Measuring and influencing social factors to improve the health of all Asian Americans

Research advances over the last two decades have deepened our understanding of both the biological underpinnings and the social and environmental effects on health and disease. The social determinants of health (SDoH) collectively include social and environmental factors estimated to account for 50-60% of most health outcomes.^1-3 As we define and investigate which and how social/environmental factors impact health, it is incumbent on the research community to broaden our frameworks to include experiences from all population groups, especially those who are often hidden by data aggregation or wholly neglected in research studies. The AHA Scientific Statement titled "Social Determinants of Cardiovascular Health in Asian Americans" by Shah and colleagues provides detailed population characteristics and the state of the science of SDoH among Asian Americans, the fastest-growing racial group in the United States currently. This Scientific Statement proposes an adapted framework for conceptualizing SDoH in Asian American populations, summarizes the available data across several of the largest Asian subgroups, and includes several research gaps with recommendations for future investigations and interventions. The Statement is a timely contribution given the recent investments by the National Institutes of Health to launch new longitudinal cohort studies to fill knowledge gaps among the diverse and growing Asian American populations.^4-6

What are SDOH, and are they different for Asian Americans?

The social determinants of health include multi-level factors that can be categorized as larger structural factors, including the natural and built environment, transportation, housing, food, and healthcare systems; social, economic, and political contexts and policies; neighborhood and community-level factors; interpersonal and individual-level social and cultural factors. An important consideration for framing SDOH in Asian Americans is that a majority of this population is comprised of first-generation immigrants, with growing numbers of refugees, asylees, and undocumented immigrants.^{7, 8} Immigrants face different barriers and challenges due to their varied experiences, acculturative stressors, language, and cultural differences that may influence all other social, economic, and material circumstances.⁹ While the more recent Asian immigrant experiences may be similar to immigrants from other parts of the world, the geopolitical and societal contexts and policies may differentially impact some Asian American groups, as recently evidenced during the COVID-19 pandemic.^{10, 11}

Why are SDOH important?

A growing body of literature supports that SDoH are more strongly associated with cardiovascular health outcomes than traditional risk factors.^{2, 3} These social and environmental factors influence all stages of the lifecourse, starting with basic biology and heritability of diseases. Gene x environment interactions have been well-recognized to affect the phenotypic expression of genes for complex disease traits; however, the scientific community is still developing tools to measure and understand these mechanisms.¹² Epidemiologic studies have shown that SDOH influence downstream behaviors, mental health, and overall quality of life.¹³ Most importantly, many SDoH can be modified by more significant structural and policy interventions to improve health equity on a population scale.

How can SDOH be assessed and the science of SDOH be improved?

The AHA Scientific Statement outlines many categories of SDoH that should be assessed to identify where disparities exist and as potential levers for intervention among Asian American populations. However, many existing tools and instruments used to measure SDoH were created and validated in non-Asian populations.⁴ Because immigrant and acculturation experiences are diverse, there is a need to develop, test, and validate newer multidimensional measures that include current societal contexts. Research teams must include sociologists, cultural anthropologists, clinical psychologists, and measurement methodologists to develop new survey instruments or modify existing measures with cross-cultural adaptation.¹⁴

To further advance the science of SDoH, social and environmental factors need to be measured repeatedly over time since many of these factors evolve with changes in circumstances, settings, and with aging. Additionally, overlaying the relevant societal and geopolitical policies and contexts, such as changes to immigration or healthcare policies, can help with data interpretation and policy evaluation. Taking a lifecourse approach in multilevel data analysis can improve our understanding of critical periods for intervention and prevention of chronic disease and the effects of policy changes on health.

Lastly, as these SDoH measures are validated and shown to add value in research studies, these items should be implemented as routine patient-reported measures into the electronic health records to highlight paths for interventions to promote health equity.¹⁵ Many health systems have started to capture some basic SDoH, but data on nativity, immigration, acculturation, intergenerational family/household structure, and social support have yet to be included.

Conclusion

The social and environmental factors and contexts that Asian Americans live, work, and play in are important contributors to cardiovascular health. Measuring these SDoH well and repeatedly over time, with a purposeful inclusion of the broader societal contexts, will provide new insights into how to mitigate health disparities and advance health equity. As we launch new studies among Asian American populations, we must use meaningful and carefully evaluated measures for these diverse population groups and disseminate these tools for broader use both in future research studies and within our healthcare systems.