Social Determinants of Health and Effects on Cardiovascular Disease

Abstract

Research has shown that social determinants of health (SDOH) can influence health outcomes by up to 30 to 55% and can account for 80 to 90% of a person's health status. Our review evaluates SDOH in cardiovascular disease patients and assesses their impact in the field of cardiology as evidenced by research in the literature. Such SDOH as housing availability, access to healthy foods, access to transportation, access to medications, quality of living conditions, quality of schooling, and many other factors, have a great impact upon our patients' outcomes. Nowhere is this more true than in the field of cardiovascular disease, which is the leading cause of death worldwide. By recognizing SDOH and managing them through detection and prevention, patient outcomes can be affected in a positive direction. The key to being successful in this endeavor is to improve our patients' health literacy, promote prevention, and ameliorate the negative factors that affect health outcomes.

Social determinants of health (SDOH) are the conditions that influence societal and environmental factors that impact health status. ¹ Healthy People 2030 defines SDOH as the conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect many aspects of life, including health, functioning, and quality of life outcomes and risks. ² The SDOH can be broken down into five different domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. ²

Cardiovascular diseases (CVD) are diseases, including aortic atherosclerosis, coronary heart disease, stroke, and peripheral artery disease, that represent a group of conditions that impact the heart and blood vessels. CVD consistently ranks as the leading cause of death in the world and the United States. CVD causes 17.9 million deaths worldwide annually, so it is essential to see how SDOH impacts CVD. ^{3 4} There has been an escalation in CVD cases from 1990 to 2019, which is a substantial increase from 271 million to 523 million cases. ⁴ Concurrently, mortality rates have experienced a concerning uptick, rising from 12.1 million to 18.6 million fatalities. ⁴ In the United States, cardiometabolic diseases were responsible for an estimated 4.8 million deaths among working-age adults between 1990 and 2017. ⁵

One of the pivotal advancements in cardiovascular research during the 20th century was the discovery of risk factors linked to CVD. This led to the development and testing of treatments aimed at modifying these risk factors with the hopes of preventing CVD. These risk factors include hyperlipidemia, hypertension, diabetes, obesity, smoking, diet, and physical inactivity. ⁶ Together, they account for over 90% of CVD risks in various epidemiological studies. ⁶ However, identifying, modifying, and treating individual risk factors are not enough to prevent CVD, as many cardiovascular risk factors have been increasing at different rates worldwide. ⁷ In an attempt to reduce the incidence of CVD, there have been efforts to study the causes of the risk factors, including SDOH. ⁷

Variations in CVD occurrence and outcomes are influenced by the complex interactions between SDOH and cardiovascular health. ^{8 9} For example, throughout an individual's lifespan, inadequate social well-being can impact numerous health habits, such as substance misuse, obesity, and unhealthy eating patterns. ⁴ These behaviors are also associated with established CVD risk factors. For instance, research suggests that SDOH correlates with elevated blood pressure, inflammation, chronic stress, and high cholesterol levels. ⁴ Moreover, insufficient understanding of health information and challenges in accessing health care services result in delayed diagnoses of diseases, which can lead to critical outcomes such as CVD-related mortality. ⁴

In this manuscript, we will break down each subsection of the SDOH and how they each impact CVD outcomes. Furthermore, we will discuss ways and efforts to mitigate the SDOH, and why it should be routinely assessed as a part of all medical care by health care professionals, as there is a current gap in research of mitigation techniques for CVD health outcomes in relation to the SDOH.

Materials and Methods

We conducted a thorough literature review to collect relevant publications, articles, and peer-reviewed journals relevant to the SDOH and their relation to the field of CVD. Multiple academic databases were utilized to gather the relevant information using keywords including “social determinants of health,” “social determinants of health cardiovascular disease,” “cardiovascular disease mitigation,” and other related terms. The Boolean search string used was “AND” between the keywords listed above. These databases include PubMed, JAMA Network, Google Scholar, and SCOPUS. Multiple searches were conducted from March 9, 2024, to May 30, 2025. The search includes studies published in the past 15 years to warrant relevance to current progressions. The past 15 years were selected because there were more articles relevant to the review. Further articles were found relevant to the topic earlier than the 15-year period and those were included because we felt that they were relevant to the paper ( Fig. 1 ).

Fig. 1.

PRISMA flow diagram of study selection. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Articles and studies gathered during the search focused on the SDOH and their relation to CVD, specifically in regard to diet, neighborhood and built environment, economic stability, education access and quality, social community, health care access and quality, and mitigation of the SDOH. These studies and articles were thoroughly reviewed. Inclusion criteria included studies and articles relevant to the SDOH, describing and defining each determinant of health, the health outcomes of each determinant of health, and their relation to cardiology. The review was limited to predominantly U.S. populations. The full inclusion and exclusion criteria are listed below ( Table 1 ). We carefully analyzed and synthesized the chosen literature to discern crucial themes, methodologies, and findings concerning the correlation between SDOH and CVD. The process of this data synthesis included categorizing the different SDOH, defining each category, relating them to health outcomes in general, relating them to CVD, and the mitigation of each category.

Table 1. Search criteria for social determinants of health and cardiovascular disease.

Inclusion criteria	Exclusion criteria
English language studies/articles	Non-English language studies/articles
Studies from 2007 to 2024 Social determinants of health Health outcomes Cardiovascular disease U.S. studies	Studies published prior to 2007 Reviews of meta-analyses Animal studies Non-peer-reviewed studies Non-U.S. studies

We assessed the quality and credibility of the selected studies by considering factors such as study figure design, methodology, sample size, statistical analysis, and relevance to the focus of the manuscript. Only peer-reviewed studies characterized by methodologies and dependable data sources were incorporated into the synthesis. This narrative literature review adopted a qualitative synthesis methodology with the goal of crafting a cohesive narrative that integrates and interprets the findings from the chosen studies. The ultimate measure of quality was publication in peer-reviewed, indexed journals with impact factors. This review explores the health outcomes and mitigation of the SDOH effects on CVD.

Social Determinants of Health Factors for Consideration

Within the expansive landscape of SDOH, a multitude of interconnected factors play pivotal roles in shaping individual and community well-being. In this section, we will perform a comprehensive examination of the diverse dimensions that constitute each factor of SDOH. Fig. 2 categorizes and defines the SDOH simply and concisely. As we navigate through the intricate web of influences encompassing insurance coverage, transportation, familial and social support networks, job security, and language barriers, our objective is to unravel the intricate interplay between these factors and health outcomes. We will break down each subsection and see how each SDOH affects CVD.

Fig. 2.

Concept map describing the different categories of the social determinants of health.

