Volunteerism and Cardiovascular Health: The HCHS/SOL Sociocultural Ancillary Study

Abstract

Objectives:

The objective of this study was to examine the association between volunteerism and favorable cardiovascular health (CVH) among Hispanics/Latinos living in the US.

Methods:

Data from the Hispanic Community Health Study/Study of Latinos (2008-2011) Sociocultural Ancillary Study were used (N = 4,926; ages 18-74 years). Favorable CVH was defined as positive profiles of all major CVD risk factors: low total serum cholesterol, blood pressure, and body mass index; not having diabetes; and not smoking. Survey-weighted logistic regression models were adjusted for sociodemographic, lifestyle, and psychological factors. In secondary analyses, we tested whether the volunteerism-CVH association was modified by sex, age, or years lived in the US (<10 vs. ≥10 years; a proxy acculturation measure).

Results:

Prevalence of volunteerism was 14.5%. Compared to non-volunteers, volunteers had 1.67 higher odds of favorable CVH in the fully-adjusted model (Odds Ratio [OR] = 1.67, 95% Confidence Interval [CI] = 1.11, 2.52). There was evidence of effect modification by acculturation; only volunteers who had lived in the US ≥10 years had 2.41 higher odds of favorable CVH (OR = 2.41, 95% CI=1.53, 3.80). There was no evidence of effect modification by sex or age.

Conclusions:

Volunteerism was associated with favorable CVH among US Hispanics/Latinos.

The promotion of favorable cardiovascular health (CVH) among Hispanics/Latinos living in the United States (US) is emerging as a national public health challenge.¹ Favorable CVH is defined as the presence of positive profiles of all major cardiovascular disease (CVD) risk factors: low total serum cholesterol, blood pressure, and body mass index (BMI); not having diabetes mellitus; and not currently smoking.² A focus on favorable CVH profiles as opposed to individual levels of CVD risk factors represents a paradigm shift in the field of cardiovascular epidemiology by underscoring the significance of population-based primordial prevention (defined as the prevention of risk factors themselves).³ Substantial empirical evidence has demonstrated that the presence of favorable CVH in young adulthood and middle-age is associated with better health-related quality of life,⁴ lower health-care costs,⁵ and lower all-cause mortality^6,7 at older age. Despite progress in extending life expectancy, health disparities in the burden of CVD risk factors among US Hispanics/Latinos compared with non-Hispanic whites still persist.⁸ Moreover, findings from the landmark Hispanic Community Health Study/Study of Latinos (HCHS/SOL) demonstrated that the age-adjusted prevalence of favorable CVH among US Hispanic/Latino adults is lower than their non-Hispanic white counterparts.^2,9 Such evidence suggests there is a critical need to identify protective factors that are potentially modifiable and culturally-appropriate to promote favorable CVH in Hispanics/Latinos, one of the US fastest growing and largest racial/ethnic minority populations.¹⁰

Numerous factors contribute to shape the distribution of favorable CVH at the population level. The social capital model¹¹ suggests that one such factor is volunteerism, a form of civic participation encompassing activities that benefit the individual, community, and society. In considering the role of volunteerism on favorable CVH, we are guided by communitarian approaches which define social capital as resources and relationships that originate from social networks, including the trustworthiness, reciprocity, and civic engagement that is formed by these networks.¹¹ Residents of a community with high social capital may provide each other with greater social resources and instrumental support than those living in a community with low social capital. Some scholars have distinguished between bonding and bridging social capital. Bonding social capital refers to relationships between people of similar socioeconomic backgrounds, while bridging social capital refers to relationships between people of different socioeconomic backgrounds.¹¹ To date, the available research suggests that bridging social capital may be more important for health promotion that bonding social capital, in part, due to the greater access to social resources outside one’s social network.¹²

The field of public health has highlighted the importance of promoting social capital and volunteerism in one’s social and community context as a tool to address the social determinants of health.¹² Epidemiologists have applied these concepts to examine the associations of volunteerism (and related constructs of altruism) and health outcomes, particularly in samples of older non-Hispanic white adults. Prospective studies have shown that volunteerism is associated with higher health care use among older adults,¹⁶ lower risk of incident CVD in women,¹⁷ and lower premature CVD-related mortality.¹⁸ Similarly, cross-sectional studies have concluded that volunteerism is associated with better self-reported health,¹⁹ fewer functional limitations,²⁰ lower depressive symptoms,²¹ and lower inflammation,²² among other beneficial health outcomes. In the Health and Retirement Study, it was shown that middle-aged volunteers (versus non-volunteers) had a lower prevalence of the metabolic syndrome, high central adiposity, lipid dysregulation, and elevated blood glucose.²³ Additionally, older adults who volunteered were less likely to be hypertensive compared with non-volunteers.²³ Less attention has been given to examining the association between volunteerism and health among US Hispanics/Latinos. However, volunteerism is an important factor to study among Hispanics/Latinos because collectivism¹³ and reliance on social networks¹⁴ are central cultural values. Further, Hispanics/Latinos living in the US have a long-standing history of advocating for their rights through civic participation in social justice initiatives.¹⁵

