Psychology Topic 5 Assignment

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Journal of Immigrant and Minority Health (2023) 25:50–61 https://doi.org/10.1007/s10903-022-01376-y

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ORIGINAL PAPER

Identifying the Social Determinants of Treated Hypertension in New and Established Latino Destination States

Adriana Maldonado1  · Richard M. Hoffman2 · Barbara Baquero3 · Daniel K. Sewell4 · Helena H. Laroche5 · Rima Afifi6 · Paul A. Gilbert6

Accepted: 30 May 2022 / Published online: 6 July 2022 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract Little is known about the influence of social and environmental contexts on Latino hypertension-related disparities. This study examined the influence of social determinants of cardiovascular health on medically treated hypertension, contrasting established vs. new Latino destination states. Logistic regression models were fitted to analyze 2017 Behavioral Risk Fac- tors Surveillance Survey data from 8,999 Latinos. Overall, 70.4% indicated having treated hypertension. History of diabetes (OR = 2.60) and access to healthcare (OR = 2.38) were associated with treated hypertension, regardless of destination state. In established destinations, Latinos who graduated high school (OR = 1.19) or attended college (OR = 1.32) had higher odds of treated hypertension; whereas those who completed college were less likely to have treated hypertension (OR = 0.80). In contrast, in both new and non-destination states, the odds of treated hypertension were consistently lower across levels of educational attainment. Results highlight the need for cardiovascular-risk reduction interventions to incorporate the social and environmental context in the development process.

Keywords Latino health disparities · Hypertension treatment · New and established Latino destination states · Social determinants of health

Background

Hypertension accounts for more cardiovascular deaths than any other modifiable risk factor such as obesity and diabetes [1]. Among Latinos, cardiovascular diseases (CVD), such as coronary heart disease, stroke, and heart failure, are the sec- ond leading cause of death, and hypertension is the leading risk factor for CVD [2–6]. Latinos are at an increased risk of hypertension-related as compared to Whites, disparities including having less hypertension awareness, treatment, and control [1, 7–10]. While estimates indicate that 27.8% of the Latino population have hypertension, which is equivalent to that found among Whites (27.8%); Latinos often fail to achieve proper hypertension control [6, 8, 9, 11, 12].

Historically, most of the U.S. Latino population has been concentrated in 10 established Latino destination states located in the Southwest and Northeast regions of the country (e.g., California and Texas) [13, 14]. However, since the mid-1980s Latinos have been migrating through- out the U.S., settling in new destination states [13, 15–17]. Briefly described, new Latino destinations are states that experienced a growth of at least 150 percent in their Latino

* Adriana Maldonado [email protected]

1 Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, 390 S. Country Club, Suite 330, Tucson, AZ 85714, USA

2 Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA

3 School of Public Health, Health Systems and Population Health, University of Washington, Seattle, WA 98195, USA

4 Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA 52242, USA

5 Department of Pediatrics, Children’s Mercy Kansas City and University of Missouri- Kansas City, Kansas City, MO 64108, USA

6 Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA 52242, USA

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population between 1990 and 2010; whereas established destinations are states where at least 10 percent of the popu- lation identified as Latino in 1990 [18, 19]. While residence in established destinations might create an environment con- ducive to positive cardiovascular health outcomes via the health-related structural advantages that these states have developed over time (e.g., advocacy groups, strong com- munity ties, Spanish speaking healthcare providers); new destination states without these environmental advantages might pose a risk to Latinos’ hypertension-related outcomes. The rapid changing demographics of new destinations can provoke social tensions and stressors [20] contributing to the onset of hypertension [21, 22]. In addition, among the few studies exploring Latino health in new destinations, results show that Latinos in these locations tend to be unaware of local public health programs, have feelings of not being wel- comed by the community, tend to suffer from social isola- tion, and have limited access to health care services [23, 24].

While evidence confirms that aspects of the environment are major social determinants of CVD [25], to date, most epidemiological studies have focused on individual-level risk factors (i.e., behavioral and biological), neglecting the influence of the social context on the emergence of hyperten- sion disparities [26]. Thus, this study aimed to understand how the impact of social and environmental determinants of cardiovascular health influenced receipt of antihyperten- sive medication in Latinos in established vs. new destination states.