Lowering the amount of risk factors one has for CVD is essential in its prevention. The risk factors for CVD are age, gender, genetics, race/ethnicity, obesity, hypertension, hyperlipidemia, alcohol intake, cigarette smoking, and overeating healthy foods. Of these risk factors for CVD, several of them are unmodifiable, including age, gender, genetics, and race/ethnicity. The rest of the risk factors are modifiable. Lately, there has been much emphasis on the impact of modifiable risk factors. Therefore, it is vital to understand exactly what modifies these specific risk factors. ¹⁰ Inadequate dietary habits represent one of the most detrimental lifestyles contributing to CVD morbidity and mortality, responsible for approximately 10 million deaths globally. ¹¹

Food and Nutrition

The food environment of an individual is characterized by factors such as food access, the capability to obtain food, food security, proximity to grocery stores and supermarkets, nutrition education and literacy, and the availability of food assistance programs. These factors are defined as the consistent availability of nutritionally adequate foods acquired through socially acceptable means, which play a significant role in shaping dietary habits and CVD risk factors. SDOH structures that acknowledge the food environment as a separate social determinant provide a deeper understanding of how food environments interact with collective action, policy development, and broader social dynamics. ^{11 12} Numerous longitudinal studies have linked the abundance and variety of food outlets, including supermarkets, smaller chain food stores, fast-food establishments, and full-service restaurants, with dietary intake and overall diet quality. ⁴ Notably, these associations are observed across urban and rural settings, with a pronounced impact in lower-income or predominantly Black or Hispanic neighborhoods. ⁴ Social determinants, such as social support and cohesion, also exert influence on dietary patterns, contingent upon the built environment context. ⁴ Moreover, occupation, including factors like work hours, significantly influences food access and dietary choices. ⁴ The interplay between the food environment and dietary intake intersects with biological and psychological mechanisms associated with SDOH domains, such as inflammation, stress response, and immune function. ⁴ Future research avenues should delve into understanding the individual experience within the food environment, the significance of activity spaces, and the impact of travel routes within nonresidential food environments on dietary behavior and cardiovascular health markers.

Nutrition insecurity (NI) and food insecurity (FI) represent various challenges. FI entails limited or uncertain access to sufficient food, whereas NI encompasses issues related to the availability, access, affordability, and utilization of foods and beverages that support health and prevent disease. ¹³ Adults dealing with FI typically have lower-quality diets, marked by reduced consumption of fruits and vegetables. ¹³ Such dietary patterns can heighten the risk of developing CVD, primarily through intermediary conditions like diabetes, hypertension, obesity, and dyslipidemia. ¹³ Given that CVD stands as the leading cause of mortality in the United States, and diet constitutes its primary contributor, individuals facing FI and NI are likely to bear a disproportionate burden of diet-related CVD. ¹³ The connection between FI and cardiovascular health often goes unnoticed in clinical settings, despite individuals with CVD being twice as likely to experience FI. ¹³

Managing one's diet is an important factor in relation to CVD risk. Consumption of whole grains, vegetables, fruits, nuts, legumes, and fish is negatively associated with the risk of CVD, while consumption of eggs, dairy, red meat, and processed meat is positively associated with CVD. ¹⁴ The consumption of whole grains, vegetables, and fruits is associated with reducing CVD risk. ¹⁴ Mechanisms include the presence of essential nutrients, fiber, antioxidants, and phytochemicals, which collectively contribute to improved cardiovascular health. ¹⁴ Cooking methods can alter the nutrient content depending on the method and the nutrients involved. While high-heat or water-based methods like boiling may cause nutrient loss, methods like steaming or microwaving help retain nutrients. ¹⁵ Deep-frying increases the formation of trans fats and advanced glycation end products, which lead to endothelial dysfunctions and inflammation. ¹⁶ Egg consumption showed a positive association with CVD risk, likely due to choline and its metabolite linked to atherosclerosis. ¹⁴ Dairy intake presented mixed results; it increased heart failure risk linearly but reduced stroke risk nonlinearly. ¹⁴ Fish consumption consistently reduced the risk of CVD, supported by their long-chain omega-3 fatty acids. ¹⁴ However, the presence of environmental contaminants in fish necessitates balanced consumption. ¹⁴ Both farmed and wild-caught fish provide cardioprotective omega-3 fatty acids. Wild-caught salmon contains lower levels of total fat, lower levels of saturated fat, and higher omega-3-to-omega-6 ratios. ¹⁷ Red and processed meat consumption was associated with increased risk of CVD, likely due to their proinflammatory and oxidative compounds. ¹⁴ This study shows that consuming vegetables, fruits, whole grains, nuts, legumes, and fish, while limiting red and processed meats, decreases risk for CVD. ¹⁴

The most significant dietary risks associated with CVD mortality include low intake of whole grains (10.2%), high sodium consumption (9.5%), low fruit intake (8.5%), and low intake of nuts and seeds (7.5%). ¹⁸ Excessive intake of saturated fats, refined sugars, and processed meats heightens cardiovascular risk. ¹⁹ In contrast, fiber-rich foods, polyunsaturated fats (particularly omega-3 fatty acids), and polyphenol-containing plant foods offer protective cardiovascular effects. ¹⁹

The Mediterranean diet, characterized by high intake of fruits, vegetables, whole grains, legumes, olive oil, and moderate fish and wine consumption, has been associated with reduced rates of coronary heart disease, stroke, and total mortality. ¹⁹ In an analysis of the Mediterranean diet's impact on survival, certain dietary components contributed more significantly than others. Moderate alcohol intake, particularly wine, had the strongest association with improved survival, accounting for 24% of the benefit. ¹⁹ This was followed by low consumption of red and processed meats (17%), high intake of vegetables (16%), and frequent consumption of fruits and nuts (11%). ¹⁹ Other beneficial factors included a high ratio of monounsaturated to saturated fats, greater intake of legumes, cereals, and limited dairy. ¹⁹ Interestingly, fish and seafood intake did not show a statistically significant effect on survival in this specific population. ¹⁹ The DASH (Dietary Approaches to Stop Hypertension) diet similarly emphasizes fruits, vegetables, and low-fat dairy, with a particular focus on sodium reduction, and has shown benefits in reducing blood pressure and improving lipid profiles. ¹⁹ Vegetarian and vegan diets, while also cardioprotective due to high fiber and low saturated fat content, require careful planning to avoid nutrient deficiencies such as vitamin B12 and iron. ¹⁹

