Hypertension, the leading cause of death from heart disease and stroke both in the U.S. and worldwide, presents significant public health challenges. Globally, many health systems are individual-focused. This means that health interventions and treatments are typically designed and implemented with the individual patient in mind, often overlooking the influence and potential of interpersonal relationships.
However, our study, recently published in the Journal of the American Heart Association, suggests that couple-focused strategies may have the potential to make a difference and improve the diagnosis and management of hypertension across the world.
Using nationally representative data of middle-aged and older heterosexual couples from four countries, we found a high prevalence of concordant hypertension among couples (defined as both husband and wife in a couple having hypertension). This prevalence is 37.9% among couples in the U.S., 47.1% in England, 20.8% in China, and 19.8% in India.
Additionally, we observed a positive association in hypertension status among couples, indicating that individuals are more likely to have hypertension if their spouse does as well. This phenomenon is referred to as spousal concordance of disease. A main explanation for spousal concordance of disease is that couples may share unhealthy lifestyles and living environments, and therefore diseases.
Although the prevalence of concordant hypertension among couples is higher in the U.S. and England compared to China and India, the association of hypertension between couples is stronger in China and India. One reason for the stronger association in China and India might be cultural: in these countries there’s a strong belief in sticking together as a family. In contrast, in the U.S. and England, people value being independent, which might mean couples don’t influence each other’s health as much.
The findings of our study are consistent with previous reports of spousal concordance of hypertension. However, our study advances previous studies given the larger, nationally representative samples and its cross-national nature. The consistently observed spousal concordance of hypertension across different countries highlights the potential of couple-focused strategies in diagnosing and treating hypertension.
For example, despite the fact that the marriage rates in the U.S. have been declining over the past 50 years, decreasing from 76.5% in 1970 to 31% in 2023, most older Americans are married or live with a partner. In 2021, a report showed that 69% of older men and 47% of older women were married, and 60% of them lived with their spouse or partner. Similar or higher numbers have been reported among middle-aged and older populations in England, China, and India. These numbers highlight a significant opportunity to leverage couple-focused interventions in diagnosing and managing hypertension, especially among older populations.
Couple-focused interventions may be beneficial in improving health outcomes. Although our study does not explore the exact mechanisms for spousal concordance in middle-aged and older adults, previous studies report concordance in health behaviors like diet, exercise, sleep, and smoking. Marriage can lead to positive health behavior changes in individuals if their partner is likely to make positive behavior changes. Moreover, marriage can be protective against loneliness and isolation. In 2023, loneliness and isolation were labeled as an epidemic by the Surgeon General, which may contribute to multiple disease outcomes and death.
Our study joins numerous others in calling for a paradigm shift in how hypertension and other cardiometabolic diseases (such as diabetes, heart disease, and obesity) are prevented, screened for, and treated. Previous studies have reported benefits in joint disease screening and management strategies, which are both practical and easy to implement, in promoting mutual accountability for health among couples.
These strategies can include pursuing healthy eating habits together, exercising together, reminding each other to take medication, and even visiting primary care providers together. We also believe that insurance providers, employers, and healthcare providers could play a leading role by incentivizing these joint marital health pursuits.
As clinicians and public health practitioners, what should we immediately focus on given these findings?
From the public health perspective, it is a way of identifying people who do not know if they have hypertension and exploring new ways to incentivize blood pressure control at the policy level. Communication strategies should encourage individuals with a spouse who has hypertension to undergo regular screening, thereby helping to reduce the burden of undiagnosed hypertension in the U.S. (nearly 11 million) and elsewhere.
Clinicians can lead the way in identifying innovative couple-focused strategies for achieving blood pressure control among those with diagnosed hypertension (nearly 37 million U.S. adults). Moreover, from a mechanistic standpoint, we need to understand the pathophysiology of hypertension in the individual, and the role of their close social influences — such as spouses and their community — to minimize the future burden of this deadly but treatable disease.
The current clinical guidelines and public health approaches to disease prevention and management are predominantly individual-centric. With accumulating evidence of spousal, familial, and community concordance of disease, we nudge researchers, practitioners, and policymakers to re-evaluate the current individual-centric paradigm of health through innovative interventions targeting at-risk families and communities.
In summary, your patient’s spouse may be the key to their health. Couple-focused health interventions can change the paradigm of how we view marital relationships to prevent and manage non-communicable diseases.
Jithin Sam Varghese, PhD, is an assistant research professor at Emory University in Atlanta. Peiyi Lu, PhD, is a postdoctoral researcher at Columbia University in New York City. Chihua Li, DrPH, MPH, is a postdoctoral fellow at the University of Michigan in Ann Arbor and Johns Hopkins University in Baltimore.
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