Methods

Data Source and Sample

A secondary data analysis of the 2017 Behavioral Risk Fac- tor Surveillance System (BRFSS) Latino sample was con- ducted [27]. The analytical sample was restricted to Latinos residing in the 50 states and that responded affirmatively to the question, “Have you ever been told by a doctor, nurse, or other health professional that you have high blood pres- sure?” (n = 9,049). Fifty respondents had missing values for the outcome (i.e., taking blood pressure medication vs no blood pressure medication) and thus were excluded from all subsequent analysis. Hence, the final analytical sample con- sisted of 8,999 Latinos with a previous hypertension diag- nosis. For detailed information on how the analytic sample was derived, refer to Fig. 1. The Human Subjects Protection Program Institutional Review Board (IRB) at the University of Iowa determined that the study did not constitute human subjects research because it was a secondary analysis of pub- licly available, de-identified data. Therefore, the study was exempt from IRB oversight.

Variables of Interest

Receipt of antihypertensive medication, hereafter referred to as hypertension treatment, was the primary outcome of interest in the study. It was derived from the BRFSS question, “Are you currently taking medicine for your high blood pressure?”. A binary indicator of CVD risk was modeled after the Life’s Simple Seven metric proposed by the American Heart Association [32] and included indi- cators on depression, cholesterol, BMI, dietary practices, smoking, binge drinking, and physical activity. Partici- pants with four or more risk factors were categorized as high risk, whereas those with less than four were classi- fied as low risk. History of diabetes was defined as the percentage of Latinos who reported being previously told that they had diabetes.

Environmental determinants of CVD. Latino migration patterns were classified as (1) established, (2) new destina- tions, and (3) non-destination states. Established destina- tion states were defined as states whose Latino popula- tions comprised at least 10% of the total population in the 1990 Census, regardless of population growth [28, 29]. Whereas states that experienced Latino population growth of at least 150% and at least 1,000 Latinos between 1990 and 2000 were categorized as new destinations [20, 30, 31]. States that did not meet any of these criteria were classified as non-destination states.

Social determinants of CVD. A binary healthcare ser- vices index was created based on four indicators: (1) health insurance, (2) personal healthcare provider, (3) costs as a barrier to care, and (4) time since last routine checkup. A value of one was assigned to affirmative responses, while all other responses were assigned a score of 0. A total score ranging from 0 to 4 was computed and later dichotomized as high access (scores of 4) and low access (< 4). Educational attainment was assessed from Latinos’ responses to the question: “What is the highest grade or year of school you completed?”. Following a previously published method for BRFSS data, households’ federal poverty level (FPL) was obtained and classified as (1) below FPL, (2) 100%-200% FPL, and greater than 200% FPL [33–35]. Survey of language (English or Spanish) was used as an indicator of respondents’ acculturation level. Lastly, demographic and health variables were included as covariates in the analyses of the current study.

Statistical Analysis

Data analysis was conducted using SAS software [36]. Descriptive statistics for each of the variables on interest were calculated. Multiple imputation using the functions

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logistic regression, predictive mean matching, and discri- minant was used to estimate missing data. Bivariate analy- ses to explore the unadjusted relationship between each of the variables of interest and treated hypertension were conducted. Two multivariate logistic regression models were fit. Model 1 tested the relationship between hyper- tension treatment on educational attainment, household’s federal poverty level, access to healthcare, acculturation, CVD risk, diabetes, and Latino migration patterns while controlling for the influence of demographic and health

variables. Model 2 regressed hypertension treatment on the six variables included in model 1 with the addition of six interaction terms. To better understand the statisti- cally significant interactions, conditional odds of hyperten- sion treatment for the different levels of the interactions were estimated, using a previously published approach for complex survey data [37]. BRFSS survey weights were incorporated in all analyses to account for study’s complex sampling design.