Neighborhood and Built Environment

Neighborhood and built environments are recognized as crucial SDOH, encompassing various physical aspects of the surroundings where individuals reside. These include housing quality, access to green spaces, safety and crime rates, transportation infrastructure, and exposure to environmental hazards. The condition of housing can significantly impact health outcomes, with poor housing conditions contributing to respiratory illnesses, injuries, and mental health issues. ²⁰ Additionally, access to green spaces has been associated with improved physical activity (PA), reduced stress, and better mental well-being. ²¹ Moreover, transportation infrastructure and safety concerns, such as crime rates, affect access to health care, employment, and healthy food options, influencing overall health outcomes. ²² CVD risk is positively linked to high traffic density and proximity to major roads, while it is negatively linked to the availability of parks and recreational facilities. ²³ Built environment and lack of green spaces directly expose individuals to environmental factors such as air pollution, noise, and extreme temperatures, which are closely linked to the development and occurrence of CVD. ²³ Furthermore, they can indirectly affect CVD risks by shaping individuals' behaviors and lifestyles. For example, residing in areas with limited green spaces might hinder regular physical activities essential for cardiovascular health. ²³ The risk factors for CVD are likely influenced by the walkability of neighborhoods, which is determined by factors such as street connectivity, public transit availability, population density, land-use diversity, and the presence of green and open spaces. ²³ Exposure to heavy traffic is linked to higher levels of coronary artery calcium, with men and individuals of lower socioeconomic status being particularly vulnerable. ²³ Studies have explored the connection between active mobility, walkable streets, public transportation, and early signs of atherosclerosis. Despite the expected cardiovascular benefits of greater active mobility, these advantages might be offset by high levels of exposure to ambient air pollution in heavily polluted areas. ²³ Living in close proximity to major roads (less than 150 m vs. more than 300 m) was associated with a 6.67% increase in carotid intima-media thickness. ²³ Additionally, researchers have documented that greater greenery is linked to reduced odds of severe coronary artery narrowing in adults. ²³

Living in neighborhoods characterized by poor housing quality and limited access to green spaces is associated with higher rates of CVD risk factors such as hypertension, obesity, and physical inactivity. ²⁴ Neighborhoods with higher levels of safety concerns and limited access to healthy food options have been linked to increased prevalence of CVD and related conditions. ⁸ Furthermore, exposure to environmental hazards such as air pollution and noise pollution in urban areas has been identified as a significant risk factor for CVD morbidity and mortality. ²⁵ Neighborhood walkability is associated with increased PA levels, thereby reducing CVD risk. ²⁶ Moreover, access to healthy food options in the built environment has emerged as a critical determinant of cardiovascular health. Neighborhoods with greater access to supermarkets and walkable environments were associated with lower obesity rates and improved cardiovascular outcomes. ²⁷ These findings underscore the importance of addressing neighborhood and built environment factors in comprehensive strategies aimed at preventing and managing CVD in contemporary settings. Recent studies have shed light on the negative impacts of residing in underprivileged neighborhoods marked by limited access to health care services, increased pollution levels, and insufficient infrastructure. Individuals residing in neighborhoods with fewer resources for PA and healthy foods had a higher incidence of type 2 diabetes, a major risk factor for CVD. ²⁸ Furthermore, neighborhoods with poor walkability and limited access to green spaces have been associated with lower levels of PA and higher rates of obesity and hypertension, contributing to CVD burden. ^{29 30 31} Additionally, socioeconomic disparities prevalent in disadvantaged neighborhoods, such as limited educational and employment opportunities, exacerbate stress levels and increase the likelihood of unhealthy behaviors, further amplifying CVD risk. ²⁴

Rural environments, like urban environments, have many advantages and disadvantages regarding SDOH. Between 2015 and 2019, in the United States, rural counties had worsening measures of health outcomes across multiple SDOH indicators, with many measures deteriorating more rapidly than in urban areas. ³² Although living in rural areas has numerous benefits, including better air quality and housing stability, the benefits are outweighed by the disadvantages. ³² These disadvantages include lower life expectancy, increased obesity, and less PA compared with urban settings. ³² Living in rural settings has less amounts of excessive alcohol consumption, but this advantage is diminishing. ³²

Although the CVD mortality rate declined from 2009 to 2018 in the United States, in rural counties, the CVD mortality rate increased. There was an inverse relationship between median household income and CVD mortality that was more pronounced in rural counties, suggesting that income and poverty contribute significantly to rural–urban health disparities. ³³ The association between socioeconomic status and CVD risk may vary depending on geographic context, with notable differences between urban and rural populations. ³³

Economic Stability

Economic stability is a critical SDOH that encompasses various factors related to individuals' financial resources, employment status, and access to economic opportunities. Socioeconomic status, which is closely linked to economic stability, significantly influences access to health care, housing quality, nutrition, and education, ultimately shaping health trajectories. ³⁴ Individuals with higher socioeconomic status generally have better access to resources and opportunities that promote health and well-being. Conversely, those experiencing economic hardship often face barriers to health care services, struggle to afford nutritious food and stable housing, and may encounter stressors associated with financial insecurity, all of which contribute to disparities in health outcomes. ³⁵ Individuals with lower economic stability may be more likely to reside in neighborhoods with limited access to health care facilities and healthy food options, exacerbating health risks. ⁸ Additionally, economic instability can contribute to chronic stress, which is associated with adverse health outcomes such as CVD, depression, and compromised immune function. ³⁶ Addressing economic stability as an SDOH requires comprehensive strategies aimed at reducing poverty, promoting employment opportunities, and providing social safety nets to mitigate the impact of financial hardships on health. Policies that support fair wages, affordable housing, access to education and training, and social welfare programs play a crucial role in improving economic stability, and, consequently, population health. ³⁷

Lower income is associated with increased risks of nonfatal myocardial infarction and sudden cardiac death, independent of factors like smoking and alcohol consumption. ³⁸ Studies show that for every $10,000 rise in neighborhood median income, there is a corresponding 10% decrease in mortality risk. ³⁸ Additionally, individuals with lower incomes are less likely to receive essential medications such as statins, β-blockers, and antiplatelet agents following acute myocardial infarction. ³⁸ These disparities stem from limited access to quality health care among socially disadvantaged groups, which contributes to higher rates of hospital readmissions and poorer health outcomes. ³⁸ Economic instability may result in chronic stress, triggering activation of the sympathetic nervous system and adrenal cortex, consequently leading to elevated levels of stress hormones like catecholamines, which are recognized as independent predictors for CVD development. ^{5 39 40} Individuals facing financial instability may encounter difficulties accessing timely medical care and covering the costs of their prescription medications, particularly if they are required to pay out of their own pockets. ^{41 42 43 44} Economic instability could also lead to other diseases that influence CVD, like diabetes mellitus and hypertension. ⁴⁵ Individuals experiencing economic instability, including those facing homelessness or FI, often encounter limited dietary options and struggle to meet basic needs such as food, shelter, and clothing. ⁴⁶ Additionally, they may experience inadequate sleep quality and quantity, engage in heavy drinking, excessive alcohol consumption, and illicit drug use. ⁴⁶ These factors are more prevalent among economically vulnerable populations and may contribute to the increased incidence of CVD. Economic instability often leads to the consumption of less-nutritious, high-energy foods, with a higher intake of sugar-sweetened beverages and processed meats, which can further exacerbate the risk of developing CVD. ^{47 48 49 50} Economic stability also influences obesity, which is a risk factor for CVD, in the United States. Among women, obesity prevalence was lowest in the highest income group (29.7%) and higher in the middle (42.9%) and the highest (45.2%) in the lowest income groups. ⁵¹ For men, obesity was less prevalent in the lowest (31.5%) and the highest (32.6%) income groups compared with the middle-income group (38.5%). ⁵¹ This is likely due to a combination of food and nutrition access and education variation among the different income groups. It could also be due to the variation of health care access among the different income groups.

