Behind the Missed Pill: Tracing the Social Determinants of Uncontrolled Hypertension From Behavior to Housing, Income, and Access
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Doctor of Nursing Practice Program, Aspen University
DNP875: Population Health and Person-Centered Care
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Month Day, Year
Behind the Missed Pill: Tracing the Social Determinants of Uncontrolled Hypertension From Behavior to Housing, Income, and Access
When blood pressure is uncontrolled, clinical records often cite nonadherence: the patient did not take medication, did not follow a low-sodium diet, or missed appointments. These explanations are accurate but incomplete. They describe what patients did without asking why. This paper traces the determinants of uncontrolled hypertension in the composite Delmont County population from individual behaviors back to the social and economic conditions that shape them, using a framework from the cardiovascular literature and the theory of fundamental causes, and draws implications for intervention.
A Framework for Social Determinants
An American Heart Association scientific statement reviewed social determinants of cardiovascular risk and outcomes and organized them into domains including socioeconomic position, race and ethnicity, social support and social networks, culture and language, access to care, and the residential environment (Havranek et al., 2015). Link and Phelan (1995) called social conditions fundamental causes of disease: they govern whether people have the money, knowledge, power, and social ties needed to avoid risks and to make use of treatment. When one mechanism linking poverty to disease is removed, the fundamental cause finds another. The theory predicts that improving blood pressure care alone will not close gaps unless the resources that allow people to use that care are also addressed.
From Behavior to Conditions: Medication
In Delmont County's clinical data, patients without insurance or with high-deductible plans had lower control than those with Medicaid or traditional Medicare. Chart reviews of 60 patients with uncontrolled hypertension found that 22 had documented gaps in filling prescriptions. Follow-up calls revealed reasons beyond forgetfulness: medication costs after a deductible reset in January, a pharmacy 20 miles away after the town's only pharmacy closed, and work schedules that did not allow pharmacy visits during open hours. What the chart called nonadherence was, for many patients, a cost, a distance, or a shift schedule.
From Behavior to Conditions: Diet
Advice to reduce sodium and eat more fruits and vegetables assumes access to affordable food. In a national study of low-income adults, food insecurity was associated with self-reported hypertension and with laboratory or examination evidence of hypertension, after adjustment for age, sex, race, education, and income (Seligman et al., 2010). In Delmont County, two rural townships have no full-service grocery store, and residents rely on convenience stores where processed, high-sodium foods are cheapest. Dietary behavior here reflects the residential environment and household budgets as much as knowledge or motivation.
From Behavior to Conditions: Appointments and Access
Missed follow-up visits were concentrated among patients who rely on public transportation, which runs only twice daily in the rural townships, and among hourly workers who lose pay when they miss work. The federally qualified health center offers evening hours two days a week, but the hospital-owned practices close at 5 p.m. Language also matters: among patients whose preferred language was Spanish, control was lower, and interviews revealed that some did not understand dose changes discussed without an interpreter. These are access and communication barriers produced by how care is organized, not by patients' indifference.
Housing and Stress
Housing instability adds another layer. Patients facing eviction or living in crowded or unsafe housing report difficulty storing medications, keeping appointments, and managing stress. The scientific statement notes that chronic stress associated with low socioeconomic position and adverse neighborhood conditions may contribute to cardiovascular risk through physiological as well as behavioral pathways (Havranek et al., 2015). For some patients, blood pressure is a marker of an unstable life, not simply a failure of self-management.
Race, Discrimination, and Trust
In the county data, Black adults in the hypertension population had lower control than White adults, a gap that persisted after accounting for insurance type. Race is not a biological explanation for this difference; it is a marker of exposure to conditions shaped by historical and current discrimination, including residential segregation, lower average wealth, and experiences of bias in health care (Havranek et al., 2015). Several Black patients interviewed for the chart review described feeling rushed or disbelieved at visits and preferring to manage medications on their own terms. Trust is a determinant too: a patient who doubts that a clinician has their interests in mind is less likely to follow advice, and that doubt often has a basis in experience. Addressing this gap requires attention to how care is delivered, including continuity with the same clinician, time to discuss concerns, and involvement of community partners whom patients already trust.
Implications for Intervention
Tracing behaviors to conditions changes what the project should do. Medication gaps call for low-cost generic regimens, 90-day supplies, and mail-order or delivery options. Diet advice must be paired with food resources, such as produce prescriptions or partnerships with food banks. Appointment gaps call for evening and telehealth visits and transportation assistance. Language gaps call for professional interpreters and translated written plans. And screening for social needs, with referral to housing and income supports, belongs in hypertension care. Fundamental cause theory warns that these steps must be sustained and broad, because narrow fixes are easily outpaced by the conditions that produce disparities (Link & Phelan, 1995).
Limits of This Analysis
The local findings come from a chart review of 60 patients and follow-up calls, which illustrate mechanisms but cannot measure how common each barrier is across the population. The next module will compare rates across subgroups with the full clinical data to test whether the patterns described here hold at scale. Where they do, the project can prioritize the determinants that affect the most people; where they do not, it will revisit its assumptions before designing interventions.
Conclusion
Uncontrolled hypertension in Delmont County is often recorded as nonadherence, but tracing that behavior upstream reveals costs, distances, food environments, work schedules, language barriers, and housing instability. A social determinants framework and the theory of fundamental causes explain why these conditions matter and why they persist. Population health interventions that address them, not only the behaviors they produce, have a better chance of improving control across the whole population.
References
Havranek, E. P., Mujahid, M. S., Barr, D. A., Blair, I. V., Cohen, M. S., Cruz-Flores, S., Davey-Smith, G., Dennison-Himmelfarb, C. R., Lauer, M. S., Lockwood, D. W., Rosal, M., & Yancy, C. W. (2015). Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American Heart Association. Circulation, 132(9), 873-898. https://doi.org/10.1161/CIR.0000000000000228
Link, B. G., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of Health and Social Behavior, 35(Extra Issue), 80-94. https://doi.org/10.2307/2626958
Seligman, H. K., Laraia, B. A., & Kushel, M. B. (2010). Food insecurity is associated with chronic disease among low-income NHANES participants. The Journal of Nutrition, 140(2), 304-310. https://doi.org/10.3945/jn.109.112573
How this DNP 875 Module 3 example is structured
DNP875 Module 3 work often traces determinants past behavior into housing, income and access. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example introduces two frameworks, traces three behaviors to their social conditions with local data and published evidence, adds housing and stress and draws specific intervention implications.
DNP875 Module 3 questions, answered
What does DNP875 Module 3 usually ask for?
The module often asks you to analyze the social determinants behind a health problem in your population, tracing causes beyond individual behavior to conditions such as income, housing and access to care. Aspen does not publish module deliverables, so your classroom's instructions govern.
What is fundamental cause theory?
Link and Phelan's argument that social conditions cause disease by shaping access to resources such as money, knowledge, power and social connections, so that when one pathway is blocked, the disparity reappears through another.
Is food insecurity linked to hypertension?
In a national study of low-income adults, food insecurity was associated with both self-reported and measured hypertension after adjusting for age, sex, race, education and income.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.