Understanding and addressing the impact of social determinants of health in cardiovascular disease prevention

Cardiovascular disease (CVD) has been and continues to be the the leading cause of death globally¹. Hence, over the last several decades, a lot of research and efforts have focused on identifying risk factors associated with CVD and ways of modifying these risk factors in order to prevent CVD and promote cardiovascular health. These efforts have led to a reduction in the incidence of adverse cardiovascular events, but there is still a long way to go.

While identifying and treating risk factors remain critically important, scientists and clinicians have come to understand, recognize, and appreciate how other aspects of an individual's life can affect his/her CV health. The contribution of several other factors, including, for example, physical fitness, mental state, sleep, pollution, other medical conditions (example inflammatory diseases) to CV health have all been recognized. Another very important factor that has been identified and now appreciated are the socio-economic aspects that appear to influence several aspects of healthcare delivery and consumption. These "social determinants of health" (SDoH) which include a large spectrum of factors from healthcare accessibility to affordability, the living environment to economics and disparities in the delivery of healthcare are critical, as, even if we find improved options to treat risk factors that can help prevent CVD, without access to these therapies we will not be able to optimally reduce the incidence of CVD. Hence, the American Heart Association has now published a scientific statement titled "Implementation of Prevention Science to Eliminate Healthcare Inequities in Achieving Cardiovascular Health"² which aims to educate healthcare providers about the importance of SDoH in the occurrence of CVD and in its prevention and provides some guidance about how to implement steps in addressing these healthcare inequities.

 In this scientific statement, Agarwala et al expertly provide us with an excellent overview on the impact of social factors on cardiovascular health, how they affect CVD prevention and then discuss how the medical community, society, patients, and the government can help mitigate the adverse consequences of societal inequalities on cardiovascular health.

 The authors using the World Health Organizations definition of "core social determinants of health" describe how the key components of SDoH namely health literacy, neighborhood and built environment, access to healthcare, economic stability, and racial and ethnic inequities affect CV health. They discuss how health literacy is associated with educational attainment, economic stability and in turn how this impacts medical care. They point out how neighborhoods can differ with respect to the availability of safe greenspaces which in turn can affect the opportunity for individuals to pursue physical activity. Similarly, neighborhoods can also impact the access to healthy food choices (food deserts/ food insecurity) which in turn will impact CV health. Furthermore, access to healthcare can vary depending on the neighborhood. Socio-economic status is another important factor which will not only affect access to face-to-face healthcare but also access to more recent innovations in healthcare delivery such as telehealth. Finally, the authors discuss how groups that are typically discriminated against have been shown to have a higher prevalence of adverse behaviors which consequently can affect health.

 Ultimately, those involved directly in patient care and healthcare delivery will have the most impact on an individual's health. Hence, for individuals working in the healthcare environment knowledge of SDoH and how to identify disparities and help with the same will be key. The scientific statement provides us with some guidance as to steps that may be helpful in this regard. The statement describes how members of healthcare teams/ environments should be educated and provided with tools such as polysocial risk scores which could help. Similarly, having a diverse workforce could help the patients and the healthcare system foster effective communication. The statement emphasizes the need for effective communication using the centers for disease controls 5 key principles for communication. Another important aspect of communication is the ever-expanding role of technology. Electronic medical records are now almost irreplaceable and while it provides a quick and efficient way for communication between the patient and healthcare team it must also be effective. Overall literacy and comfort with navigating electronic tools can be an impediment for many patients. On the other end, there are an ever-increasing number of wearable technologies that are emerging which can truly help and guide healthcare- there are now reliable ways to transmit blood pressure, blood sugar, other vitals including sleep health. These advances can clearly help in health promotion and prevention of disease. However, we must also be cognizant of the accessibility and availability of such technology to all individuals as, if not, this will introduce an additional disparity in the monitoring and hence delivery of health.

To help at least partially mitigate some of the issues related to accessibility of healthcare, the authors note how community health workers can play a crucial role in under-resourced areas. In addition to community health workers, engaging the community itself could be very helpful and useful. Innovative efforts have used barber shops, churches, grocery stores to help monitor, promote health and even intervene have shown value and continue to be studied. The authors also point out the value of community-academic partnerships that emerged during the COVID-19 pandemic and how similar approaches could be leveraged to promote several prevention efforts. Finally, the authors note the importance of government and their health policies which can help improve and optimize healthcare accessibility and delivery by focusing on the specific needs of local community.

As with solutions to any problem, one first needs to recognize that the problem exists, then understand the scope of the problem and come up with solutions. Currently our healthcare community is clearly beginning to understand the impact that disparities have on health promotion and CVD prevention. Although, individual providers in the past may have wondered how they could help a particular patient the education and mobilization of healthcare systems and teams now allow for resources that could help the providers to make impactful changes. Ultimately therapies will only work if administered- hence beyond identifying new therapies efforts to make these available to all will be important. Partnerships between patient-healthcare provider, patient-healthcare systems, healthcare systems-community and government-community-healthcare systems will all help in improving and hopefully largely mitigating the adverse impacts of disparities on health. Scientific statements such as the current one published by the American Heart Association are helpful to shine a spotlight on the issues at hand and provide a framework for approaches and solutions for patients, healthcare teams, the community and government at large.