[Thesis defense] Léna Silberzan

On December 12th, 2025, Léna Silberzan defended her thesis in epidemiology:

‘An intersectional perspective on social inequalities in arterial hypertension’

Jury:

• Anne McMunn, Professor, University College London (rapporteur)
• Laurent Rigal, Professor, CESP, Université Paris-Saclay, INSERM (rapporteur)
• Charles Agyemang, Professor, University of Amsterdam (examiner)
• Anne Gosselin, Researcher, INED—French Institute for Demographic Studies (examiner)
• Michelle Kelly-Irving, Research Director, CERPOP, INSERM (thesis supervisor)
• Nathalie Bajos, Research Director, Iris, EHESS, INSERM (co-supervisor)

Abstract:

Abstract

Hypertension is one of the leading risk factors for mortality and morbidity worldwide, accounting each year for an estimated 10 million premature deaths and 235 million years of life lost or lived with disability. It affects nearly one in three adults, including in high-income countries, and its management remains insufficient when assessed through the “cascade of care” framework (sequential steps of prevalence, awareness, treatment, and control). Both the prevalence of hypertension and progression along the cascade of care are unequally distributed, depending on their association with social factors such as gender, age, and socioeconomic position, and, in certain national contexts (United States, Canada, United Kingdom, the Netherlands), race/ethnicity or migration background. Recent approaches, drawing on the intersectionality framework, highlight the importance of jointly analyzing multiple social dimensions to identify subgroups of the population most disadvantaged in hypertension and its management. In France, where more than one in three individuals has hypertension, fewer than two-thirds are aware of their diagnosis, three-quarters of those diagnosed receive treatment, and only half of those achieve blood pressure control. While some social determinants have been investigated, no population-based study has yet included race/ethnicity or migration background in the analysis of social inequalities in hypertension and its management. This thesis aims to explore social inequalities in hypertension and its cascade of care through the lens of intersectionality, using data from the CONSTANCES cohort (2012–2021), a large population-based sample linked to the French National Health Data System (n = 205,203). The analyses, grounded in an intersectional perspective and mobilizing both classical approaches (stratification, interaction) and innovative methods (MAIHDA), reveal pronounced social and ethnoracial inequalities: individuals of sub-Saharan African or French overseas origin with more disadvantaged socioeconomic positions exhibit the highest blood pressure levels, across all ages and genders, whereas individuals with more advantaged socioeconomic positions originating from North Africa, Asia, or other regions present the lowest levels. Barriers within the cascade of care also differ across groups: women of sub-Saharan African origin face difficulties achieving blood pressure control despite treatment, while European women and Asian men who are aware of their diagnosis are more likely to encounter barriers at the stage of accessing treatment. Finally, this work offers a critical perspective on the cascade of care model, which, while constituting an essential public health tool, also reflects socially situated biases. These findings contribute to a better identification of the populations most vulnerable to hypertension and open new perspectives for more equitable management.