Addressing the Social Determinants of Cardiovascular Health for All: Defining the Problem and Creating Solutions

Social determinants are commonly viewed as the primary drivers of health because they impact biology, physiology, health behaviors, health factors, clinical management, clinical outcomes, and community health. The impact of social disadvantage on health is substantial. Socially disadvantaged groups lose ideal cardiovascular health at an earlier age and experience an excess risk of clinical cardiovascular disease and mortality across the lifecycle. Indeed, health is determined, at least in part, by the places people live, work, and play. There is a 14-year difference in life expectancy due primarily to differences in cardiovascular mortality among different groups in different parts of the US. This observation reflects the fact that social factors not only influence the incidence of cardiovascular disease, but they also impact the management (treatment) and the outcomes of clinical cardiovascular diseases. As a result, there is a need to understand the role of social determinants in cardiovascular health and to develop innovative approaches that address social barriers to cardiovascular health.

The AHA scientific statement on Social Determinants of Risk and Outcomes for Cardiovascular Disease fills an important gap in the cardiovascular literature.¹ It will increase awareness of the influence of social factors on the incidence, treatment, and outcomes of cardiovascular disease. It summarizes current knowledge related to social determinants and suggests future directions in research, particularly the need for interventions that address the social circumstances that are drivers of cardiovascular health in the population. An important premise of the statement is that social factors affect cardiovascular health for all, not merely among the socially disadvantaged.

The statement is a primer on the social determinants of cardiovascular health. The term social determinant is used to characterize a broad set of interrelated societal influences that are clearly defined in the statement. It summarizes what’s known and what’s not known about the role of the following as potential determinants of cardiovascular health: socioeconomic position (SEP); race-ethnicity; social support and networks; culture and language; access to medical care; and, residential environment. It notes the complexity of these factors, the limitations of available metrics, and the need for analytics that include multi-level modeling. The statement also summarizes evidence related to plausible psychological, behavioral, and biological mechanisms that might mediate the associations of social factors with cardiovascular health. Finally, it indicates where interventions have been evaluated and where intervention studies are lacking, such as efforts to address low health literacy/numeracy and limited language proficiency.

Taken individually, metrics that reflect SEP, such as educational attainment, income, and employment/occupation, may not fully capture the influence of SEP. These characteristics are likely to interact, and the impact of these factors may vary by race-ethnicity. Additionally, the incorporation of novel constructs, such as family wealth and health literacy, and a life-course approach to SEP, such as repeated measures across the lifespan, may improve our understanding of the role of SEP in cardiovascular risk and outcomes. Of particular importance to clinicians, the statement notes the potential benefit of including measures of SEP in cardiovascular risk prediction models.

Given the focus of the statement on social determinants, race and ethnicity are considered as constructs shaped by the social, economic, and political forces of societies. While racial and ethnic differences in cardiovascular health have been documented extensively, few studies have examined the impact of racism/discrimination on cardiovascular health. The statement suggests that the experience of “implicit provider bias” and “stereotype threat” by patients from racial and ethnic minorities also has the potential to influence cardiovascular risk and outcomes. The statement calls for additional research to identify effective interventions to improve patient-provider communication and patient satisfaction/trust across racial lines. There is evidence that ethnically-, culturally-, and linguistically-tailored interventions can be highly effective for improving cardiovascular outcomes. The statement suggests that community health workers (CHWs), who serve as peer counselors, patient navigators, and link health care and community-based efforts, may be critical to the sustainability of culturally appropriate interventions.

Access to care is another complex social determinant addressed in the statement. There are several characteristics that affect access to care for cardiovascular disease and stroke including: approachability, availability and accommodation, affordability, and appropriateness. Additionally, these characteristics interact with various patient abilities, such as patient beliefs, literacy, culture and language. As a result, there are multiple potential barriers to access to care. Both the shortage of neurology care and the need to improve access to cardiovascular specialty care for Medicaid patients is noted in the statement; and it is suggested that improving access will require more than the provision of health care insurance for all.

Social determinants are multi-dimensional, multi-level, and multi-sectorial. For example, characteristics of residential environments, such as the built environment, housing, active transportation, and safe streets, also may impact cardiovascular risk and outcomes. Novel data sources and metrics for these and other social determinants are now being examined. Few longitudinal studies with repeated measures of social determinants in large, diverse populations across the lifecycle have been conducted to date. Social determinants are interrelated, interact, feedback, and change over time. For these reasons, prospective study designs and new analytics, such as agent-based modeling, are needed to better estimate the effects of these characteristics.

The American Heart Association has long recognized the role of social determinants in cardiovascular health; and, this is reflected in AHA support of research, scientific programming, community engagement, and policy advocacy. Recently, the AHA has emphasized the importance of addressing social determinants, if it is to achieve the 2020 goals of promoting cardiovascular health for all. The AHA has adopted the culture of health model (now being widely-promoted more formally by the Robert Wood Johnson Foundation), targeted the multi-cultural, multi-sectorial determinants of health, and promoted the concept of population health. Since population health improvement requires attention to the broader social determinants of cardiovascular health, such as education (schools), housing, transportation, and economic development, in addition to health care, the AHA is now working in several of these areas.

Given current projections, it is likely that the AHA will achieve its goal of reducing mortality from cardiovascular diseases by 20% by 2020. However, it will be difficult to achieve the goal of increasing the proportion of the population in ideal cardiovascular health by 2020, in large part due to the influence of social determinants on cardiovascular health. While modest progress has been achieved in reducing childhood obesity, approximately 50% of children lose ideal cardiovascular health due to overweight and obesity by the end of adolescence. Overweight and obesity increase the incidence of other risk factors in mid-life and cardiovascular disease later in life. Among women, the loss of ideal cardiovascular health due to overweight and obesity also impacts pre-conception health and the intra-uterine environment, potentially impacting the long-term cardiovascular health of mothers, offspring, and future generations.

The scientific statement on social determinants is a timely, important contribution: it indicates “Why?” it is critical that we address the social determinants of cardiovascular health. It also is provocative; and, it should stimulate a broader discussion of “How?” best to address the social determinants of health. In my view, it will take a substantial interdisciplinary commitment, such as a population (cardiovascular) health science and technology accelerator working step-by-step with communities, to develop and test solutions that address the challenges presented by the social determinants of cardiovascular health, the “What?” There are some reasons to be optimistic. Population health initiatives focused on policy, systems, and environmental change, the re-design of health care with an increased focus on population health outcomes, and the development of digital and mobile health technologies that target individuals and families from vulnerable populations, when taken together, may now provide a unique opportunity to address more effectively known social barriers to ideal cardiovascular health.