Fig. 1 Derivation of Analytic Sample. Note: Treated hyper- tension is defined as taking blood pressure medication or not

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Results

Participant Characteristics

Of the total BRFSS Latino subsample, most participants reported being treated for hypertension (70.42%). Most Latinos resided in established Latino destination states, but the percentage was lower among those not being treated for hypertension than their peers (49.89% vs. 57.79%, p < 0.001). Most participants reported no prior history of diabetes; however, the percentage was higher among those not being treated for hypertension than their counterparts (87.44% vs. 60.81%, p < 0.001). While 69% of Latinos not being treated for hypertension had low access to healthcare services, only 37.65% of those being treated for hypertension reported low healthcare access (p < 0.001). Few Latinos not being treated for hypertension did not graduate high school, whereas more than one-third of those being treated for hypertension did not (27.94% vs. 33.01%, p < 0.001). There was no difference between the status of hypertension treatment in individuals’ risk for CVD, household federal poverty level, and language of survey completion. All other participant characteristics can be found in Table 1.

Unadjusted and Adjusted Odds of Treated Hypertension

Unadjusted bivariate logistic regression models (Table 2) showed that having a prior history of diabetes (OR = 4.60, 95%CI 3.70, 5.72) and high healthcare access (OR = 3.65, 95%CI 3.02, 4.41) were associated with higher odds of hypertension treatment. Conversely, the odds of hyper- tension treatment were 31% lower for high school gradu- ates (OR = 0.69, 95%CI 0.56, 0.86) and 30% lower for those who graduated from college or technical school (OR = 0.70, 95%CI 0.54, 0.90) compared to Latinos who did not complete high school. When compared to individu- als with an annual household income below established FPL, the odds of hypertension treatment were 29% higher for Latinos with an income between 100 and 200% FPL (OR = 1.29, 95%CI 1.02, 1.63). In contrast, the odds of hypertension treatment were 25% lower for English speak- ers (OR = 0.75, 95%CI 0.63, 0.89) compared to Spanish speaking Latinos. Likewise, Latinos residing in a new Latino destination state had 34% lower odds of hyperten- sion treatment than peers in an established destination state (OR = 0.66, 95%CI 0.55, 0.78).

The adjusted multivariate regression Model 1 (Table 2) indicated that Latinos with a self-reported history of diabetes were 2.60 times more likely to be treated for

hypertension compared to those without a diabetes diag- nosis (OR = 2.60, 95%CI 2.02, 3.33). Similarly, Latinos with access to healthcare services were 2.38 times more likely to be treated for hypertension compared to those with low healthcare access (OR = 2.38, 95%CI 1.89, 2.99). There was no significant association between educational attainment, household federal poverty level, acculturation, or place of residence and hypertension treatment. Further- more, Latina women had 28% higher odds being treated for hypertension compared to Latino men (OR = 1.28, 95%CI 1.04, 1.59). When compared to early adults, Lati- nos in their early middle-age (OR = 3.04, 95%CI 2.10, 4.39%), late middle-age (OR = 9.30, 95%CI 6.66, 12.98), and late adulthood (OR = 23.88, 95%CI 15.56, 36.66) had significantly higher odds of being treated for hypertension. Further, Latinos out of the labor force were 2.10 times more likely to be treated for hypertension than currently employed Latinos (OR = 2.10, 95%CI 1.61, 2.73). Hyper- tension treatment was not associated with marital status, housing status, or self-reported health.

Place of Residence as an Effect Modifier

Examining interaction effects (Model 2), only the impact of educational attainment on Latinos’ hypertension treat- ment was moderated by place of residence (Table 3). Among Latinos in established Latino destination states those who graduated high school (OR = 1.19) or attended college/tech- nical school (OR = 1.32) had higher odds of hypertension treatment compared to those who did not finish high school (Fig. 2), while those who graduated from college or techni- cal school were 20% less likely to be treated for hypertension (OR = 0.80). Among Latinos in new destination states, the odds of treated for hypertension were 32% lower for those who graduated high school (OR = 0.68), 21% lower for those who attended college or technical school (OR = 0.79), and 19% lower for Latinos who graduated from college or tech- nical school (OR = 0.81) as compared to those who did not finish high school. Similarly, for Latinos in non-destination states, the odds of hypertension treatment were 37% lower for those who graduated high school (OR = 0.63), 25% lower for those who attended college/technical school (OR = 0.75), and 40% lower for Latinos who graduated from college or technical school (OR = 0.60) compared to their peers who did not graduate high school.

