Impact of Neighborhood on Cardiovascular Health: A Contemporary Narrative Review

Abstract

Purpose of Review

This review summarizes approaches towards neighborhood characterization in relation to cardiovascular health; contemporary investigations relating neighborhood factors to cardiovascular risk and disease; and initiatives to support community-based interventions to address neighborhood-based social determinants related to cardiovascular health.

Recent Findings

Neighborhoods may be characterized by Census-derived measures, geospatial data, historical databases, and metrics that incorporate data from electronic medical records and health information exchange databases. Current research has examined neighborhood determinants spanning racial segregation, access to healthcare and food, educational opportunities, physical and built environment, and social environment, and their relations to cardiovascular health and associated outcomes. Community-based interventions have potential to alleviate health disparities but remain limited by implementation challenges.

Summary

Consideration of neighborhood context is essential in the design of interventions to prevent cardiovascular disease (CVD) and promote health equity. Partnership with community stakeholders may enhance implementation of programs addressing neighborhood-based health determinants.

Introduction

Neighborhoods are complex, geographic areas of residence, work, and play and facilitate health-related behaviors, exposure to environmental factors, and access to health care. The contribution of neighborhood residence to cardiovascular outcomes is well established. Early data from the Atherosclerosis Risk in Communities (ARIC) study demonstrated the association between neighborhood socioeconomic status and incident coronary heart disease risk. After adjusting for individual-level socioeconomic indicators, residence in disadvantaged neighborhoods increased risk of coronary disease by 30 to 50% among Black ARIC participants and 70 to 90% among White participants, compared to cohort participants residing in the most advantaged neighborhoods [1]. Additional studies have since demonstrated associations between neighborhood disadvantage and health outcomes including cardiovascular risk factor control (i.e., diabetes mellitus, cholesterol, and blood pressure) [2], and cardiovascular mortality [3].

This review characterizes how neighborhoods contribute to cardiovascular health and summarizes selected literature describing the extensive associations between the neighborhood and cardiovascular health. The review further summarizes community-based approaches to prevention, and presents how attention to neighborhood-based health factors can elucidate intervention targets to improve cardiovascular and general health. Understanding the neighborhood-level factors that contribute to cardiovascular health may inform public health policies, identify targets for population-level interventions, and in turn reduce racial and socioeconomic disparities. By design, our scope is limited to studies in developed Western nations and not intended as comprehensive.

Characterization and Definition of the Neighborhood

The definition of what constitutes a neighborhood has varied by the scope of inquiry employed by study investigators. Principal measures utilized to characterize neighborhoods have incorporated diverse social, geographic, and place-based data. Here, we categorize measures broadly as (1) Census-derived metrics, which capture socioeconomic variables; (2) geospatial data, reflecting physical characteristics of a neighborhood; (3) historical databases that incorporate the legacy of policy; and (4) electronic medical record (EMR) and Health Information Exchange (HIE) databases, which may reflect disease prevalence and treatment. Table 1 summarizes these different approaches towards defining the neighborhood. As indicated by the variability of approaches, investigators have employed definitions of the neighborhood informed by geography, residency, risk factor characterization, and the proposed mechanisms relating neighborhood-based exposure to CVD outcomes.

Table 1.

Summary of neighborhood designation and measures used for neighborhood-level measures