Education Access and Quality

Individuals with greater educational attainment tend to experience better health and increased longevity. ² Children from low-income families, those with disabilities, and those who face social discrimination—such as bullying—are more likely to encounter difficulties in math and reading. ² Additionally, they have lower graduation rates from high school and reduced access to college education. ² Consequently, they are less likely to secure safe, well-paying jobs and more prone to health issues like heart disease, diabetes, and depression. ² Furthermore, some children reside in areas with underperforming schools, while many families struggle to afford college tuition. ² The stress of poverty can impact children's brain development, hindering their academic performance. ² Implementing interventions to support students and assist families in covering college costs can yield long-term health benefits. ² Early childhood education plays a pivotal role in shaping lifelong beliefs and behaviors that contribute to positive health outcomes. ⁵² However, the extent to which a child benefits from these interventions depends on their social, educational, and economic context. ⁵² Significant health disparities exist between individuals with varying levels of education. ⁵² Notably, in 1999, the age-adjusted mortality rate for high school dropouts aged 25 to 64 was more than twice that of individuals with some college education. ⁵³ A connection exists between educational level and health outcomes, impacting both chronic and acute conditions. ⁵² However, the strength of this relationship tends to be more pronounced for chronic health issues. ⁵² For adults aged 25 and above, extending education by 4 years correlates with a decrease in 5-year mortality by 1.8 percentage points, dropping from 11 to 9.2%. ⁵⁴ Moreover, it is associated with a reduced risk of heart disease by 2.2 percentage points, declining from 31 to 28.8%, and a lower risk of diabetes by 1.3 percentage points, falling from 7 to 5.7%. ⁵⁴ Individuals with higher levels of education experience reduced morbidity rates for prevalent acute and chronic illnesses such as heart disease, stroke, hypertension, high cholesterol, emphysema, diabetes, asthma, and ulcers. ⁵⁴ Studies have demonstrated that educational achievement provides a notable protective effect against the risk of stroke and heart attack, irrespective of socioeconomic status and other cardiovascular risk factors. ⁵⁴

A study from JAMA Cardiology examines the relationship between education and lifetime CVD risk. ⁵⁵ Utilizing data from six community-based cohort studies spanning from 1985 to 2015, the study assesses the association between educational attainment and incident CVD, along with years lived with and without CVD. ⁵⁰ Participants aged 40 to 79 years, initially free of CVD, were analyzed based on their education level, cardiovascular risk factors, and prospective CVD outcomes. ⁵⁵ Results indicate that individuals with lower education levels, such as less than high school or high school completion, exhibit higher lifetime CVD risks compared with college graduates. ⁵⁵ Furthermore, higher education correlates with a longer duration of life before experiencing CVD events. ⁵⁵ However, while education contributes to healthy longevity, its impact on enhancing CVD risk prediction remains limited. ⁵⁵ This underscores the importance of educational policies in promoting long-term health benefits.

Health literacy is crucial in managing CVD. Limited education leads to reduced health literacy, which can prevent people from using medications properly and navigating health services effectively. ¹³ Generally, lower educational levels are associated with higher risks for acute myocardial infarction, coronary heart disease, stroke, heart failure, all-cause mortality, and sudden cardiac death. ¹³ However, it is important to recognize that among racially minoritized communities, such as non-Hispanic Black individuals, the benefits of higher education may be diminished due to chronic discrimination, which can outweigh the protective effects of education. ¹³

Social and Community Context

People's connections with family, friends, colleagues, and community members significantly influence their health and overall well-being. Social and community context includes an individual's place of birth, residence, education, employment, leisure activities, religious affiliations, and aging process. ² Many individuals encounter uncontrollable challenges and hazards, including unsafe living environments, discrimination, or financial hardships. These adversely affect their health and safety throughout their lifetimes. ² Establishing positive relationships within familial, professional, and communal spheres can mitigate these adverse effects. ² Children with incarcerated parents and bullied adolescents often lack support from their social networks. ² Implementing interventions aimed at fostering social and community support systems is necessary for enhancing health and well-being. ²

Social roles, isolation, loneliness, ethnicity, and discrimination were linked to increased CVD risk. ⁴ Nonetheless, some reviews within this area reported inconsistent or inconclusive associations. ⁴ For instance, most reviews did not find a correlation between social support and CVD, while social capital was not consistently linked to specific types of CVD. ⁴ However, one study showed that inadequate social well-being, specifically social isolation, and loneliness, as a risk factor for CVD. ⁵⁶ This factor is associated with a one-third rise in CVD incidence, a 4-fold increase in mortality risk, and elevated chances of hospitalization and emergency department visits. ⁵⁶ Psychosocial factors, which encompass characteristics that affect individuals psychologically or socially, are strongly linked to cardiovascular health outcomes. ⁵ This association is evident through direct pathways involving the chronic activation of physiological stress responses and systemic inflammation. ⁵ There is also evidence that these factors contribute by raising the frequency of behaviors that may have detrimental effects on cardiovascular health. ⁵ Several psychosocial factors influence cardiovascular health, including chronic psychological stress, subjective social status, job strain, adverse childhood experiences, depression, perceived discrimination, and feelings of loneliness or social isolation. ⁵ Inadequate social well-being, like loneliness, correlates with depression, anger, and hostility, along with diminished capacity to cope with external stressors. ⁵² Adverse psychological conditions can exacerbate detrimental physiological responses, such as activation of the hypothalamic–pituitary–adrenal axis and increased levels of inflammatory markers. ⁵ These markers of inflammation, coupled with cardiometabolic alterations stemming from inadequate social well-being, particularly loneliness, may elevate blood pressure and induce fluctuations in heart rate. ^{57 58} Individuals experiencing inadequate social or community involvement are at higher risk of having heightened behavioral CVD risk factors, including smoking, substance abuse, and low PA. ⁵⁸ Deficient social well-being hampers individuals' access to medical assistance, potentially leading to the advancement of various health conditions, including CVD. ⁵⁹ When investigating psychosocial determinants of cardiovascular health, it is essential to consider upstream social factors, such as adverse childhood experiences, which disrupt typical developmental processes and heighten vulnerability to disease. ⁶⁰ These effects persist into adulthood, with adults scoring four or higher on the adverse childhood experience scale being twice as likely to develop CVD. ⁶⁰ Furthermore, beneficial psychological attributes such as resilience and self-efficacy are linked to favorable impacts on cardiovascular health. ⁶¹ Similarly, motivation and executive function can indirectly affect cardiovascular well-being by influencing outcomes related to obesity, including weight loss, weight maintenance, and achieving PA goals. ⁶²

