Social Inequities in Cardiovascular Disease Risk Factors Among Black Women in Texas during the Rush Hour of Life

Background and Purpose: The “established adulthood” life stage between the ages of 30-45 years is critical for women, given the competing demands of occupational advancement, intimate partner relationships, and childcare responsibilities. Cardiovascular disease (CVD) is the leading cause of mortality among women in the U.S., with Black women experiencing disproportionately higher rates of diabetes, hypertension, and obesity—key risk factors for CVD. These disparities are embedded in structural inequities across individual-, neighborhood-, and county-level contexts. While prior research has examined social inequities in CVD risk among women, few studies have examined inequities among Black women specifically, and none have focused on those aged 30-45. This study analyzes inequities in pre-pregnancy CVD risk factors among Black women in Texas, with a focus on individual-level education, neighborhood- and county-level effects.

Methods: We analyzed 214,449 birth records from Black women aged 30-45 years in Texas (2005-2020), using geocoded natality data linked with census tract- and county-level characteristics. Dependent variables included pre-pregnancy diabetes (1.4%), hypertension (4.2%), obesity (37.2%), and smoking (3.8%). Independent variables included educational attainment, tract-level poverty and Black concentrations, and county-level urban/rural status, with controls for age, marital status, and time trend. Cross-tabulations examined joint distributions of urbanicity and poverty or Black concentrations, and random-intercept hierarchical generalized logistic regression models estimated associations (intraclass correlation coefficients ranged from 4.8% for obesity to 28.4% for smoking).

Results: Prevalence rates of each CVD risk factor increased with higher tract-level poverty and Black concentrations and, within each poverty/Black concentration level, rates increased as urbanicity decreased. Significant inequities at the individual-, tract-, and county-levels were observed for all four CVD risk factors. In general, lower educational attainment was associated with higher odds of having the risk factor, and this gradient was especially pronounced for smoking. At the tract level, Black women in high-poverty tracts had 11-25% higher odds, depending on the risk factor, compared to those in moderate-poverty tracts. Conversely, Black women in low-poverty tracts had 14-33% lower odds, depending on the risk factor, compared to those in moderate-poverty tracts. Residence in high Black concentration tracts was also associated with increased odds of diabetes (OR=1.17), hypertension (OR=1.15), and obesity (OR=1.20), but not smoking, compared with lower Black concentration tracts. Compared to those in large metropolitan counties, Black women in nonmetropolitan counties had 69% higher odds of diabetes (OR=1.69), 111% higher odds of hypertension (OR=2.11), 76% higher odds of obesity (OR=1.76), and 242% higher odds of smoking (OR=3.42).

Conclusions and Implications: This study highlights structural drivers of CVD disparities, showing that tract- and county-level social determinants significantly shape health risks. The compounding effects of racial and economic segregation, healthcare access gaps, and rural resource inequities contribute to persistent CVD risk. Findings emphasize the urgent need for place-based interventions that improve preventive healthcare access, nutritional and physical activity resources, and economic mobility for Black women. Public health and social work researchers, practitioners, and policymakers must align health equity interventions with systemic policy reforms to address structural determinants of health and reduce racial and geographic CVD disparities.

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