	Created or maintained by	Measure(s)	Composition	Strengths	Limitations
Census-derived metrics
Area Deprivation Index [6]	University of Wisconsin	Decile [1–10] by state or percentile (1–100) ranking	17 social and financial indicators	Granularit Publicly available	Absence of neighborhood physical characteristics
Social Vulnerability Index [7, 99]	Center for Disease Control	State percentile ranking (1–100)	16 measures, 4 categories: socioeconomic status, household characteristics, race and ethnic minority status, housing and transportation	Stratifies maps by category Includes access to resources and housing	Designed primarily to assess disaster preparedness
Neighborhood Deprivation Index [4]	Messer et. al	Continuous variable	8 measures, 5 categories: wealth/income, education, employment, housing, occupation	Uses US census data Multiple measures Validated	Absence of standardization
Distressed communities index [100]	Economic Innovation Group	Percentile ranking [1–100] nationally	7 socioeconomic factors: high school diploma, housing vacancy, adults not working, poverty, median income ratio, change in employment, change in establishments	Focus on economic indicators	Limited number of indicators Proprietary data not publicly available
Child opportunity index [8]	Kirwan Institute for the Study of Race and Ethnicity, Ohio State University	Percentile ranking (1–100)	29 socioeconomic indicators, 3 domains: education, health and environment, social and economic	Child-relevant indicators Summarizes neighborhood resources to facilitate healthy child development	Limited number of indicators
Evenness Dissimilarity Index [101, 102]	Duncan and Duncan (1955), refined by Allen et al. (2015)	Racial integration scale, 0 to 1	Weighted mean absolute deviation of the minority proportion in a census tract from the city’s minority population	Accounts for spatial patterns of populations Incorporates population composition	May overestimate segregation
Isolation index [9]	Reardon and O’Sullivan (2004)	Probability 2 individuals from same neighborhood are same ethnicity or race, 0 to 1	Extent of exposure of minority members of a population only to one another	Measures exposure	Does not consider the population composition
Geospatial metrics
National Walkability Index [103]	Environmental Protection Agency	Walkability (0–20)	Variables from the Smart Location Database: intersection density, proximity to transit stops, and diversity of land uses	Public, downloadable data Includes every block group in the USA	Expected index will vary based on whether rural, suburban, or urban area
Walk Score® [104]	Front Seat Management	Walkability (0–100)	Multiple data sources	Validated Free web-based tool	Commercial product primarily for real estate Algorithms not accessible to the public Generalizability outside of USA
Transit score® [105]	Front Seat Management	Public transit accessibility (0–100)	Public transit agency data	Correlates with density of bus and subway stops	Commercial product primarily for real estate Algorithms not accessible to the public Only available in 40 US cities
Google street view audits [106, 107]	Google’s Maps application (2007)	57 built environment elements	Video library	Facilitates virtual field audits of neighborhoods Potential to archive	Variability of observations by timing and image acquisition
Historical databases
Redline maps [12, 13]	Home Owners’ Loan Corporation	Primarily racial composition	Ethnic/racial composition, local assets/hazards, housing quality	Highlights persistent impacts of historical federal and local housing discrimination	Used to devalue investments in minority communities
EMR and health information exchange databases
PHOENIX Database [19]	Wayne State University	Electronic health information	Combines state-level health information exchange from electronic medical record	Medical record data incorporated with neighborhood health Able to analyze trends over time	Limited ability to utilize the electronic health record

Census-derived Metrics

Census-derived metrics combine multiple dimensions of socioeconomic deprivation into a single measure to yield a comprehensive measure of neighborhood-based social determinants. Such composite indices have stronger associations with health outcomes in comparison to single-variable measures [4, 5]. A distinguishing feature of these indices is the granularity of the geographic unit upon which they are based. For example, the Area Deprivation Index (ADI) employs Census block groups, which typically contain 250 to 550 housing units. Census-derived metrics include the ADI, which incorporates 17 socioeconomic factors [6]; the Social Vulnerability Index, devised to measure neighborhood resiliency against disaster [7]; the Childhood Opportunity Index, focused on resource availability to promote childhood development [8]; and the Isolation Index, which reflects neighborhood racial homogeneity [9].

Geospatial Metrics

Geospatial metrics explore the physical characteristics of a neighborhood, often utilizing global positioning system data. The walkability index incorporates street connectivity with land use mix data and residential density. Residing in the least walkable neighborhoods has been associated with increased likelihood of coronary artery disease, hypertension, diabetes, and obesity relative to the most walkable [10, 11]. Studies analyzing availability of healthy food options can define a Euclidean or network buffer to measure proximity to food stores. Such geospatial metrics define the physical characteristics of a neighborhood and residents’ access to resources to optimize general and cardiovascular health.

Redlining

Created by the Home Owners’ Loan Corporation (HOLC) between 1935 and 1940, redline maps were among the most comprehensive real estate valuations, intended to provide an assessment of mortgage lending risk. These maps devalued federal investment and decreased home ownership in Black communities. In 2016, through a partnership between the University of Richmond and the National Community Reinvestment Coalition, the HOLC maps were digitized with the goal to compare classifications to current economic and demographic status of neighborhoods [12, 13]. Comparison of HOLC maps with contemporary indices such as the Social Vulnerability Index and the Home Mortgage Disclosure Act data has demonstrated the persistent neighborhood disadvantage resulting from redlining [13–15]. Residents of historically redlined neighborhoods are at higher risk of multiple adverse health outcomes and experience a 3.6-year reduction in life expectancy compared to those in historically high-graded neighborhoods [16, 17]. An analysis conducted in the Multi-Ethnic Study of Atherosclerosis (MESA) combined redlining maps and individual-level cohort data to determine that residing in a lower HOLC grade of historically redlined neighborhood was associated with worse cardiovascular outcomes. Black MESA participants residing in historically grade D “hazardous” neighborhoods had lower odds of ideal blood pressure (Odds Ratio [OR] 0.22, 95% confidence interval [CI]: 0.10–0.50) and ideal body mass index (OR 0.40, 95% CI: 0.18–0.86) compared with those residing in grade “A: best” neighborhoods. This association persisted for Black MESA participants following contemporary improvements to the neighborhood social environment [18•].