Notably, some studies suggest that the associations of volunteerism with CVH indicators may not extend across all racial/ethnic groups. For instance, researchers in the Health and Retirement Study showed that among non-Hispanic whites, but not African Americans, volunteers had lower odds of hypertension than non-volunteers.²⁴ Previous literature also suggests that the associations of volunteerism and health may be stronger in women than in men,¹⁷ and stronger in older adults than in young and middle-aged adults.^21,25,26 Furthermore, findings from the acculturation literature suggest that the association of volunteerism and favorable CVH health may differ across acculturation levels due to divergent sociocultural experiences as exposure to the US increases.⁹ For example, those who have lived in the US for a longer time may have gained increased access to large social networks characterized with stronger ties compared to more recent immigrants.²⁷ Among those who are more acculturated, these strong social networks could provide access to health-promoting assets such as higher social capital and socioeconomic resources, which have been shown to serve as buffers against the negative impact of psychosocial stressors.²⁸

To date, various potential mechanisms through which volunteerism may contribute to positive health outcomes at the individual and community level have been proposed. For example, at the individual level, it has been posited that volunteerism promotes higher social support and access to socioeconomic resources which, in turn, are associated with better CVH profiles and lower cardiovascular-related mortality.^19,21 Other potential mechanisms include that volunteerism contributes to lower perceived social isolation and higher sense of purpose in life, both of which are associated with a lower burden of cardiovascular risk factors.²⁹ Further, volunteerism has also been found to be associated with healthier lifestyles (ie, physical activity, healthy diet, and/or none-to-moderate alcohol intake) and psychological well-being (ie, lower depressive symptoms and anxiety).²⁹ On the other hand, it is widely acknowledged that volunteerism, along with other forms of civic engagement, can have benefits for the well-being of communities by addressing and bringing attention to urgent issues affecting public health, including matters related to the environment, education, and safety.

To address gaps in the literature, the objective of this study is to examine the prevalence of volunteerism and its cross-sectional associations with presence of favorable CVH among Hispanics/Latinos from the Hispanic Community Health Study (HCHS/SOL) and its Sociocultural Ancillary Study (SCAS). We hypothesized that volunteerism will be positively associated with favorable CVH, regardless of sociodemographic, lifestyle, and psychological factors. In secondary analyses, we examined the associations of volunteerism with each CVH component (to assess the role of each one separately). We also examined whether the association between volunteerism and favorable CVH is modified by sex, age, or years lived in the US (a proxy measure of acculturation)- all which have been the target of previous work examining Hispanic/Latino health.^9,14 Based on the available literature, we hypothesized that the association of volunteerism and favorable CVH will be stronger among women compared to men, among older adults compared to younger and middle-aged adults, and among those more acculturated compared to those less acculturated. A better understanding of the associations of volunteerism and CVH in Hispanic/Latino adults has implications for public health promotion and prevention efforts in community-based and non-profit settings.

METHODS

Data Collection and Participants

Baseline (2008-2011) data from participants of the HCHS/SOL SCAS were used. Details of the HCHS/SOL and SCAS sampling design, cohort selection, and study protocols have been previously reported.^14,30,31 Briefly, the HCHS/SOL is a multi-center prospective population-based study designed to examine CVD prevalence and incidence among Hispanic/Latino adults of diverse backgrounds (Cuban, Central American, Dominican, Mexican, Puerto Rican, and South American). A stratified two-stage sampling design was used to recruit self-identified Hispanics/Latinos (N = 16,415), aged 18–74 years at screening. Enrollment was conducted from selected households in the Bronx, NY; Chicago, IL; Miami, FL; San Diego, CA. Participants were asked to fast and refrain from smoking for 12 hours prior to the study, and to avoid physical activity the morning of the examination. Participation was comprised of anthropometric assessment, blood draw, medication review, and self-reported health assessments collected via face-to-face interviews by bilingual interviewers.