Discussion

This study delineated the role of social and contextual deter- minants of treating hypertension in Latinos living in estab- lished and new destination states. In summary, hypertension treatment was associated with healthcare access and history

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Table 1 Participant characteristics by self-reported hypertension

Treated hypertension

BRFSS indicator Untreated hypertension (n = 2,662)

Treated hypertension (n = 6337)

p-value

n % n %

Health-related factors CVD risk  Low CVD risk 1,800 67.62 4,329 68.31 0.52  High CVD risk 862 32.38 2,008 31.69

History of diabetes  No 2,312 87.44 3,843 60.81 < 0.001  Yes 332 12.56 2,477 39.19

Healthcare access  Low access 1,837 69.01 2,386 37.65 < 0.001  High access 2,386 37.65 3,951 62.35

Socioeconomic factors Educational attainment  Did not graduate high school 739 27.94 2,082 33.01 < 0.001  Graduated high school 821 31.04 1,725 27.35  Attended college 588 22.23 1,371 21.74  Graduated from college 497 18.79 1,129 17.90

Household FPL  Below FPL 1,279 48.05 2,933 46.28 0.11  100–200% FPL 642 24.12 1,659 26.18  Greater than 200% FPL 741 27.84 1,745 27.54

Social factors Language  Spanish 907 34.07 2,102 33.17 0.28  English 1,746 65.59 4,223 66.64

Environmental factors Place of residence  Established Latino destinations 1,328 49.89 3,662 57.79 < 0.001  New Latino destinations 903 33.92 1,631 25.74  Non-destinations 431 16.19 1,044 16.47

Demographic characteristics Sex  Male 1,558 58.57 2,762 43.61 < 0.001  Female 1,102 41.43 3,572 56.39

Age  Early adulthood (18 – 34 years) 851 32.13 236 3.75 < 0.001  Early middle age (35 – 44 years) 620 23.41 512 8.14  Late middle age (45 -64 years) 959 36.20 3,053 48.54  Late adulthood (65 years and older) 219 8.27 2,489 39.57

Marital status  Never married 650 24.58 695 11.02 < 0.001  Married or cohabitating 1,332 50.38 3,334 52.85  Divorced, separated, widowed 662 25.04 2,279 36.13

Housing status  Rent 1,454 54.97 2,436 38.70 < 0.001  Own 1,027 38.83 3,481 55.30  Other arrangement 164 6.20 378 6.00

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of diabetes but not with CVD risk, household poverty sta- tus, acculturation, or Latino migration patterns. Further, the effect of educational attainment on Latinos’ hypertension treatment was partially modified by patterns of migration. This work suggests that Latinos’ high levels of untreated hypertension may be partially explained by the synergistic effect of social and environmental factors. Thus, identify- ing and implementing protective practices and multilevel context-specific interventions could promote healthier car- diovascular outcomes and address well-documented hyper- tension disparities in the Latino community.

Though residing in new Latino destination states has been previously associated with an increased risk of experiencing predisposing factors for uncontrolled hypertension [23], in the current study, migration patterns were not directly asso- ciated with hypertension treatment. As evidence suggests that the growth of the Latino population in new destination states has been spurred by increased employment opportu- nities that resulted from the restructuring of the agri-food sector of the Midwest and the South [38, 39], it may be possible that the lack of an association between migration patterns and hypertension treatment is primarily due to the demographic characteristics of Latinos in these new desti- nation states (e.g., young and growing families). However, as research on Latino health disparities in new destination states is in its early stages, it deserves further exploration to determine the impact of migration patterns on Latinos’ cardiovascular health outcomes.

Nevertheless, migration patterns moderated the rela- tionship between educational attainment and hypertension treatment. While in established destination states there was a beneficial effect of completing high school or hav- ing attended some college/technical school education, this was not the case in new Latino destination and non-desti- nation states. Latinos’ cultural preference to live in estab- lished Latino destination states to ease in the adjustment into U.S. society might offer some health-protective factors

by fostering stronger social ties, providing health-promoting cultural and economic resources, and protecting them from discrimination or migration-related stresses which have been previously linked to hypertension [40–43]. However, as Lati- nos move up on the educational ladder, contact with the dominant Anglo-American society increases, exposing them to discrimination and psychosocial stressors that negatively impact individuals’ health [44, 45]. Although the study’s findings appear to be perplexing, they are in line with evi- dence suggesting that an inverse educational gradient exists among Latinos. Mainly, it has been found that higher lev- els of educational attainment are associated with increased levels of C-reactive protein – a biological risk indicator for cardiovascular disease – and risk of hypertension among Mexican-heritage Latinos [46, 47]. Taken together, this work suggests that the expected educational gradient in hyperten- sion treatment is observed when educational attainment is coupled with the protective factors that established Latino destination states offer to individuals. However, because new Latino destination and non-destination states often lack health-related resources tailored to Latinos’ needs and expose them to higher levels of psychosocial stressors [48], the buffering effects of higher educational attainment are obscured. Nonetheless, it remains to be determined how these distal mechanisms influence Latinos’ likelihood of being treated for hypertension in established and new des- tination states.