Electronic Medical Record and Health Information Exchange Databases

The incorporation of individual-level information from EMR and HIE data with social determinants of health provides a potent epidemiological tool. For example, the Wayne State Population Health Outcomes and Information Exchange (PHOENIX) has incorporated HIE data in combination with geospatial data, educational statistics, crime reports, and policy environment, facilitating assessments of neighborhood health in southeast Michigan and metropolitan Detroit [19]. PHOENIX has been additionally leveraged to target mobile health interventions for hypertension screening and COVID testing [20, 21].

Neighborhood Contributors to Cardiovascular Health

The mechanisms by which neighborhood impacts cardiovascular health are complex and informed by local context. Here, we focus on the foremost and most studied neighborhood-based factors that contribute to cardiovascular health: racial segregation, physical environment, educational access, healthcare access, food environment, and social cohesion.

Racial Segregation

The migration of Black families from the rural South to Northern urban cities in the late 1890s to mid-1940s catalyzed the emergence of urban Black communities [22, 23]. Segregation was fostered by discriminatory housing policies such as the National Housing Act of 1934 and remains supported by persistent discriminatory mortgage lending practices [14, 15]. Since 1970s, integration of upper- and middle-class Black individuals into White neighborhoods has further concentrated poverty in primarily Black neighborhoods [24]. Concomitant urban renewal efforts and gentrification have often resulted in displacement, eroding the beneficial effects of community in Black neighborhoods [25, 26]. Black communities remain more segregated than Asian and Hispanic communities [24], with segregation and poverty concentration exacerbating reduced access to resources, including education [22, 27, 28], high-quality food [29], healthcare [30–33], and infrastructure to foster physical activity [34].

Segregation may result in disproportionate access to resources and quality of care. Black patients residing in neighborhoods characterized by greater racial segregation, for example, are less likely to undergo coronary artery bypass graft surgery (OR 0.77, 95% CI: 0.73–0.82) and abdominal aortic aneurysm repair (OR 0.76, 95% CI: 0.68–0.85) in high-quality hospitals compared to White patients. The discrepancy in hospital quality was not observed in low-segregation areas [35]. This disproportionate access to resources translates to worse health outcomes for minority groups. For example, several studies have shown poorer pregnancy outcomes and increased mortality for Black residents in segregated Black neighborhoods [36]. For Native American women, living in ethnically segregated neighborhoods carries a six-fold increase in the 10-year risk of coronary heart disease compared living in less segregated neighborhoods [37]. In the MESA cohort, White participants living in areas with higher racial segregation experienced higher individual and neighborhood socioeconomic position, better neighborhood physical and social environments, lower rates of current smoking and physical inactivity, and lower body mass index compared with living in areas with less racial segregation. However, in Black individuals, each standard deviation increase in racial segregation was associated with a 12% higher 10-year risk of developing CVD after adjusting for demographics (Hazard Ratio [HR] 1.12, 95% CI: 1.02–1.22). The association persisted after adjustment for neighborhood-level characteristics, individual socioeconomic position, and CVD risk factors [38].

The impact of segregation on cardiovascular health may be complicated as particular demographics may also benefit from the health protective effects of community and social networks. For example, residing in a neighborhood with greater percentages of Black residents was associated with lower coronary heart disease mortality rate (β = −11.72, SE: 3.6, P: 0.002) and all-cause mortality rate (β = −9.83, SE: 3.46, P: 0.005) among older Black adults in New York City [39]. For low-income women living in the most segregated communities, the 10-year coronary heart disease risk was 36% lower for Black, 41% lower for Hispanic, and 91% lower for Asian women when compared to similar women living in less segregated neighborhoods [37]. In general, however, segregated Black neighborhoods experience worse physical environments and resource access, outweighing social benefits and yielding worse cardiovascular risk [22, 27–34, 39].

In summary, a large body of evidence supports that racial and economic segregation has a differential effect on health outcomes with worse outcomes in minority populations.