The SCAS examined sociocultural and psychosocial correlates of CVD risk factors in Hispanic/Latino adults. All HCHS/SOL participants who consented to be contacted for future studies and were willing to attend a visit within 9 months of their baseline examination were eligible.¹⁴ Study recruiters contacted eligible individuals; 72.6% of those contacted agreed to participate. The SCAS sample is representative of the main HCHS/SOL cohort, except that individuals of higher socioeconomic status were less likely to participate.¹⁴ All participants provided written informed consent and were compensated for their participation. From the SCAS 5,313 participants, we excluded 387 participants with missing data on volunteerism (N = 24), favorable CVH factors (N = 134), or study covariates (N = 229), for a final analytic sample of 4,926.

Study Measures

Favorable CVH.

Factors comprising favorable CVH were assessed as part of the HCHS/SOL baseline examination following standardized procedures.² According to national guidelines and as previously defined in the HCHS/SOL cohort,^2,9 favorable CVH status was defined as presence all of the following factors: total serum cholesterol <200 mg/dL and not taking cholesterol-lowering medication; systolic blood pressure <120 mm Hg, diastolic blood pressure <80 mm Hg, and not taking hypertensive medication; BMI <25.0 kg/m2; fasting plasma glucose <100 mg/dL, hemoglobin A1c <5.7%, not taking medication for diabetes mellitus, and no self-reported history of diabetes mellitus; and not currently smoking (self-reported). Participants were asked to bring medications used in the past month to the examination and medication data was transcribed and coded. Participants were classified according to presence (yes/no) of all CVH factors and each CVH factor.

Volunteerism.

Volunteerism was measured at the SCAS study with a question from Cohen’s Social Network Index:³² “Are you currently involved in regular volunteer work?” Participants were categorized as volunteers or non-volunteers. A 1-item screener has been similarly used in previous studies to measure volunteerism across populations.^16,23,24,33

Covariates.

Sociodemographic characteristics were self-reported: age (treated as continuous and categorical), sex, Hispanic/Latino background (self-identification as: Central American, Cuban, Dominican, Mexican, Puerto Rican, South American, and other or more than one Hispanic/Latino background), education (<High school, High school graduate, or >High school), employment status (employed vs. unemployed retired), and annual household income (<$30,000, ≥$30,000, or Not reported). Participants who declined to report their household income were included as a category to avoid deleting those observations. Additional sociodemographic factors included self-reported household size, marital status (single, married, or other), health insurance coverage, and years lived in the US (defined as non-US born and lived in the US <10 years vs. non-US born and US born and lived in the US ≥10 years).

Lifestyle factors were self-reported physical activity, dietary quality, and alcohol intake. Physical activity in a typical week was assessed using the Global Physical Activity Questionnaire.³⁴ Total minutes per week of moderate and vigorous physical activity including work, travel, and leisure activities were calculated. Participants were classified according to self-reported alcohol consumption (current vs. former/never).³⁵ Diet quality was assessed via two 24-hour dietary recalls administered by trained interviewers.³⁶ A modified version of the 2010-Alternate Healthy Eating Index (AHEI) was computed based on servings/day of vegetables (not including potatoes), whole fruit, whole grains, sugar-sweetened beverages and fruit juices, nuts and legumes, red/processed meats, trans fats, long-chain (n-3) fats, polyunsaturated fatty acids, and sodium.³⁷ The alcohol component was excluded since it was considered separately as a covariate. The modified AHEI score (range: 0–100) is the sum of scores from each of the 10 components; higher scores represent healthier diet quality.³⁸ Psychological factors included depressive symptoms and trait anxiety. Depressive symptoms were measured with the 10-item version of the Center for Epidemiologic Studies Depression Scale (CES-D);³⁹ higher scores (range: 0–30) indicate presence of more depressive symptoms.⁴⁰ Trait anxiety was assessed using the shortened 10-item Spielberger State Trait Anxiety Inventory (STAI)⁴¹ with higher scores (range: 0 –40) indicative of more anxiety symptoms.

Statistical Analysis

Prevalence of volunteerism was calculated for the target population. Descriptive statistics were generated for the overall sample and by volunteerism status (volunteers vs. non-volunteers). Differences in the prevalence of volunteerism by sociodemographic, lifestyle, and psychological factors, and favorable CVH, were examined using χ² tests for categorical variables F tests for continuous variables.

Logistic regression models were used to compute odds ratios (OR) and 95% confidence intervals (CI) for the associations between volunteerism and the presence of favorable CVH (ideal levels of all 5 factors, as defined above). Models were sequentially adjusted for potential confounders. Model 1 was adjusted for sociodemographic factors. Model 2 additionally adjusted for lifestyle factors. Model 3 additionally adjusted for psychological factors. In secondary analyses, we tested whether statistically significant associations might be attributable to individual CVH components. To do so, analogous models were used to test associations between volunteerism and the presence of each favorable CVH factor. Finally, we also examined whether sex, age (categorized as 18-49 vs. ≥50 years), or years lived in the US (<10 years and ≥10 years) modified the association between volunteerism and CVH by adding each interaction term (volunteerism*sex, volunteerism*age groups, and volunteerism*years lived in the US) separately into the fully-adjusted model.

