DPH 801 Module 1 Determinants and Roots of Disparities Example

The Causes of the Causes: Determinants Behind Racial Disparities in Uncontrolled Hypertension

Student Name

Doctor of Public Health Program, Aspen University

DPH 801: Health Determinants, Disparities, Behavior and Promotion

Instructor Name

Month Day, Year

The Causes of the Causes: Determinants Behind Racial Disparities in Uncontrolled Hypertension

Disparities in health do not arise from individual choices alone. They follow patterns laid down by where people live, what work they do, how they are treated and what resources their communities hold. A doctoral public health practitioner must trace a disparity from its visible clinical expression back to the structures that produce it. This paper traces the determinants of racial disparities in uncontrolled hypertension in a composite city, as a foundation for choosing theories and interventions later in the course.

The Disparity

In the composite city of 620,000, Black adults with hypertension are about 40% more likely than White adults with hypertension to have blood pressure above 140/90 despite diagnosis, and stroke death rates among Black residents are nearly twice those of White residents. The gap persists after accounting for insurance status, suggesting that more than access to a clinic is involved.

Causes of the Causes

A widely cited review urged public health to trace problems back to the causes behind the causes, the policy-shaped conditions of daily life that set people's exposure to risk and their access to resources from childhood onward. It emphasized that health behaviors themselves are shaped by these conditions, so interventions targeting behavior alone rarely close gaps (Braveman & Gottlieb, 2014).

Determinants by Level

The table traces hypertension disparities from downstream to upstream.

Discrimination as a Stressor

A review of research on discrimination and health found that self-reported discrimination is associated with poorer mental and physical health, including elevated blood pressure and cardiovascular risk markers, through pathways involving chronic stress, altered health behaviors and reduced access to quality care (Williams & Mohammed, 2009). Repeated exposure to discrimination can act as a persistent stressor that raises blood pressure over time.

Structural Racism

Structural racism describes how interlocking institutions, from housing markets and schools to lending, labor, media, medicine and policing, produce and sustain racial inequity even without individual intent. A review in a major medical journal described how historical redlining, segregation and unequal investment continue to shape health, and argued for interventions that address structures rather than individuals alone (Bailey et al., 2017).

Applying Structure to the City

In the composite city, neighborhoods redlined in the 1930s still have lower home values, fewer grocery stores, more fast-food outlets and fewer primary care practices per resident. Residents work disproportionately in hourly jobs without paid sick leave, making daytime appointments costly. These conditions shape the downstream factors clinicians see: missed visits, high-sodium diets and stress.

Life Course Perspective

Determinants accumulate across the life course. Childhood poverty, adverse experiences and early exposure to stress are associated with higher blood pressure in adulthood. A life course view helps explain why disparities appear early and widen with age, and it points to prevention before hypertension develops. Programs for young adults, such as screening at community colleges and workplaces, can catch rising pressure before it becomes entrenched.

Measuring Determinants

Measuring structural determinants is difficult. Analysts use proxies such as neighborhood deprivation indexes, segregation measures, historical redlining maps, eviction rates and wealth data, alongside survey measures of discrimination. Each has limits, and combining area-level and individual-level measures gives a fuller picture.

Implications for Theory Choice

Because hypertension disparities are driven at every level, individual-level behavior theories alone will not suffice. Later modules will compare individual, interpersonal and community theories and consider how they can be combined, for instance by addressing individual beliefs within community settings that residents trust and by pairing programs with policy change.

Ethical Considerations

Analyzing disparities through determinants avoids blaming individuals for conditions they did not create. It also carries responsibility: naming structural racism implies that public health must engage with policies in housing, labor and justice, not only health care.

Health Care as a Determinant

Health care itself can reproduce disparities. Black patients are less likely to have medication intensified when blood pressure is high, are more likely to receive care in under-resourced clinics and report more experiences of being dismissed by clinicians. These patterns reflect bias and institutional practices, not only patient behavior, and they fall within public health's scope.

Neighborhood Food and Activity Environments

Sodium-heavy processed foods are cheaper and more available in many segregated neighborhoods, while fresh produce is scarce. Unsafe streets and few parks limit walking. These environments make the healthy choices recommended for blood pressure harder, which is why food access and built environment appear at the midstream level of the analysis.

Intersections of Determinants

Determinants interact. A man working two hourly jobs in a neighborhood without a grocery store, who has experienced discrimination at clinics, faces compounding barriers. Analyses that isolate single factors may miss how they combine, so doctoral practitioners should consider intersections of race, income, gender and place.

Data Sources for the Analysis

The analysis would draw on electronic health record data for blood pressure control by race and neighborhood, the behavioral risk survey, census data on income and segregation, historical redlining maps, food environment databases and qualitative interviews with residents, each chosen to illuminate a different level.

Policy Levers

Because the causes are structural, levers lie partly outside health: affordable housing, minimum wage and paid sick leave, investment in grocery stores and parks in disinvested neighborhoods, anti-discrimination enforcement in health care and expanded insurance coverage. Public health can advocate for these alongside clinical and behavioral programs.

Summary of the Analysis

Taken together, the analysis shows a chain from structural history to present-day neighborhood conditions, work constraints, care quality and, finally, the blood pressure readings clinicians record.

Conclusion

Racial disparities in uncontrolled hypertension in the composite city arise from clinical and behavioral factors that are themselves shaped by living and working conditions and by structural forces such as segregation and discrimination. Tracing these causes of the causes shows that effective promotion must reach beyond individual behavior. That insight will guide theory selection and intervention design in the modules ahead.

References

Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. (2017). Structural racism and health inequities in the USA: Evidence and interventions. The Lancet, 389(10077), 1453-1463. https://doi.org/10.1016/S0140-6736(17)30569-X

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes. Public Health Reports, 129(Suppl. 2), 19-31. https://doi.org/10.1177/00333549141291S206

Williams, D. R., & Mohammed, S. A. (2009). Discrimination and racial disparities in health: Evidence and needed research. Journal of Behavioral Medicine, 32(1), 20-47. https://doi.org/10.1007/s10865-008-9185-0