Physical and Built Environment

The physical neighborhood in which individuals live impacts cardiovascular outcomes and contributes to health disparities. Examining the relationships of air pollution and heat to cardiovascular health illustrates examples of the contributions of urban design to health.

Air pollution was responsible for 108,000 deaths in the USA in 2017, and globally over 7 million premature deaths and 16% of deaths from ischemic heart disease [40, 41, 42•]. Fine particulate matter has a causal association with cardiovascular morbidity due to inflammatory, metabolic, and autonomic neurological pathways [40, 42•]. Air quality standards have resulted in a 74% reduction in the aggregate emissions of common pollutants between 1970 and 2018, but climate change threatens to exacerbate existing challenges [40]. Extreme heat, measured as the 99th percentile of mean daily temperature, is linked to a 6% increase in coronary artery disease admissions compared to the lowest risk temperature percentile [43], and a 1 °C increase in temperature corresponds to a 3.4% increase in cardiovascular mortality [44]. Climate change impacts air quality through various mechanisms, including intensity of wildfires, electricity demand for cooling, and atmospheric processes. Many pollutants, such as black carbon, have been associated with both climate change and cardiovascular mortality [40].

The neighborhood built environment impacts residents’ hazardous exposures to air pollution and heat and may contribute to racial health disparities. The MESA and Air Pollution cohort (MESA Air) has demonstrated that racial disparities in air pollution exposure likely reflect the combined consequences of racial segregation and urban design [45]. Communities of color have increased exposure to high-traffic areas resulting in increased individual exposure to air pollutants during neighborhood-based activities [40, 45, 46]. The impacts of climate change are similarly not equitably distributed, as neighborhoods with a greater proportion of residents that are lower income or people of color experience higher temperatures [47–51]. These disparities in heat exposure are reflected in comparisons of historically redlined neighborhoods [52–54]; 94% of urban areas in the USA experience higher land surface temperatures in historically grade D neighborhoods compared to historically grade A neighborhoods, resulting in an average national difference of 2.6 °C [52]. Furthermore, the same level of exposure can present greater risk of CVD for different groups [55, 56]. For example, among Medicare recipients, White residents experienced increased mortality with a HR 1.06 (95% CI: 1.06–1.07) for every 10 μg/m³ increase in fine particulate matter exposure; the HR for mortality in Black residents for the same exposure was 1.21 (95% CI: 1.20–1.22) [56].

The differential health impacts of air pollution exposure may be mediated by neighborhood design, affecting physical activity and in turn metabolic syndrome, diabetes mellitus, and CVD risk [57, 58]. Systematic reviews have consistently demonstrated a relationship between neighborhood walkability and physical activity mediated by neighborhood density, diversity of land uses, and design related to street layout and connectivity [58]. Indeed, among survivors of Hurricane Katrina who had little control of relocation, a relationship was observed between urban sprawl and increased body mass index [59]. Thus, built environment may contribute to health by both decreasing hazardous exposures that threaten cardiovascular health and fostering opportunities for health promotion that reduce individual susceptibility to exposures [58].

Educational Access

Education has a consistent and well-established association with CVD [60, 61]. The relationship between education and cardiovascular health may be mediated by vocational opportunity and health literacy on health behaviors, which influence biologic factors including obesity, high blood pressure, diabetes mellitus, and high cholesterol levels [62, 63]. Educational attainment is often assessed at the family level through measures of parental educational attainment or at the neighborhood level through parallel measures of Census-derived educational attainment describing the proportion of residents who completed a selected stage of education. Individuals residing in neighborhoods with lower summary educational attainment levels experience decreased cardiovascular health [64] and increased risk of incident coronary heart disease (HR 1.25, 95% CI: 1.02–1.54) compared to those living in neighborhoods with higher summary educational attainment, independent of individual educational attainment [65].

The Child Opportunity Index (COI) is a comprehensive population-level measure of children’s neighborhood opportunity based on 29 indicators that include factors such as proximity to licensed early childhood education centers (Table 1). Children residing in neighborhoods with more favorable educational opportunity as measured by COI experience better cardiometabolic health than those living in neighborhoods with lower COI. Specifically, each unit of COI was associated with lower C-reactive protein levels (β = −0.13 mg/L, 95% CI: −0.28 to 0.01) [66].

