We screened 126 titles and reviewed 120 guidelines after excluding 6 duplicates. Thirty-six guidelines met our inclusion criteria (see Table 1 for PRISMA diagram). Of the 36 guidelines reviewed, 10 guidelines (28%) included awareness activities. Twenty-one guidelines (58%) made adjustment recommendations. Six guidelines (17%) mentioned assistance strategies. Five (14%) guidelines mentioned alignment strategies, and eight guidelines (22%) included advocacy recommendations. One guideline acknowledged SDH without referencing any social care activities. Of all reviewed guidelines, 28% (n=10) neither acknowledged SDH nor referenced health activities related to SDH (See Table 2 for summary and Appendix 2 for breakdown of results). Guidelines published in 2019 were more likely to include multiple categories of social care activities than guidelines published in 1991 (the earliest guideline included).
Ten guidelines (28%) recommended activities to identify or screen for social risks and assests of defined patients and populations. This included screening for patients’ ability to pay for medication, health literacy, food access, and transportation availability. As example, a 2004 guideline discussed screening for financial security, health literacy, and insurance status(20); a 1993 guideline on mild hypertension, suggested screening for health literacy(21); the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure encouraged clinicians to inquire about care affordability(5). Only the 2019 Clinical Performance and Quality Measures report recommended the use of a standardized social risk screening tool(22).
Twenty-one guidelines (58%) recommended activities to adjust clinical care based on patients’ social risks. The NASEM report underscores that these activities (to accommodate care to patients’ social circumstances) differ from assistance interventions in that they do not intervene on the social risk itself, but instead change care planning based on the social risk. Of the total 63 specific care adjustments mentioned across the 21 guidelines, over half (57% n=36/63) focused on adjustments to accommodate patients’ financial security. In these cases, authors acknowledged that cost is a barrier to medication adherence (and therefore hypertension control) and in various ways suggested changing care to reduce medication cost burdens(21,23). Specific examples included prescribing generic alternatives(5,24–27), once daily dosages(5,25), combination pills(28), long-acting medication formulations(5,27), and increasing the number of pills dispensed in each prescription to minimize pharmacy visits and co-payments(5). The 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure also recommended providing patients with scored tablets or pill cutters to reduce costs(5).
Guidelines also included other strategies to accommodate access barriers. For instance, guidelines described efforts to limit the number and frequency of medical vists(29); increase telehealth(22); utilize electronic health record to tailor health advice to patients based on their social risk(22); use remote blood pressure monitoring(26,30,31); or offer medication home delivery(22). Two highlighted opportunities to minimize laboratory tests(23,31). Three others suggested addressing patients’ transportation barriers through reducing frequency of office visits to minimize co-payments(5,31,32). A 2013 guideline recommended that emergency medicine physicians initiate blood pressure medications in asymptomatic patients when patients were in social circumstances that might prevent them from establishing primary care(33).
In addition to adjustments to reduce patient cost, several guidelines recommended adjusting care for patients based on education, literacy level, and cultural background(5,23). Specific examples included ensuring the presence of translators, improving providers’ cultural competency, and increasing the availability of linguistically-appropriate educational materials(5,23,34).
A 2019 Clinical Performance and Quality Measures report highlighted that health systems can omit patients from the denominator of some hypertension quality metrics if patients have economic or access barriers to medication adherence(22).
Six guidelines (17%) described assistance strategies for health care teams to improve patients’ hypertension management by directly intervening on social risks themselves. These recommendations involved using clinic or community-based social service providers, e.g. community health workers, social workers, or case managers, to facilitate connections with community or government social services(22,29), including housing programs, food banks or other nutrition programs(23,35), insurance or medication access programs(35), or utility assistance programs(5).
The 2019 NASEM framework also defined health care sector activities outside of clinical care related to strengthening community SDH resources and supports. Five (14%) guidelines raised topics related to alignment strategies. For example, a 2005 publication on cardiovascular disease and minority health recommended several community education strategies, such as dissemination of physical activity and nutrition information to marginalized communities(34). JNC7 and the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure elevated community organizations as liaisons to bridge cultural and language barriers and establish community-based HTN screening and referral programs(5,35). A 2019 report highlighted ways to strengthen community partnerships that provide healthy food and enroll individuals in federal nutrition assistance programs(22).
Eight guidelines (22%) described ways that health care organizations can promote policies or societal investments that increase the availability of social resources as part of a strategy for reducing hypertension prevalence and morbidity. Seven of these described ways health systems can work with insurers to improve incentives and/or lower costs of care. In the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure, the authors wrote: “Greater attention is being paid to the influence of health insurance coverage and benefit designs focused on reducing patient copayments for antihypertensive medications”(5). Beyond copayments and coverage, several guidelines referenced specific activities that if reimburseable, could improve hypertension control, including obesity treatments(34) and home blood pressure monitors (HBPM)(36); one emphasized the importance of developing quality measures related to SDH to standardize blood pressure management(22).
Five guidelines surfaced the importance of healthy food access as a key area for societal interventions(5,34,35,37,38). These guidelines emphasized the need for policy changes to increase the availability of healthy foods and access to physical activity. A 2017 guideline called on food manufacturers to reduce “the amount of sodium in food processing, as well as in fast food and restaurant food preparation”(5). This echoes earlier guidelines’ suggestions to reduce marketing of “high-calorie, low-nutrient-density products to young children or people of color”(34) and to lobby the food industry “to progressively reduce the salt added to foods by 50% over the next 10 years”(38).
Four guidelines called for increased research funding to improve evidence on the social and economic aspects of blood pressure control(5,22,23,34). This included advocating for researchers, clinicians, and research subjects from diverse backgrounds(34) and increased focus on care in low socioeconomic settings(5).
Of the 36 guidelines, 10 did not reference social determinants of health or related search terms. Of the remaining 26, one guideline described the relevance of SDH to hypertension management but did not refer to any NASEM action categories (awareness, assistance, adjustment, alignment, or advocacy) in the rest of the guideline sections. Seventeen guidelines included text acknowledging that SDH influence hypertension management in sections that did not otherwise recommend a specific social care activity. In these seventeen guidelines, authors referred to at least one NASEM action category in another section. Economic constraints (described in 36 of the 84 references to acknowledgement activities) were the most common social domain mentioned without explicit social care recommendations. In these instances, financial status was generally linked with hypertension risk factors and care(5,21,22,26,29,34,35,39) or to more specific hypertension treatment barriers, such as medication affordability(5,22–24,26,29,35,40), lack of health insurance coverage(5,23,29,34,41), or otherwise limited access to care(25–27,29,34,35,39). Beyond financial risk, multiple guidelines referred to language and education barriers to prevention and treatment (5,22,23,25,26,29,35), absence of safe space for physical activity(5,35), and lack of adequate healthy food(5,27,31,34,35,38).