Health Care Access and Quality

Many individuals in the United States face barriers to accessing necessary health care services. Approximately 1 in 10 Americans lack health insurance. ² This leads to reduced access to primary care providers and difficulties affording essential health care and medications. ² Strategies aimed at increasing insurance coverage rates are crucial to ensuring broader access to preventive care and treatment for chronic illnesses. ² Additionally, some individuals miss out on recommended health care services, such as cancer screenings, either due to the absence of a primary care provider or limited proximity to health care facilities. ² Interventions to improve access to health care professionals and enhance communication, including in-person or remotely, are vital to addressing these disparities and facilitating equitable access to necessary care. ²

Access to different insurance policies is the primary method in which individuals receive access to health care. In 2018, approximately 13.0% of individuals did not have health insurance coverage. ⁶³ Also in 2018, 19.7% of individuals were covered by public insurance plans, and 69.0% had private health insurance plans. ⁶³ Having health insurance is linked to improved access to medical services and acts as a safeguard against the substantial expenses associated with severe illnesses. ⁶³ Furthermore, studies have revealed that insured individuals tend to have more frequent visits to physicians and a greater adherence to preventive health measures. ⁶³ Additionally, private health coverage has been correlated with reduced overall mortality rates. ⁶³ Accounting for age and sex, individuals with private insurance exhibited a diminished mortality risk across various health conditions, including CVD, cancer, heart disease, stroke, chronic lower respiratory disease, diabetes, influenza and pneumonia, kidney disease, and accidents. ⁶³ In contrast, those relying on public insurance faced an elevated risk of mortality from these same causes. ⁶³ These public health insurances should grant access to the proper providers and resources that private health insurances provide. This can be a multitude of resources, including primary care physicians, cardiologists, medications, and other health care providers. Private coverage remained associated with approximately 21% lower CVD mortality risk even when compared with individuals without insurance. ⁶³ These findings underscore the critical role of health insurance in promoting well-being and mitigating health-related risks.

Utilization of primary care providers has decreased by 24% between 2008 and 2016. ⁶² This was evident among young adults and individuals residing in low-income areas in the United States. ⁶⁴ Improving access to primary care providers is crucial for delivering health care services, particularly amid the growing burden of preventable chronic diseases. ¹³ Primary care plays a vital role in connecting individuals to specialty care and essential resources, such as the Supplemental Nutrition Assistance Program (SNAP), which is a federal government program that offers food-purchasing aid to low-income individuals to assist in providing nutritious food essential to health and well-being. ¹³ Innovative health care delivery models emphasizing improved integration between primary and specialty care are emerging. ¹³ However, the success of these models hinges on addressing SDOH comprehensively. ¹³ A patient-centered approach that prioritizes timely access to specialty care while addressing SDOH is highly desirable. ¹³

Social Determinants of Health Mitigation Considerations

Mitigation of the SDOH is essential as they often underlie health disparities, which lead to unequal access to health care services and unequal health outcomes among different populations. While many of the mitigation strategies discussed in this review are drawn from the context of the United States, the underlying issues presented by SDOH, such as FI, inadequate housing, limited education, and poor health care access are global in scope. Different countries may have varying methods to address these SDOH. Although they may be implemented in differing ways, the core principles of community engagement, interdisciplinary collaboration, and equity-centered care remain consistent. Societies can promote health equity and improve the overall health of the population by addressing these SDOH. This is possible through the engagement of policy implementation and involvements pointed at lowering poverty, improving access to education and employment opportunities, ensuring affordable housing, and eliminating discrimination. Mitigating SDOH is essential for establishing a more just and reasonable society where everyone has the opportunity to live a healthy life.

Mitigation of the SDOH internationally has shown promise. In Brazil, there is a program called the Bolsa Familia, which translates to family grant. ⁶⁵ It expands access to health and education for families in poverty and aims to reduce poverty and income inequities. ⁶⁵ It has lifted millions of people out of poverty, supported people with the greatest unmet need to access health services, and has contributed to progressive realization of universal health coverage. ⁶⁵ In Europe, the World Health Organization (WHO) European region adopted a health policy framework that aims to support action across government and society to significantly improve the health and well-being of populations, reduce health inequalities, and strengthen public health. ⁶⁶ Many countries in the European Union elected to participate in this attempt to improve the quality of life of the people. In 2015, the 53 members of the WHO European region signed the Minsk agreement, which involves committing to the adoption of the life-course approach that would improve health and well-being, promote social justice and contribute to sustainable development and inclusive growth and wealth in all involved countries. ⁶⁶ In Sub-Saharan Africa, a study of reproductive-aged females showed that accessing health care is influenced by different infrastructures, such as roads, distance to a health facility and transport service, as well as access to education, economic limitations, and the influence of sociocultural behaviors where women ask permission from their husbands before seeking health care. ⁶⁷ Therefore, health care access for this demographic can be improved through targeted efforts to enhance services for women who reside in rural settings, women with limited education, and women from lower socioeconomic backgrounds.

Although our main focus is on mitigation efforts within the United States, they can also be applied globally. These mitigation techniques include transformation of the health care system, food prescription programs, and value-based care models. It is important to recognize that these approaches often align with international strategies when viewed at a system level rather than a political one. Universal challenges such as FI, social isolation, and unstable housing transcend borders. Therefore, solutions typically include equity, community involvement, and upstream prevention are potential solutions in diverse global contexts ( Fig. 3 ).

Fig. 3.

Flow chart showing the mitigation techniques to improve the social determinants of health.