All analyses accounted for the complex survey design (including stratification) and all reported values were weighted with the exception of the sample size. Tests of significance were two-sided at a significance level of 5%. Analyses were performed using SAS 9.4 software (SAS Institute, Cary, NC). The research was reviewed and approved by Institutional Review Boards of all affiliated sites. All participants provided written informed consent.

RESULTS

Characteristics of the Target Population

Volunteerism prevalence was 14.5% for the target population. The mean age of the target population was 42.3 years. Overall, 31.9% had less than a high school education, and most were currently employed (55.3%), reported an annual household income below $30,000 (66.4%), had lived in the US ≥10 years (73.0%) (Table 1). Compared with non-volunteers, volunteers were more likely to be of Mexican background, had higher educational attainment, and higher annual household income (all p-values < .01). Diet quality, depressive symptoms, and trait anxiety scores of volunteers and non-volunteers were significantly different (all p-values < .001).

Table 1.

Descriptive Statistics for the Overall Target Population and by Volunteerism Status among Hispanic/Latino adults, HCHS/SOL SCAS

	All		Volunteers	Non-Volunteers
	N	% or M (95% CI)	% or M (95% CI)	% or M (95% CI)	p-value
			(N = 725, 14.5%)	(N = 4201, 85.5%)
Age, years; M	4926	42.3 (41.5, 43.1)	42.4 (40.1, 44.7)	42.3 (41.5, 43.1)	0.946
Female, %	3054	54.8 (52.7, 56.9)	56.6 (51.0, 62.1)	54.5 (52.3, 56.6)	0.473
Hispanic/Latino Background, %
Dominican	487	11.6 (9.5, 13.6)	9.4 (6.4, 12.5)	11.9 (9.8, 14.1)	0.129
Central American	527	7.7 (6.1, 9.3)	7.0 (4.7, 9.4)	7.8 (6.1, 9.6)	0.529
Cuban	710	20.0 (15.7, 24.3)	10.0 (7.0, 13.1)	21.7 (17.2, 26.3)	<0.001
Mexican	1951	37.1 (32.9, 41.2)	47.9 (41.2, 54.6)	35.2 (31.0, 39.5)	0.001
Puerto Rican	803	15.4 (13.3, 17.6)	16.4 (11.0, 21.9)	15.3 (13.1, 17.5)	0.688
South American	321	4.8 (3.8, 5.7)	3.6 (2.1, 5.1)	5.0 (4.0, 5.9)	0.061
Multiple/Othera	127	3.4 (2.3,4.5)	5.6 (0.0, 11.3)	3.0 (2.2, 3.9)	0.383
Education, %
<High School	1751	31.9 (29.5, 34.2)	25.5 (20.3, 30.7)	32.9 (30.6, 35.3)	0.005
High School	1291	28.0 (26.2, 29.9)	25.6 (20.4, 30.8)	28.5 (26.5, 30.4)	0.303
>High School	1884	40.1 (37.5, 42.7)	49.0 (43.1, 54.9)	38.6 (36.0, 41.2)	0.000
Employment Status, %
Employedb	2268	55.3 (53.1, 57.6)	51.0 (44.7, 57.4)	55.3 (53.1, 57.6)	0.178
Unemployed/Retired	2658	44.7 (42.4, 46.9)	49.0 (42.6, 55.3)	44.7 (42.4, 46.9)	0.178
Household Income, %
<$30,000	3387	66.4 (63.8, 69.0)	61.4 (54.8, 68.0)	67.3 (64.7, 69.9)	0.082
≥$30,000	1311	28.5 (25.8, 31.3)	36.1 (29.4, 42.8)	27.2 (24.5, 29.9)	0.009
Not reported	228	66.4 (63.8, 69.0)	61.4 (54.8, 68.0)	67.3 (64.7, 69.9)	0.000
Household Size,c M	4926	3.3 (3.2, 3.4)	3.4 (3.2, 3.6)	3.3 (3.2, 3.4)	0.342
Marital Status, %
Single	1380	33.6 (31.7, 35.4)	33.1 (26.3, 39.9)	33.6 (31.5, 35.8)	0.890
Married	2492	49.0 (46.7, 51.3)	47.8 (41.6, 53.9)	49.2 (46.6, 51.8)	0.689
Other	1054	17.5 (15.6, 19.3)	19.2 (13.5, 24.8)	17.2 (15.3, 19.1)	0.504
Health Insurance, %	2483	33.6 (31.7, 35.4)	33.1 (26.3, 39.9)	33.6 (31.5, 35.8)	0.043
≥10 years in the US, %	3774	73.0 (70.1, 76.0)	82.0 (77.5, 86.6)	71.5 (68.5, 74.5)	<0.001
Field Site, %
Bronx	1212	29.7 (25.6, 33.9)	28.6 (21.3, 35.9)	29.9 (25.9, 34.0)	0.694
Chicago	1253	15.9 (13.2, 18.7)	19.0 (14.9, 23.0)	15.4 (12.7, 18.1)	0.057
Miami	1220	28.9 (23.2, 34.6)	16.3 (11.6, 21.0)	31.1 (25.2, 36.9)	<0.001
San Diego	1241	25.5 (21.2, 29.8)	36.2 (29.4, 42.9)	23.6 (19.3, 28.0)	0.000
PA, mins/week, M	4926	1123.7 (1038.6, 1208.8)	1314.4 (1068.0, 1560.8)	1091.2 (1002.5, 1180.0)	0.095
Diet Quality Score, %	4926	42.8 (42.4, 43.2)	44.4 (43.5, 45.3)	42.6 (42.2, 42.9)	0.000
Alcohol Intake, %
Current	2286	50.3 (47.6, 52.9)	44.3 (37.0, 51.6)	51.3 (48.6, 53.9)	0.059
Former or Never	2640	49.7 (47.1, 52.4)	55.7 (48.4, 63.0)	48.7 (46.1, 51.4)	0.059
Depressive Symptoms, M	4926	7.8 (7.5, 8.1)	7.1 (6.5, 7.7)	7.9 (7.6, 8.2)	0.012
Trait Anxiety, M	4926	17.7 (17.5, 17.9)	16.9 (16.3, 17.6)	17.8 (17.6, 18.1)	0.006
Favorable CVH, %	265	7.5 (6.3, 8.7)	10.3 (7.1, 13.6)	7.0 (5.7, 8.2)	0.054