Both healthcare access and a self-reported history of diabetes were positively associated with Latinos hyperten- sion treatment. Historically, Latinos have disproportionally lacked adequate health care; yet, in the current study, more than three-fourths of the sample reported having access to these services (i.e., health insurance, personal healthcare provider, cost as a barrier to care, and time since last routine checkup). Thus, our study results suggest that individuals with healthcare insurance are more likely to visit a health- care provider and be aware of and receive treatment for

Table 1 (continued) Treated hypertension

BRFSS indicator Untreated hypertension (n = 2,662)

Treated hypertension (n = 6337)

p-value

n % n %

Employment status  Employed 1,665 63.36 2,220 35.41 < 0.001  Unemployed 234 8.90 362 5.77  Out of labor forcea,* 729 27.74 3,688 58.82

Self-reported health  Good, fair, and poor health 1,907 72.07 5,032 80.01 < 0.001  Excellent/very good health 739 27.93 1,257 19.99

a Out of labor force includes full-time students, homemakers, retired, and disabled individuals *Unweighted percentages.

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Table 2 Unadjusted and Adjusted Multivariate Logistic Regression Models

Predictor Unadjusted Bivariate Logistic Regressions Adjusted Multiple Logistic Regression

Odds Ratio 95% Confidence Interval

p-value Odds Ratio 95% Confidence Interval

p-value

Health-related factors CVD risk profile  Low CVD risk Ref – – Ref – –  High CVD risk 0.98 0.82, 2.27 0.84 0.93 0.75, 1.16 0.52

History of diabetes  No Ref – – Ref – –  Yes 4.60 3.70, 5.72 < 0.001 2.60 2.02, 3.33 < 0.001

Healthcare access  Low healthcare access Ref – – Ref – –  High healthcare access 3.65 3.02, 4.41 < 0.001 2.38 1.89, 2.99 < 0.001

Socioeconomic factors Educational attainment  Did not graduate high school Ref – – Ref – –  Graduated high school 0.69 0.56, 0.86 < 0.001 0.98 0.74, 1.29 0.88  Attended college or technical school 0.83 0.65, 1.06 0.13 1.11 0.81, 1.52 0.52  Graduated from college or technical school 0.70 0.54, 0.90 0.01 0.77 0.53, 1.13 0.18

Household federal poverty level  Below FPL Ref – – Ref – –  100–200% FPL 1.29 1.02, 1.63 0.03 1.24 0.92, 1.68 0.16  Greater than 200% FPL 1.05 0.85, 1.31 0.64 1.20 0.85, 1.69 0.31

Social factors Acculturation  Spanish language use Ref – – Ref – –  English language use 0.75 0.63, 0.89 < 0.01 1.02 0.79, 1.32 0.88

Environmental factors Place  Established Latino destination state Ref – – Ref – –  New Latino destination state 0.66 0.55, 0.78 < 0.001 1.12 0.90, 1.39 0.31  Non-destination state 0.92 0.75, 1.14 0.45 1.01 0.77, 1.31 0.96

Demographic characteristics Sex  Male Ref – –  Female 1.28 1.04, 1.59 0.02

Age  Early adulthood (18–34 years) Ref – –  Early middle age (35–44 years) 3.04 2.10, 4.39 < 0.001  Late middle age (45–64 years) 9.30 6.66, 12.98 < 0.001  Late adulthood (> 65 years) 23.88 15.56, 36.66 < 0.001

Marital status  Never married Ref – –  Married or cohabitating 0.99 0.74, 1.34 0.97  Divorced, separated, widowed 0.76 0.55, 1.04 0.09

Housing status  Rent Ref – –  Own 1.19 0.93, 1.53 0.17  Other arrangement 1.05 0.70, 1.55 0.82

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hypertension, corroborating previous findings [11, 49–58]. In addition, given that hypertension treatment guidelines are stricter for individuals with comorbidities such as dia- betes [59], it might be possible that Latinos with diabetes are prescribed antihypertensive medication as the first line of treatment compared to Latinos without diabetes. How- ever, additional research is needed to fully untangle the role of both healthcare and diabetes history on Latinos’ treated hypertension, particularly in new Latino destination states.

