,19].

On the other hand, there are studies in the literature that show that hypertensive patients who experience displacement from their place of origin have differences in blood pressure control when they change their place of origin. Although in our study we did not find this association, in Colombia there is a large volume of internal migrations that are attributed, in large part, to the internal armed conflict that produces forced displacement, psychosocial stress and geographical barriers to access to health services and administrative [20,21].

Income inequality has also been associated with arterial hypertension control and CVD risk. There are differences in the prevalence of hypertension and its control according to the level of socioeconomic income and its different measures that include income level, educational level, employment status and environmental factors [22]. Lower quintiles of household income have been found to be associated with poorer blood pressure control and increased risk of all-cause mortality [23].

Today there are calculators that model and predict global cardiovascular risk at 10 years and include traditional risk factors (smoking, age, sex, serum cholesterol, among others) and some biomarkers such as High-sensitivity C-reactive protein. Nontraditional cardiovascular risk factors such as autoimmune disease (systemic lupus erythematosus, rheumatoid arthritis), HIV infection, psychosocial stressors, and social determinants, among others, could be applied to better inform treatment decisions in patients in whom the risk remains intermediate or uncertain [24]. These determinants of health, including social support, social networks, socioeconomic status, and mental health disorders, affect the risk of cardiovascular disease [25]. Larger numbers of adults older than 85 years need to be included in clinical trials to determine how hard cardiovascular outcomes are shared in this age group [26].

In conclusion, in the older adult population with uncontrolled hypertension, primary care physicians should pay close attention to exploring the psychosocial and health determinant factors that are directly associated with poorer control of hypertension and increased CV risk or that they do so indirectly by affecting medication adherence [27], changes in lifestyles and geographic and administrative barriers to access to the health system. The differential focus of public policies towards the vulnerable elderly population in remote and rural areas and the reduction of geographic and administrative barriers to access to health services can impact cardiovascular morbidity and mortality associated with poor blood pressure control and improve health inequities that are a result, in part, of social inequalities in low-and middle-income countries.


  1. Galvis S, Candamil AF, Herrera JA, Calzada MT (2022) Social, clinical and psychosocial determinants associated with uncontrolled arterial hypertension in older adults: SABE Survey Colombia 2016. Rev Esp Geriatr Gerontol 57(3):139-145.
  2. Kanasi E, Ayilavarapu S, Jones J (2016) The aging population: Demographics and the biology of aging. Periodontology 2000 72(1): 13-18.
  3. Murray CJL, Aravkin AY, Zheng P, Abbafati C, Abbas KM, et al. (2020) Global burden of 87 risk factors in 204 countries and territories, 1990-2019: A systematic analysis for the global burden of disease study 2019. The Lancet 396(10258): 1223-1249.
  4. Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, et al. (2020) Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: A systematic analysis for the global burden of disease study 2019. Lancet 396(10258): 1204-1222.
  5. World Health Organization (2008) Closing the gap in a generation: Health equity through action on the social determinants of health.
  6. Ferenchick EK, Ramanuj P, Pincus HA (2019) Depression in primary care: Part 1-screening and diagnosis. BMJ 365: 1794.
  7. Chacón J, Sandoval D, Muñoz R, Romero T (2015) Evaluation of blood pressure control and therapeutic adherence in hypertensive patients followed in the cardiovascular health program (PSCV): Association with clinical, socioeconomic and psychosocial characteristics. Chilean Journal of Cardiology 34(1): 18-27.
  8. Rubio AF, Rodriguez L, Vargas G, Huerta S, Serna DC, et al. (2013) Depression increases the risk for uncontrolled hypertension. Experimental and Clinical Cardiology 18(1): 10-12.
  9. Michal M, Wiltink J, Lackner K, Wild PS, Zwiener I, et al. (2013) Association of hypertension with depression in the community: Results from the Gutenberg health study. Journal of Hypertension 31(5): 893-899.
  10. Brown ES, Varghese FP, McEwen BS (2004) Association of depression with medical illness: Does cortisol play a role? Biological Psychiatry 55(1): 1-9.
  11. Strine TW, Mokdad AH, Dube SR, Balluz LS, et al. (2008) The association of depression and anxiety with obesity and unhealthy behaviors among community-dwelling US adults. General Hospital Psychiatry 30(2): 127-137.
  12. Wang PS, Bohn RL, Knight E, Glynn RJ, Mogun H, et al. (2002) Noncompliance with antihypertensive medications: The impact of depressive symptoms and psychosocial factors. J Gen Intern Med 17(7): 504-511.
  13. Douglas H, Georgiou A, Westbrook J (2017) Social participation as an indicator of successful aging: An overview of concepts and their associations with health. Aust Health Rev 41(4): 455-462.
  14. Bahari G, Scafide K, Krall J, Mallinson RK, Weinstein A (2019) Mediating role of self‐efficacy in the relationship between family social support and hypertension self‐care behaviours: Across‐sectional study of Saudi men with hypertension. International Journal of nursing practice 25(6): 1-8.
  15. Poblete F, Barticevic N, Sapag JC, Tapia P, Bastías G, et al. (2018) Perceived social support in patients with arterial hypertension and type II diabetes mellitus in primary care and its relationship with self-perceived health. Chilean Medical Journal 146(10): 1135-1142.
  16. Thuy LQ, Thanh NH, Trung LH, Tan PH, Nam HTP, et al. (2021) Blood pressure control and associations with social support among hypertensive outpatients in a developing country. Biomed Res Int 2021: 7420985.
  17. Nyaaba GN, Stronks K, Meeks K, Beune E, Owusu-Dabo E, et al. (2019) Is social support associated with hypertension control among Ghanaian migrants in Europe and non-migrants in Ghana? The RODAM study. Internal and Emergency Medicine 14(6): 957-966.
  18. Pirkle CM, Ylli A, Burazeri G, Sentell TL (2018) Social and community factors associated with hypertension awareness and control among older adults in Tirana, Albania. European Journal of Public Health 28(6): 1163-1168.
  19. Burr JA, Tavares J, Mutchler JE (2011) Volunteering and hypertension risk in later life. J Aging Health 23(1): 24-51.
  20. Lucumi DI, Schulz AJ, Israel BA (2016) Local actors’ frames of the role of living conditions in shaping hypertension risk and disparities in a colombian municipality. J Urban Health 93(2): 345-363.
  21. Shami S (1993) The social implications of population displacement and resettlement: An overview with a focus on the Arab Middle East. Int Migr Rev 27(1): 4-33.
  22. Anstey DE, Christian J, Shimbo D (2019) Income inequality and hypertension control. J Am Heart Assoc 8(15): e013636.
  23. Shahu A, Herrin J, Dhruva SS, Desai NR, Davis BR, et al. (2019) Disparities in socioeconomic context and association with blood pressure control and cardiovascular outcomes in ALLHAT. Journal of the American Heart Association 8(15): e012277.
  24. Khambhati J, Allard-Ratick M, Dhindsa D, Lee S, Chen J, et al. (2018) The art of cardiovascular risk assessment. Clinical Cardiology 41(5): 677-684.
  25. Marmot M, Bobak M (2000) International comparators and poverty and health in Europe. BMJ 321(7269): 1124-1128.
  26. Aronow WS (2020) Managing hypertension in the elderly: What’s new? Am J Prev Cardiol 1: 100001.
  27. Sanchez JA, Galvis S, Preciado CJ, Solarte W (2021) Psychosocial determinants and pharmacologic adherence in geriatric patients. Atención Familiar 29(2): 126-129.

© 2022 Sebastian Galvis Acevedo. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and build upon your work non-commercially.