Note: Sample size is unweighted. All other values are weighted to account for survey design and nonresponse.

Abbreviations: M = mean; CI = Confidence Interval; PA = Physical Activity; CVH = Cardiovascular health.

^aOther category includes: More than one Hispanic/Latino background and other Hispanic/Latino backgrounds.

^bEmployed category includes those working full- and part-time.

^cHousehold size refers to the number people supported by household income.

Association Between Volunteerism and Favorable CVH

Table 2 displays results of logistic regression models for the association between volunteerism and favorable CVH. In the first model, compared to non-volunteerism, volunteerism was significantly associated with 1.72 higher odds of presence of favorable CVH, regardless of sociodemographic factors (OR = 1.72, 95% CI = 1.14–2.60). Upon addition of lifestyle factors, the association remained significant, although somewhat attenuated (OR = 1.66, 95% CI = 1.11–2.50). Finally, when psychological factors were added to the final model, the association between volunteerism and favorable CVH remained almost unchanged (OR = 1.67, 95% CI = 1.11–2.52).

Table 2.

Association between Volunteerism and Favorable Cardiovascular Health among Hispanic/Latino adults, HCHS/SOL SCAS

N = 4,926	Model 1	Model 2	Model 3
	OR (95% CI)	OR (95% CI)	OR (95% CI)
Favorable CVHa	1.72 (1.14, 2.60)	1.66 (1.11, 2.50)	1.67 (1.11, 2.52)
Covariates
Age, years, M	0.92 (0.90, 0.94)	0.91 (0.89, 0.93)	0.91 (0.89, 0.93)
Female, %	2.13 (1.50, 3.02)	2.03 (1.43, 2.89)	2.13 (1.49, 3.05)
Hispanic/Latino Background, %
Dominican	0.56 (0.20, 1.54)	0.59 (0.22, 1.62)	0.58 (0.21, 1.57)
Central American	0.60 (0.28, 1.27)	0.62 (0.29, 1.33)	0.63 (0.29, 1.36)
Cuban	0.65 (0.29, 1.48)	0.77 (0.33, 1.83)	0.75 (0.32, 1.76)
Mexican	Ref	Ref	Ref
Puerto Rican	0.59 (0.25, 1.37)	0.74 (0.29, 1.87)	0.68 (0.27, 1.75)
South American	0.57 (0.24, 1.39)	0.66 (0.26, 1.64)	0.65 (0.26, 1.62)
Multiple/Otherb	0.59 (0.19, 1.87)	0.70 (0.20, 2.39)	0.69 (0.20, 2.33)
Education, %
<High School	Ref	Ref	Ref
High School Graduate	2.08 (1.30, 3.32)	2.06 (1.29, 3.28)	2.03 (1.27, 3.24)
>High School	2.42 (1.47, 3.98)	2.47 (1.51, 4.06)	2.38 (1.46, 3.90)
Employment Status, %
Employedc	1.04 (0.75, 1.46)	1.08 (0.77, 1.50)	1.05 (0.75, 1.46)
Unemployed/Retired	Ref	Ref	Ref
Household Income, %
<$30,000	Ref	Ref	Ref
≥$30,000	1.19 (0.75, 1.88)	1.24 (0.78, 1.96)	1.21 (0.77, 1.91)
Not reported	1.16 (0.64, 2.12)	1.16 (0.64, 2.11)	1.15 (0.63, 2.11)
Household Size,d M	0.97 (0.86, 1.09)	0.97 (0.85, 1.09)	0.96 (0.85, 1.09)
Marital Status, %
Single	Ref	Ref	Ref
Married	0.87 (0.54, 1.40)	0.85 (0.53, 1.38)	0.85 (0.52, 1.38)