Mitigation of Food Insecurity and Nutrition Insecurity

Mitigation of FI and NI is a way to improve overall health for those in need. FI and NI can be addressed through collaborative efforts involving various health care professionals, such as clinicians, registered dietitians, social workers, and case managers, as well as referrals to state social service departments. ¹³ Clinicians play a vital role in informing patients about available resources within the health care system, including clinic food pantries and produce prescriptions. ¹³ Providers can also refer patients to social workers or case managers for access to local resources and government food assistance programs. Examples of these government food assistance programs are SNAP or the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). ¹³ Many individuals may be unaware of their eligibility for SNAP benefits, highlighting the need for proactive identification. Enrolling in food assistance programs like SNAP can have significant implications for clinical outcomes. SNAP, as the largest public food benefit program, has been linked to reduced FI, increased medication adherence, and decreased health care costs and hospitalizations. ¹³ SNAP participants may benefit from initiatives like the Double Up Food Bucks program, which is available in 25 states, which doubles SNAP dollars (up to $20 per day) for purchases of fruits and vegetables. ¹³ This program has been shown to enhance fruit and vegetable consumption and alleviate FI. ¹³ The integration of efforts to address FI and NI into routine cardiovascular care is becoming increasingly recognized, particularly considering the “food is medicine” movement. ¹³ Investments in initiatives that integrate nutrition into health care, such as Massachusetts' and California's medically tailored meals programs and Oregon's collaborations with Meals on Wheels, underscore the growing importance of addressing FI as part of comprehensive health care strategies. ¹³ The Special Supplemental Program for WIC showed numerous benefits including improved maternal and child health outcomes. ⁶⁸ A National Health Interview Study found that those who participated in WIC were less likely to delay filling a prescription, skip medication doses, or take less medication that prescribed due to costs. ⁶⁸ The Older Americans Act funded nutritional services to older adults and improved their health care outcomes. ⁶⁸ An evaluation of the services funded by the Older Americans Act found that lower-income older adults that participated in these congregate meal programs experienced significant lower levels in FI compared with nonparticipants. ⁶⁸ Additionally, 61% of individuals receiving home-delivered meals and 42% of congregate meal participants reported that, without the program, they would likely skip meals or reduce their food intake. ⁶⁸ Participants in the home-delivered meal program also showed notable improvements in self-reported health and anxiety levels, along with decreased rates of hospitalizations and falls compared with those still on waiting lists. ⁶⁸ These programs have helped mitigate the health outcomes of CVD in relation to the SDOH.

Another methods that can increase access to food are food pharmacies, food prescription programs, and home-delivered meals. ⁶⁸ Food pharmacies are pharmacies, health care clinics, or hospitals that store and dispense healthy food. ⁶⁸ At Geisinger Health System, a “Fresh Food Farmacy” program launched in 2016 provided diabetic patients with 5 days' worth of healthy meals per week, along with supportive services. Participants saw a 20% reduction in HbA1c levels, and it was estimated that each percentage point drop in HbA1c corresponded to approximately $8,000 in health care savings. ^{69 70} Similar prescription programs at health clinics have reported improved health metrics such as lower body mass index, better glucose control, and enhanced patient-provider relationships. ⁶⁸ Home-delivered meal programs have also been successful. Medicaid beneficiaries in Philadelphia and Southern New Jersey who received three free, healthy meals a day per day had reduced overall health care expenditures, reduced hospitalizations, reduced lengths of stay, and higher percentages of discharge home compared with acute care. ⁷¹ Dually eligible Medicare and Medicaid beneficiaries who received participation in a food delivery program had fewer emergency department visits and lower medical charges compared with matched controls. ⁷² These methods may help mitigate FI and NI.

Mitigation of Neighborhood and Built Environment

There are many ways in which the negative impacts of neighborhood and built environments can be mitigated. In the context of mitigating housing instability among patients, clinicians have several potential interventions. These interventions include simplifying drug regimens for chronic CVDs that can alleviate treatment burdens. ¹³ This is because housing-unstable individuals often face challenges prioritizing housing over other basic needs. ¹³ Clinicians should tailor CVD education to the specific conditions of housing-unstable patients by presenting preventive guidance that acknowledges their distinctive tradeoffs. ¹³ Providing information on diuretic titration or symptom recognition in heart failure without reliable access to objective measures could be beneficial to these housing-unstable patients. ¹³ Clinicians must use nonstigmatizing language when interacting with housing-unstable patients to promote trust and respect, thus recognizing the impact of provider language on treatment decisions in stigmatized conditions. ¹³ On another note, homeless patients pose challenges for health care systems due to their lack of stable discharge destinations. Housing interventions effectively reduce hospitalizations, hospital days, and emergency department visits for adults experiencing homelessness with chronic illnesses like heart disease, diabetes, renal failure, cirrhosis, asthma, and HIV. ⁷³ Collaborations between health systems and community housing providers can address this issue. This issue can be mitigated by providing health systems with financial support to fulfill their Affordable Care Act (ACA)-required community health benefit. ¹³ Establishing safe discharge destinations can alleviate the burden on hospitals and emergency departments, such as medical respite programs. ¹³ These programs have demonstrated success in reducing hospital readmissions and promoting patient recovery, providing stability and fostering health-related routines for patients transitioning from hospital care. ¹³ Improved walkability and safety in neighborhoods and creating parks and recreational areas to encourage outdoor activities and reduce stress through PA.

Ensuring housing is safe and well-maintained positively impacts health. Studies demonstrate that improving existing homes through renovations or modifications leads to better health outcomes. ⁶⁸ For instance, children living in redeveloped, lower-density public housing experienced fewer repeat acute care visits compared with those in older, nonredeveloped public housing. ⁷⁴ Addressing specific health hazards within the home also shows benefits. An intervention that provided dust mite covers, professional cleaning, and roach control for children with asthma resulted in lower dust mite levels and improved functional health, even if overall asthma severity remained unchanged. ⁷⁵ Implementing smoke-free housing policies also improves health by reducing secondhand smoke exposure. ⁶⁸ A 2014 analysis estimated that prohibiting smoking in all U.S. subsidized housing could save $310 million annually in health care costs related to secondhand smoke. ⁷⁶

To promote lasting weight loss in underserved communities, health coaches can create personalized plans tailored to individual circumstances, including factors related to the local environment. ¹³ Clinicians can evaluate eligibility for prescription PA programs, such as Silver Sneakers exercise classes for Medicare beneficiaries aged 65 and older. ¹³ Community centers like the YMCA provide PA facilities at reduced rates, helping individuals overcome unsafe exercise conditions. ¹³ Referrals to cardiac rehabilitation and physical therapy can also benefit those with qualifying diagnoses. Encouraging safe exercise in well-lit areas with sidewalks and pathways can reduce risks from traffic and improve accessibility. ¹³ Health care systems can adopt a multidisciplinary approach to enhance PA participation. ¹³ This involves comprehensive assessments of patients' PA levels and identifying barriers to achieving PA targets. ¹³ Exercise therapists, nutritionists, social workers, and behavioral counselors can collaborate to provide PA programs customized for each individual, dietary counseling, and address ecological safety concerns. Programs like the University of Michigan's Metabolic Fitness Program have shown success in improving metabolic health outcomes. ¹³ Mitigation of transportation barriers is necessary, and health care providers can streamline care to reduce trips and organize various needs in a single visit. Health systems can invest in transportation assistance programs, community-based point-of-care services, and robust virtual visit programs to improve access to care. ¹³ Telehealth services, supported by the Veterans Health Administration and mobile health programs, offer additional solutions to transportation limitations and enhance patient access to health care services. ¹³