Healthcare Access

Neighborhood residence is strongly associated with access to health-related services and care. [33]. Residing in a socioeconomically disadvantaged neighborhood is associated with reduced likelihood of receipt of preventive services or access to primary care independent of individual-level characteristics and health care provider supply. Specifically, individuals residing in a highly disadvantaged neighborhood have a 57% decreased likelihood of a primary care visit in the prior 2 years (OR 0.43, 95% CI: 0.21–0.87) compared to residence in a more affluent neighborhood [67, 68]. A cross-sectional study of primary care practices in London demonstrated that higher quality primary care was associated with decreased cardiac admissions. This impact was doubled in areas of higher deprivation compared to areas of low deprivation (4.28 fewer admissions per 100,000, 95% CI: 1.19–7.38 and 2.11 [95% CI: 0.68–3.55], respectively) [69]. Disparate access to hospital resources such as specialized cardiac services also varied significantly by neighborhood. Lower neighborhood median income is associated with reduced rate of use of coronary angiography and increased waiting times. Furthermore, lower neighborhood income was associated with increased 1-year mortality following myocardial infarction [32].

Access to community pharmacies varies at the neighborhood level, and decreased access is disproportionately more common in segregated Black communities, low-income neighborhoods, and federally designated Medically Underserved Areas [30]. These socioeconomically disadvantaged neighborhoods have significantly greater odds of commonly dispensed prescription medications being out of stock (OR 1.24, 95% CI: 1.02–1.52) [70] and may also have increased prices for medications and decreased access to home delivery services [31].

Food Environment

Diet constitutes a modifiable risk factor for CVD, and access to food stores may affect adherence to dietary recommendations for cardiovascular health. In general, adults shop for food within one mile of home. A model of distance to closest supermarket compared to diet as characterized by the Alternative Healthy Eating Index demonstrated healthful eating habits are inversely related to distance to a favorable food store (β = −0.39, 95% CI: −0.76 to −0.02) [71]. Neighborhood food environments may be characterized by the number, type, size, and location of food stores as well as the availability, price, and quality of different food categories. Utilization is based on proximity to food stores, vehicle availability, financial resources, and suitable home environment for meal preparation [72].

Areas with diminished access to fresh fruit, vegetables, and other whole foods tend to exist in socioeconomically deprived areas, and vulnerable populations are particularly sensitive to food costs [29, 73]. Deprivation has been linked to increases in child and adolescent obesity [74]. Increased access to fast food restaurants with energy-dense processed food with high sugar and fat content is associated with higher prevalence of obesity [75]. In contrast, living in neighborhoods with better access to supermarkets is associated with decreased likelihood of obesity (relative risk 0.89, 95% CI: 0.82–0.98) [76]. As food environments are rapidly changing, more data are needed to determine the associations between neighborhood nutritional environments and cardiovascular risk factors in the USA.

Social Environment and Social Cohesion

Social cohesion reflects resilience and includes the extent to which neighborhoods promote inclusion and foster social capital. Optimal social cohesion requires shared attitudes and norms, reciprocity, trust, social support, and collective action. Studying the impact of social environment at the neighborhood level has been limited by the ability to measure social cohesion due to its complex and multifaceted nature. Generally, social cohesion is studied using self-reported measures, although other factors such as local crime rates and neighborhood demographics can be informative as well [77]. As examples, the Jackson Heart Study (JHS) and the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study investigated social environment using Likert-scale surveys with questions about social cohesion as well as violence and neighborhood disorder in the JHS [78, 79]. The MESA cohort characterized social environment using separate tools for emotional social support, loneliness, and neighborhood social cohesion. Results from the MESA study indicated that domain of social environment characterized is important; for example, social cohesion was significantly associated with increased fruit and vegetable intake (prevalence ratio of > 5 daily fruit/vegetable intake 1.05, 95% CI: 1.01–1.09) but loneliness and emotional social support were not [80].

Studies have identified that the social environment has a role in modifying the associations between social determinants and cardiovascular health. For example, JHS investigators determined that social cohesion modified the impact of neighborhood disadvantage for men, but not women in the cohort [81]. MASALA similarly did not find an overall association between social cohesion and type 2 diabetes mellitus or hypertension, but did find that perceived social cohesion was protective against hypertension for South Asian women [79]. In the JHS, MESA, and MASALA cohorts, social cohesion was protective for individuals with greater than high school education but adverse for individuals that had not [77]. An analysis conducted in the Health and Retirement Study determined that social cohesion was protective against CVD for Black and Hispanic respondents [82]. Further research may identify biologic and social mechanisms by which neighborhood social cohesion and environment may impact cardiovascular health [77, 78, 81], as well as the modification of these associations by sex, race, ethnicity, and educational attainment.