Other	0.71 (0.33, 1.55)	0.70 (0.32, 1.53)	0.72 (0.33, 1.57)
Health Insurance, %	0.95 (0.64, 1.40)	0.94 (0.64, 1.40)	0.96 (0.64, 1.42)
Years in the US, %
<10 years	Ref	Ref	Ref
≥10 years	1.98 (1.20, 3.25)	1.91 (1.16, 3.13)	1.88 (1.15, 3.09)
Field Site, %
Bronx	Ref	Ref	Ref
Chicago	0.91 (0.41, 2.05)	0.86 (0.39, 1.93)	0.83 (0.37, 1.86)
Miami	1.14 (0.49, 2.63)	1.10 (0.47, 2.57)	1.08 (0.46, 2.54)
San Diego	0.93 (0.36, 2.37)	0.93 (0.37, 2.34)	0.89 (0.35, 2.27)
PA, mins/week, M		1.00 (1.00, 1.00)	1.00 (1.00, 1.00)
Diet Quality Score, %		1.03 (0.99, 1.07)	1.03 (0.99, 1.07)
Alcohol Intake, %
Current		0.70 (0.50, 0.98)	0.72 (0.51, 1.01)
Former or Never		Ref	Ref
Depressive Symptoms, M			0.98 (0.94, 1.02)
Trait Anxiety, M			1.00 (0.95, 1.05)

Note: Sample size is unweighted. All other values are weighted to account for survey design and nonresponse.

Abbreviations: OR = Odds ratio; M = mean; CI = Confidence Interval; CVH = Cardiovascular health.

^aPresence of favorable cardiovascular health was coded as 1= yes and 0= no. Volunteerism was coded as 1 = yes and 0 = no (Ref.)

^bOther category includes: More than one Hispanic/Latino background and other Hispanic/Latino backgrounds.

^cEmployed category includes those working full- and part-time.

^dHousehold size refers to the number people supported by household income.

Secondary Analyses

In secondary analyses, we did not observe significant associations of volunteerism with any of the favorable CVH factors regardless of adjustments (results not shown). However, most estimates were in the positive direction with the exception of the associations of volunteerism with favorable levels of blood pressure in Models 2 and 3 (which were lower than 1).

There was no evidence of effect modification in the association between volunteerism and presence of favorable CVH by sex or age (p-interaction = .91 and .29, respectively). In contrast, the association of volunteerism and favorable CVH varied across strata of years lived in the US (p-interaction = .01). Specifically, volunteerism was not associated with favorable CVH among those living in the US <10 years in regardless of adjustments and estimates were in the negative direction (Table 3). In contrast, compared to non-volunteers, volunteers that lived in the US ≥10 years had 2.45 times the odds to have favorable CVH than their non-volunteer counterparts (OR = 2.45; 95% CI = 1.52–3.95), adjusting for sociodemographic factors (Model 1). These associations remained significant upon additional adjustment for lifestyle factors (Model 2) and psychological factors (Model 3; Table 4)

Table 3.