Several plausible explanations exist for the lack of an association between acculturation or CVD risk and hyperten- sion treatment beyond a lack of statistical power. Although a positive association between acculturation and Latino hyper- tension-related outcomes has been previously established [60–65], in the current study the odds of being treated for hypertension were not statistically different between Span- ish- and English-speaking individuals. While English use has been deemed as a robust proxy measure of acculturation [66–70], it fails to account for the nuances inherent in the acculturation process (e.g., perception of self-acculturation, cultural orientation, and self-identity). For instance, a person could speak English well but not identify with or embrace the dominant Anglo-American cultural characteristics. Thus, future research should employ a mixed-methods approach to fully capture the psychological, behavioral, and attitudinal changes that occur with the adaptation between two cultures [71]. While one would expect to see a positive association between CVD risk and Latinos’ hypertension treatment, this was not the case in the current study. This lack of an association might be partially attributed to the limited work exploring the underlying causes of CVD risk factors, such as poor dietary habits, physical inactivity, smoking, and drinking patterns [72]. This is particularly important as it has been established that unhealthy lifestyle habits continue to increase individuals’ cardiovascular risk, despite receiv- ing pharmacological treatment for hypertension [73]. Thus, additional research is warranted to evaluate the impact of behavioral risk factors on Latino’s hypertension treatment.

Though this study points to the importance of social and environmental determinants on Latinos’ hyperten- sion treatment, several limitations should be noted when interpreting the results. First, BRFSS considers Latinos a homogeneous group yet differences in hypertension treat- ment have been observed within Latino subpopulations [49]. Therefore, generalizations of the study findings to Latino subpopulations should be made with caution. Nev- ertheless, the study findings are still informative as they shed light on the role that social and contextual factors play on the Latino’s hypertension treatment, an aspect that has been identified as warranting further exploration in previous studies [74]. Second, while evidence supports the use of language proficiency as a proxy measure of accul- turation [66–70], this proposition has not been exempt from criticisms as language proficiency closely overlaps with indicators of social and economic status that might prevent individuals from accessing health care services [75]. Lastly, due to BRFSS data constraints, analyses were compelled to assess hypertension treatment based on respondents' self-reports of hypertension and hypertension treatment, which limited the ability to make inferences regarding actual biological outcomes.

In conclusion, this study adds to an emerging body of literature on the association of social and environmental factors with Latinos' cardiovascular health outcomes. The results of this study have significant implications for pub- lic health interventions. Specifically, they shed light to the need for cardiovascular-risk reduction interventions to incorporate aspects of the social and environmental con- text. Suggesting that cardiovascular-risk reduction inter- ventions in new Latino destination states should be tai- lored to improve education and facilitate navigation of the healthcare system. However, future research is necessary to fully understand how Latinos’ social context impacts Latinos’ hypertension treatment.

Table 2 (continued)

Predictor Unadjusted Bivariate Logistic Regressions Adjusted Multiple Logistic Regression

Odds Ratio 95% Confidence Interval

p-value Odds Ratio 95% Confidence Interval

p-value

Employment status  Employed Ref – –  Unemployed 1.21 0.86, 1.70 0.28  Out of labor force 2.10 1.61, 2.73 < 0.001

Self-reported health  Good/fair/poor Ref –  Excellent/very good health 1.30 0.97, 1.74

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Table 3 Multivariate logistic moderation model

Predictor Odds Ratio 95% CI p-value

Main effects Health-related factors CVD Risk Profile  Low CVD risk Ref – –  High CVD risk 1.03 0.77, 1.37 0.86

History of diabetes  No Ref – –  Yes 2.50 1.78, 3.52 < 0.001

Healthcare access  No access to healthcare Ref – –  Access to healthcare 2.17 1.62, 2.91 < 0.001