Transportation problems for the underserved can be difficult to overcome. Clinicians should strategically align care to reduce the need for multiple trips. This could potentially be done by coordinating various departments to streamline the necessary workup, thus minimizing disruptions and missed appointments. Addressing multiple needs during a single visit is one way to help reduce unnecessary trips to a health care facility. An example would be organizing laboratories and imaging on the same day. A common practice is to schedule computed tomography scans and echo imaging the day before a planned transcatheter aortic valve replacement; therefore, everything that needed to be done ahead of the procedure is available. ¹³ Health care systems can implement programs aimed at tackling transportation barriers head-on by providing transportation assistance, establishing community-based point-of-care services, and developing robust virtual visit programs. For example, the Veterans Health Administration offers a van transportation service and covers airfare for patients requiring specialty care unavailable locally. ¹³ Telehealth has been a longstanding tool within the Veterans Health Administration in an effort to effectively reduce no-shows and emergency department visits by enabling remote chronic disease monitoring. ¹³ Mobile health programs can further enhance access to care, while support for clinical services like same-day percutaneous coronary intervention can eliminate the need for overnight stays for accompanying drivers. ¹³ Moreover, community partnerships, such as volunteer programs or rideshare collaborations, can help bridge transportation gaps, expanding the hospital's reach. ¹³

Mitigation of Economic Stability

Economic stability significantly influences cardiovascular health outcomes, as financial insecurity can lead to chronic stress, limited access to health care, and poor health behaviors, all of which increase the risk of CVD. Policies that enhance economic stability, such as providing fair wages, affordable housing, and accessible health care services, are essential for mitigating these risks. It is important in clinical practice for health care providers to inquire about patients' employment status and assess whether their income meets basic needs such as food, shelter, and health care. There may be concerns regarding employment or income that can lead to limitations. In this case, patients can be referred to social services for appropriate assistance. A meta-analysis examining health effects of randomized social experiments in the United States recognized multiple cash-transfer interventions and revealed that they were related with improvements in self-reported health, not including smoking status or obesity. ⁷⁷ An example of this would be the Stockton Economic Empowerment Demonstration, a universal basic income experiment in Stockton, CA, that gave randomly selected residents $500 per month for 2 years with no strings attached, which measurably improved participants' overall well-being and physical and emotional health. ⁷⁸ Health care systems should proactively engage in addressing economic stability, with initiatives such as those undertaken by state Medicaid programs. ¹³ For instance, in Oregon, collaboration with Meals on Wheels enables the delivery of meals to discharged patients requiring food support during recovery. ¹³ Similarly, programs in New York and Louisiana focus on housing-related activities to facilitate stable housing for individuals. ¹³ Additionally, certain states like Arizona, Massachusetts, and California mandate that Medicaid Managed Care Organizations tackle economic instability, particularly regarding housing and food security. ¹³ Under the ACA, which attempted to increase health insurance coverage and make it more affordable, nonprofit hospitals are required to provide community benefits. ¹³ Most of these benefits primarily fund unreimbursed care, with only a fraction allocated to community groups or activities aimed at community development. ¹³ The Earned Income Tax Credit (EITC) has demonstrably reduced poverty and increased financial resources for working families. ^{79 80} EITC eligibility is associated with increased health insurance coverage for children and a lower infant mortality rate in states with higher EITC participation. ^{79 80} A 10-percentage point increase in EITC penetration led to a 23.2 per 100,000 reduction in infant mortality, which underscores the profound public health impact of these financial policies. ⁶⁸ Beyond tax credits, supplemental income support, such as Supplemental Social Security Income, also contributes to better health. ⁶⁸ An experimental study found that a $100 monthly increase in maximum Social Security Income benefits reduced mobility limitations among older adults, highlighting how direct financial support can positively influence physical well-being. ⁸¹ Therefore, bolstering economic stability through these mechanisms can be a powerful strategy in addressing the upstream factors that contribute to the burden of CVD. A reallocation of resources toward supporting community groups and activities could help alleviate the financial barriers to accessing health care that many people face.

Mitigation of Education Access and Quality

Mitigation of education access and quality can be achieved through a variety of ways. The Centers for Disease Control and Prevention highlights two tools for measuring adult health literacy: the Agency for Healthcare Research and Quality Health Literacy measurement tools, which assess reading comprehension in medical contexts for English and Spanish speakers, and the Health Literacy Tool Shed, an online database of health literacy measures with their psychometric properties. ¹³ These tools systematically evaluate and compare patients' understanding and ability to act on medical educational materials. ¹³ The choice of tool should be based on patient population characteristics and time availability. Health care providers must prioritize understanding patients' health literacy levels. This is important because people with poor health literacy may struggle with medication adherence, particularly in conditions like hypertension, diabetes, and CVD. This can be addressed through providers utilizing teaching methods such as open-ended questions and teach-back techniques to enhance patient comprehension. ¹³ Enabling patients to attend health literacy classes or relevant courses, such as guided smoking cessation programs, can improve overall health literacy. ¹³ The American Heart Association offers strategies to overcome health literacy barriers in CVD management, an example being those related to informed consent. ¹³ Health systems can contribute substantially to increasing health literacy by simplifying health education information and incorporating complete health literacy assessments into patient interactions. ¹³ Partnership with local communities to develop health literacy programs meets community health action conditions and supports health equity. ¹³ Childhood education has been associated with improved child development and has been shown to serve as a protective factor against future disease disability. ⁸² A review of research on early childhood education programs demonstrated that programs, including Abecedarian, the Infant Health and Development Program, and the Perry Preschool Project, improved health and health behaviors. ⁸³ These include improved cardiovascular health, reduced smoking, and improved metabolic health among participants in adulthood, in comparison to controls. ⁸³ Accompanying initiatives to improve high school graduation rates align with the goal of increasing education levels and, consequently, improving health literacy. ¹³ The Agency for Healthcare Research and Quality outlines 10 attributes of a health-literate health care organization, providing a toolkit for health systems to evolve, including catering to the needs of the population served and ensuring staff education on health literacy promotion strategies. ¹³

Improving health literacy among high-risk, low-resource populations poses unique challenges. Key strategies include leveraging health information technology, such as mobile apps and platforms, to enhance self-care behaviors in CVD patients and promote healthy habits. ⁸⁴ However, limited access to smartphones and unreliable internet connections can diminish these benefits for some individuals. ⁸⁴ Community-centered interventions have proven effective, such as utilizing hairstylists to deliver health messages in predominantly Black populations, engaging houses of worship for Spanish-speaking patients, and using hip-hop music to educate urban children. ⁸⁴ Culturally tailored approaches, like community-reflective case vignettes, also show promise. ⁸⁴ Multidisciplinary interventions incorporating nonmedical providers, such as pharmacists and community health workers, have successfully addressed health literacy challenges in CVD, resulting in improved outcomes. These interventions are typically community-focused, addressing specific barriers to care within individual communities. ⁸⁴ Effective strategies also consider SDOH, including economic, cultural, and language barriers that impede public health initiatives. ⁸⁴ By integrating these factors into health literacy efforts, broader improvements in CVD screening, prevention, and management can be achieved.