Association of Volunteerism and Favorable CVH among those that Lived in the US <10 years: Hispanic/Latino adults, HCHS/SOL SCAS

N = 1,152	Model 1	Model 2	Model 3
	OR (95% CI)	OR (95% CI)	OR (95% CI)
Favorable CVHa	0.58 (0.26, 1.32)	0.57 (0.25, 1.30)	0.56 (0.24, 1.28)
Covariates
Age, years, M	0.91 (0.88, 0.94)	0.91 (0.88, 0.94)	0.91 (0.88, 0.95)
Female, %	4.35 (2.18, 8.67)	4.42 (2.19, 8.92)	4.51 (2.23, 9.12)
Hispanic/Latino Background, %
Dominican	0.82 (0.22, 3.06)	0.80 (0.22, 2.93)	0.84 (0.23, 3.10)
Central American	0.80 (0.30, 2.14)	0.81 (0.29, 2.26)	0.81 (0.28, 2.31)
Cuban	1.37 (0.39, 4.86)	1.45 (0.38, 5.63)	1.49 (0.38, 5.80)
Mexican	Ref	Ref	Ref
Puerto Rican	1.00 (0.15, 6.89)	0.92 (0.12, 6.94)	0.93 (0.12, 7.14)
South American	0.99 (0.29, 3.42)	1.08 (0.31, 3.81)	1.11 (0.31, 3.92)
Multiple/Otherb	6.56 (0.49, 8.78)	6.84 (0.44, 10.62)	6.72 (0.45, 9.99)
Education, %
<High School	Ref	Ref	Ref
High School Graduate	3.18 (1.40, 7.23)	2.99 (1.35, 6.62)	3.00 (1.35, 6.67)
>High School	2.77 (1.16, 6.60)	2.73 (1.16, 6.40)	2.68 (1.13, 6.35)
Employment Status, %
Employedc	0.76 (0.45, 1.29)	0.76 (0.44, 1.32)	0.75 (0.43, 1.31)
Unemployed/Retired	Ref	Ref	Ref
Household Income, %
<$30,000	Ref	Ref	Ref
≥$30,000	1.35 (0.58, 3.14)	1.50 (0.63, 3.56)	1.47 (0.62, 3.47)
Not reported	0.68 (0.32, 1.44)	0.71 (0.34, 1.45)	0.70 (0.34, 1.46)
Household Size,d M	1.02 (0.86, 1.21)	1.02 (0.85, 1.22)	1.02 (0.86, 1.22)
Marital Status, %
Single	Ref	Ref	Ref
Married	0.51 (0.26, 1.02)	0.50 (0.24, 1.02)	0.49 (0.23, 1.02)
Other	0.90 (0.24, 3.37)	0.85 (0.22, 3.23)	0.86 (0.23, 3.27)
Health Insurance, %	1.12 (0.59, 2.13)	1.12 (0.59, 2.12)	1.12 (0.59, 2.11)
Years in the US, %
<10 years	Ref	Ref	Ref
≥10 years	2.38 (0.76, 7.53)	2.37 (0.72, 7.80)	2.37 (0.70, 7.99)
Field Site, %	0.81 (0.17, 3.90)	0.74 (0.16, 3.45)	0.73 (0.16, 3.39)
Bronx	1.97 (0.55, 7.07)	1.96 (0.56, 6.94)	1.98 (0.56, 7.03)
Chicago		1.00 (1.00, 1.00)	1.00 (1.00, 1.00)
Miami		1.00 (0.94, 1.07)	1.00 (0.95, 1.07)
San Diego
PA, mins/week, M		0.61 (0.34, 1.10)	0.61 (0.34, 1.12)
Diet Quality Score, %		Ref	Ref
Alcohol Intake, %			1.01 (0.96, 1.07)
Current			0.97 (0.91, 1.04)

Note: Sample size is unweighted. All other values are weighted to account for survey design and nonresponse.

Abbreviations: OR = Odds ratio; M = mean; CI = Confidence Interval; CVH = Cardiovascular health.

^aPresence of favorable cardiovascular health was coded as 1= yes and 0= no. Volunteerism was coded as 1 = yes and 0 = no (Ref.)

^bOther category includes: More than one Hispanic/Latino background and other Hispanic/Latino backgrounds.

^cEmployed category includes those working full- and part-time.

^dHousehold size refers to the number people supported by household income.

Table 4.

Association of Volunteerism and Favorable CVH among those that Lived in the US ≥10 years: Hispanic/Latino adults, HCHS/SOL SCAS