Socioeconomic factors Educational attainment  Did not graduate high school Ref – –  Graduated high school 1.19 0.82, 1.72 0.36  Attended college or technical school 1.32 0.87, 2.00 0.19  Graduated from college or technical school 0.80 0.49, 1.32 0.38

Household federal poverty level  Below FPL Ref – –  100–200% FPL 1.23 0.84, 1.81 0.28  Greater than 200% FPL 1.10 0.71, 1.72 0.66

Social factors Acculturation  Spanish language use Ref – –  English language use 0.93 0.68, 1.29 0.68

Environmental factors Place  Established Latino destination states Ref – –  New Latino destination states 1.07 0.67, 1.71 0.77  Non-destination states 1.09 0.57, 2.08 0.80

Interaction terms CVD risk profile * place – – NS History of diabetes * place – – NS Healthcare access * place – – NS Educational attainment * place  Established Latino destination state Ref – –  New Latino destination state   Did not graduate high school Ref – –   Graduated high school 0.57 0.33, 0.99 0.04   Attended college or technical school 0.60 0.31, 1.16 0.13   Graduated from college or technical school 1.02 0.49, 2.09 0.96

 Non-destination states   Did not graduate high school Ref – –   Graduated high school 0.53 0.25, 1.10 0.09   Attended college or technical school 0.56 0.24, 1.34 0.20   Graduated from college or technical school 0.75 0.29, 1.97 0.56

Household federal poverty level * place – – NS Acculturation * place – – NS Demographic characteristics Sex  Male Ref – –

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Acknowledgements The authors would like to thank David O. Garcia and Edgar A. Villavicencio for their careful reading of early drafts of our manuscript and their insightful comments and suggestions.

Author Contributions Conceptualization: Adriana Maldonado, Paul A. Gilbert, Barbara Baquero, and Rima Afifi; Methodology: Adriana Mal- donado, Helena H. Laroche, and Richard M. Hoffman; Formal analysis and investigation: Adriana Maldonado and Daniel K. Sewell. Writ- ing - review and editing: Adriana Maldonado, Richard M. Hoffman,

Barbara Baquero, Daniel K. Sewell, Helena H. Laroche, Rima Afifi, and Paul A. Gilbert. 

Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data Availability The data represented in this study are openly avail- able at https:// www. cdc. gov/ brfss/ annual_ data/ annual_ 2017. html.

Table 3 (continued) Predictor Odds Ratio 95% CI p-value

 Female 1.29 1.04, 1.59 0.02 Age  Early adulthood (18–34 years) Ref – –  Early middle age (35–44 years) 3.12 2.14, 4.54 < 0.001  Late middle age (45–64 years) 9.57 6.80, 13.48 < 0.001  Late adulthood (65 years and older) 24.69 15.97, 38.17 < 0.001

Marital status  Never married Ref –  Married or cohabitating 1.00 0.75, 1.36 0.99  Divorced, separated, widowed 0.76 0.55, 1.04 0.09

Housing status  Rent Ref – –  Own 1.19 0.92, 1.53 0.18  Other arrangement 1.04 0.70, 1.55 0.83

Employment status  Employed Ref – –  Unemployed 1.20 0.85, 1.69 0.29  Out of labor force 2.10 1.61, 2.74 < 0.001

Self-reported health  Good/fair/poor Ref –  Excellent/very good health 1.29 0.96, 1.74 0.09

Fig. 2 Odds of treated hyperten- sion by educational attainment- by-place of residence. Note: Because multiple imputation doesn’t provide pooled standard errors, 95% confidence intervals are not shown

1.19

1.32

0.80

0.68

0.79 0.81

0.63

0.75

0.60

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

Graduated High School Attended College or Technical School Graduated from College or Technical School

Odds of treated hypertension by educational attainment-by-place (ref = did not graduate high school)

Established Latino destination state New Latino destination state Non-destination state

60 Journal of Immigrant and Minority Health (2023) 25:50–61

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Declarations

Conflict of interest The authors declare no conflict of interest.

Ethical approval The Human Subjects Protection Program Institutional Review Board (IRB) at the University of Iowa determined that the study did not constitute human subjects research because it was a sec- ondary analysis of publicly available, de-identified data. Therefore, the study was exempt from IRB oversight.

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