Mitigation of Social and Community Context

There are many ways in which social and community context as an SDOH can be mitigated. Considering sex and gender's influence on CVD prevention, diagnosis, and treatment, it is essential for personalized patient care, as treatments may vary significantly based on these factors. To promote equity in care across sex and gender, establishing specialized women's CVD prevention clinics can be beneficial. ¹³ The WISEWOMAN (Well-Integrated Screening and Evaluation for Women Across the Nation) program provided lifestyle counseling delivered by bilingual community health workers to enhance cardiovascular health behaviors among Latina women. ⁵ A diverse health care team, instructed to adopt conscious and unconscious biases, can enhance patient access to care. Furthermore, thorough medical training programs should integrate instruction on transgender patients' unique needs. ¹³ For patients exposed to loneliness and social isolation, health care providers should address the potential impact on health outcomes, as well as collaborate with social work teams to navigate supportive services tailored to patients' needs. ¹³ Numerous tactics, outlined in the National Academies of Sciences, Engineering, and Medicine's report, suggest ways to mitigate social isolation. ¹³ Identifying SDOH, including social isolation, can guide referrals to resources such as community organizations and virtual care options. ¹³ Leveraging technology and social media platforms can further disseminate public health information and raise awareness of cardiovascular health among detached inhabitants. ¹³ Strengthening partnerships between health care institutions and community-based organizations can further support the availability of resources addressing social needs. ⁵

Mitigation of Health Care Access and Quality

The mitigation of health care access and quality is an important factor in the attempt to help health care accessibility for all. Primary care plays a vital role in early CVD prevention, underlining the need for routine screening and referral for primary care provider access during all health care visits. Health care systems can engage in several initiatives to improve primary health care access. The RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) intervention aimed to address disparities in hypertension control through a collaborative care approach involving nurse care managers coordinating care for patients with multiple health conditions. ⁵ Improving access to specialist care in remote areas may be done by establishing programs to reduce the distance to primary care provider (PCP) services and implementing rural outreach clinics. ¹³ Reforms in payment and insurance policies can be crucial due to the expansion of medical insurance coverage for better primary care access are crucial. ¹³ The ACA addresses some of these concerns by prioritizing population health management, promoting accountable care organizations, and advocating for the patient-centered medical home model. ¹³ This model ensures that each patient has a designated PCP within a single health system and is also supported by a multidisciplinary team including dieticians, social workers, and others. ¹³ There are significant opportunities to integrate SDOH into clinical practice by standardizing tools in electronic health records for assessing SDOH, implementing panel management to identify and reach out to high-risk patients, and adjusting clinical decisions to consider factors such as housing conditions and health literacy. ⁵ Updating clinical guidelines for CVD management to include SDOH-informed care practices is essential. ⁵ Furthermore, enhancing clinical education to better equip health care providers in identifying and addressing patients' social needs is crucial.

Public Health Policy

Emphasis of the SDOH on CVD mitigation through public health policy and practice is critical. Policies that enhance economic stability, such as providing fair wages, affordable housing, and accessible health care services, are important to the mitigation of CVD. Policies that improve access to quality education, such as investing in early childhood education, providing equitable school funding, and supporting lifelong learning opportunities, are essential for mitigating CVD risk. Policies that promote urban planning, improve public transportation, and ensure access to green spaces and healthy food options are essential for creating health-supportive environments. Policies that promote health literacy through patient education, clear communication from health care providers, and accessible health information resources are essential for improving health outcomes. The Centers for Disease Control and Prevention addresses SDOH and health-related social needs through targeted public health initiatives aimed at reducing chronic disease disparities. ⁶⁸ Programs such as Racial and Ethnic Approaches to Community Health have provided culturally tailored, community-based interventions for over two decades, improving access to healthy food, PA, and chronic disease services for millions. ⁶⁸ Frameworks proposed by the National Academies of Sciences, Engineering, and Medicine advocate for screening SDOH, adjusting care based on individual contexts, connecting patients to community resources, and promoting policies that expand social care resources. ⁵ The American Heart Association's recommendations underscore the importance of educating cardiovascular health providers on SDOH, enhancing electronic health records for SDOH screening, and broadening interventions to address upstream factors like poverty and education. ⁵ Health care providers can adopt screening tools within electronic health records to identify patients facing housing instability. This allows for targeted interventions such as connecting patients with community resources for stable housing, facilitating access to financial assistance programs, and providing education on housing rights and resources. Calls for updating clinical guidelines and health care provider education to incorporate SDOH considerations, strengthening partnerships between health care institutions and community organizations, and engaging communities in policy development through participatory research are policies that can be easily implemented. ⁵ Examples such as the RICH LIFE and WISEWOMAN interventions demonstrate successful community-based approaches involving health care workers and tailored counseling to mitigate CVD risks among specific populations. ⁵ Integrating SDOH considerations into public health policy and health care practice requires a multidisciplinary approach involving health care providers, policymakers, and community organizations.

Limitations

The review process had limitations, including dependency on available literature, potential publication biases, and differences in methodologies among the included studies. Translating findings from the literature into practical health promotion and policy initiatives can be challenging. The narrative literature review may highlight effective strategies, but their real-world implementation might face barriers such as funding constraints, lack of political will, and varying levels of community engagement.

Conclusion

In conclusion, this analysis summarizes the key findings on the SDOH affecting CVD outcomes. It highlights the significant impact of factors such as diet, neighborhood and built environments, economic stability, education access and quality, social and community context, and health care access and quality. Addressing these determinants requires comprehensive strategies, including policy changes, health care improvements, and community programs. Recognizing and addressing SDOH is essential for creating a more just and equitable health care system, ensuring everyone has the opportunity for better health. Future research directions should focus on the mitigation of CVD health outcomes based on the SDOH. Due to the limitations in the literature of the mitigation of CVD health outcomes in relation to the SDOH, future research directions should focus on the strategies addressing the mitigation techniques for each SDOH.

It is crucial to issue a call to action for the recognition, evaluation, and mitigation of the SDOH in relation to CVD. Comprehensive strategies are needed in an effort to reduce poverty, improve access to education, improve access to employment opportunities, ensure affordable housing, and reduce discrimination. These are key steps toward encouraging health equity. Health care providers must take initiative in identifying and addressing SDOH-related issues by shaping interventions to each individual circumstance. They must also collaborate with community organizations and social services to educate the underserved populations, as well as provide a wider range of access. Attempting to improve and mitigate the SDOH is the next step in creating a more reasonable health care system where everyone has the opportunity to live a healthy life.