Interventions to Address Neighborhood Determinants

Studying the impact of neighborhood-based interventions to modify CVD risk presents difficulties. Lack of randomization, individual confounders, and an appropriate time frame to observe results present methodological challenges [83]. Studying the impact of interventions of a community’s built environment and relevant policy changes requires the incorporation of literature from sociological and urban planning sources [83–85]. However, evaluating the effective components of a neighborhood intervention is fundamental to address residence-based determinants of CVD. Indeed, the Patient Protection and Affordable Care Act of 2010 mandated that nonprofit hospitals assess community health needs and develop an implementation strategy to address them [86].

Community-centered interventions can be an effective strategy to address neighborhood determinants of cardiovascular health and reduce health inequity. A community-based intervention promotes health in a community setting using nonclinical methods and should engage community members in design, delivery, and evaluation. The core pillars of community-based interventions include strengthening communities, developing community leaders, fostering collaborations and partnerships, and increasing access to community resources [87•]. Figure 1 graphically summarizes these core components.

Fig. 1.

The components of a community-based intervention (CBI) include improving access to community resources, investment in communities, creation and maintenance of collaborations and partnerships, and engagement and training of community leaders [87•]. Examples of each component are exemplified by elements of the North Karelia Project [89, 91]

One prominent example of the potential impact of a community-based initiative is the North Karelia Project, initiated in 1972 to address cardiovascular mortality. To address the entire population rather than only those at higher risk, the program focused on prevention by targeting dietary habits and tobacco use with broad public and private sector engagement. Community partnership facilitated multilevel home- and community-based dietary and behavioral strategies and provided the foundation for national programs to address dietary standards and tobacco cessation. Between 1969 and 2011, the age-adjusted risk of cardiovascular mortality among Finnish men ages 35–64 decreased by over 80% from 690 to 100 per 100,000. Life expectancy increased from 64 to 75 years in men and from 72 to 81 years in women [88–90]. Figure 1 summarizes the core components of a community-based intervention and provides examples of elements of the North Karelia Project that represent each component [87•, 89, 91].

Focused on upstream determinants of population-level health, community-based interventions have the potential to reduce health disparities. Sponsored by the Centers for Disease Control and Prevention, The Racial and Ethnic Approaches to Community Health Across the United States (REACH) has partnered with neighborhood coalitions and health outreach programs since 1999 to increase options for good nutrition, promote community planning to enhance physical activity, reduce commercial tobacco use, and connect clinical services to community programs to prevent and manage chronic diseases [92, 93]. In 2022, REACH funded 40 programs in 26 states. Between 2014 and 2018, REACH has improved access to healthy food and beverages for 2.9 million people, opportunities to be physically active for 1.4 million people, tobacco-free environments for 322,000 people, and clinic-based chronic disease management programs for 830,000 people [93].

As a community-centered partner to the US Preventative Services Task Force, the Community Preventative Services Task Force (CPSTF) evaluated the evidence base for population-based approaches to prevention. CPSTF investigators systematically evaluated the effectiveness of built environment approaches to increase opportunities for physical activity and subsequently developed CPSTF recommendations for community interventions. For example, one recommendation is to combine interventions to improve pedestrian or bicycle transportation systems with those addressing land use and environmental design, thereby encouraging physical activity [94, 95]. Additional recommendations highlighted case examples such as the Safe Routes to School intervention, which promotes commuting safety for children walking to school [94, 96, 97].

A complementary resource is the Community Tool Box created at the University of Kansas. The Tool Box is an online resource to help communities assess needs and resources, engage stakeholders, design interventions, plan evaluations, and work towards sustainability for neighborhood-level interventions to promote health [98].

In summary, community-based interventions have broad potential to promote cardiovascular health and reduce health disparities. Engagement with neighbors, investment in capacity building and participant training, increasing accessibility of neighborhood resources, and creation of partnerships can contribute to sustainability and resident support for interventions. Federal collaborations such as CPSTF and REACH provide an evidence base for effective components of community interventions to address neighborhood-level public health.

Conclusions

This review summarized the varying definitions of the neighborhood and fundamental literature demonstrating the contribution of the neighborhood to cardiovascular health. The review emphasized the role of the neighborhood in exposure to social and economic factors, food environment, physical and built environment, educational access, segregation, and social environment. Health interventions centered in the neighborhood offer promise to foster primary and secondary prevention to reduce health disparities. Initiatives at the local, state, and federal level remain essential to promote equitable neighborhood conditions which promote optimal cardiovascular health.