Beyond biology: Social and geographic determinants of hypertension in rural Alabama communities

Hypertension remains a leading modifiable risk factor for cardiovascular morbidity and mortality in the United States. Despite advances in detection and treatment, disparities in hypertension prevalence, control, and outcomes persist across racial, gender, and geographic lines, particularly in the rural Deep South. To examine the associations between race, gender, age, and geography on systolic and diastolic blood pressure among adult patients in West Alabama, and to identify patterns that may inform equitable, place-based interventions. De-identified health records from 3,462 adult patients across nine West Alabama counties were analyzed. Systolic and diastolic blood pressure were modeled as dependent variables using multivariate analyses including race, gender, age, and zip code. Interaction terms were examined to assess moderating effects between demographic and geographic variables. Systolic blood pressure (SBP) was most strongly predicted by age (p < 0.0001), with steeper increases among men. The steeper increase for men with age was driven by Black men - Black men showed a steeper SBP increase with age than Black women while White women showed a steeper increase than White men. Diastolic blood pressure (DBP) was independently associated with race, gender, and zip code (p < 0.05), with higher DBP among Black adults across geographic areas. Geographic variation persisted for both SBP and DBP, suggesting the influence of local social determinants of health. Distinct demographic and geographic patterns in blood pressure highlight the intersection of biological and structural factors driving cardiovascular disparities in rural Alabama. Addressing these inequities will require multilevel strategies integrating clinical care, community resources, and place-based policy interventions.