N = 3,774	Model 1	Model 2	Model 3
	OR (95% CI)	OR (95% CI)	OR (95% CI)
Favorable CVHa	2.45 (1.52, 3.95)	2.40 (1.52, 3.78)	2.41 (1.53, 3.80)
Covariates
Age, years, M	0.91 (0.89, 0.93)	0.90 (0.87, 0.92)	0.90 (0.88, 0.93)
Female, %	1.68 (1.08, 2.60)	1.56 (0.99, 2.46)	1.65 (1.04, 2.63)
Hispanic/Latino Background, %
Dominican	0.65 (0.18, 2.36)	0.72 (0.21, 2.44)	0.66 (0.19, 2.28)
Central American	0.67 (0.24, 1.88)	0.72 (0.26, 1.99)	0.68 (0.25, 1.91)
Cuban	0.63 (0.21, 1.90)	0.82 (0.27, 2.51)	0.78 (0.26, 2.41)
Mexican	Ref	Ref	Ref
Puerto Rican	0.57 (0.22, 1.50)	0.81 (0.28, 2.35)	0.72 (0.25, 2.10)
South American	0.47 (0.12, 1.82)	0.55 (0.13, 2.29)	0.52 (0.13, 2.20)
Multiple/Otherb	0.32 (0.11, 0.97)	0.42 (0.14, 1.28)	0.41 (0.14, 1.22)
Education, %
<High School	Ref	Ref	Ref
High School Graduate	1.72 (0.95, 3.11)	1.72 (0.95, 3.11)	1.76 (0.97, 3.18)
>High School	2.19 (1.15, 4.18)	2.21 (1.14, 4.29)	2.17 (1.13, 4.17)
Employment Status, %
Employedc	1.29 (0.82, 2.03)	1.35 (0.87, 2.10)	1.28 (0.81, 2.00)
Unemployed/Retired	Ref	Ref	Ref
Household Income, %
<$30,000	Ref	Ref	Ref
≥$30,000	1.13 (0.68, 1.89)	1.15 (0.69, 1.92)	1.11 (0.67, 1.84)
Not reported	1.84 (0.73, 4.61)	1.71 (0.68, 4.33)	1.69 (0.65, 4.39)
Household Size,d M	0.93 (0.80, 1.09)	0.93 (0.80, 1.08)	0.92 (0.79, 1.08)
Marital Status, %
Single	Ref	Ref	Ref
Married	1.11 (0.62, 1.98)	1.09 (0.60, 1.97)	1.09 (0.60, 2.00)
Other	0.39 (0.17, 0.94)	0.40 (0.17, 0.97)	0.41 (0.17, 1.02)
Health Insurance, %	0.86 (0.53, 1.40)	0.85 (0.52, 1.39)	0.87 (0.53, 1.42)
Years in the US, %
<10 years	Ref	Ref	Ref
≥10 years	0.69 (0.26, 1.80)	0.63 (0.25, 1.57)	0.58 (0.23, 1.48)
Field Site, %	1.66 (0.56, 4.92)	1.61 (0.53, 4.85)	1.51 (0.50, 4.62)
Bronx	0.79 (0.27, 2.33)	0.79 (0.28, 2.21)	0.74 (0.26, 2.13)
Chicago		1.00 (1.00, 1.00)	1.00 (1.00, 1.00)
Miami		1.04 (0.99, 1.09)	1.04 (0.99, 1.08)
San Diego
PA, mins/week, M		0.72 (0.47, 1.09)	0.74 (0.48, 1.13)
Diet Quality Score, %		Ref	Ref
Alcohol Intake, %			0.96 (0.91, 1.01)
Current			1.01 (0.94, 1.08)

Note: Sample size is unweighted. All other values are weighted to account for survey design and nonresponse.

Abbreviations: OR = Odds ratio; M = mean; CI = Confidence Interval; CVH = Cardiovascular health.

^aPresence of favorable cardiovascular health was coded as 1 = yes and 0 = no. Volunteerism was coded as 1 = yes and 0 = no (Ref.)

^bOther category includes: More than one Hispanic/Latino background and other Hispanic/Latino backgrounds.

^cEmployed category includes those working full- and part-time.

^dHousehold size refers to the number people supported by household income.

DISCUSSION

This study contributes to fill knowledge gaps on the association of volunteerism, a form of civic engagement conceptualized to promote social capital, with favorable CVH among Hispanics/Latinos living in the US. We found that volunteerism (versus not participating in volunteerism) was significantly associated with higher odds of having favorable CVH, regardless of sociodemographic, lifestyle, and psychological factors—all of which are important to consider when examining these associations. Furthermore, our results suggest that the role of volunteerism is more important for the overall CVH score than its individual components. Moreover, CVH benefits from volunteerism may be stronger among those who have lived in the US 10 years or more, compared to those who have lived in the US less than 10 years.

Our study contributes to the literature in several ways. First, our findings highlight the need for increasing volunteerism opportunities among Hispanics/Latinos. Overall, our findings also provide public health researchers and practitioners with additional insights that may help to guide culturally appropriate efforts to promote CVH. Second, by extending the evidence for Hispanics/Latinos, we addressed gaps of prior research on the association between volunteerism and CVH indicators, which had been largely focused on older non-Hispanic whites and African American adults. As such, we provide preliminary evidence of the potential role of volunteerism on the CVH of Hispanics/Latinos. Third, we demonstrate that the association of volunteerism and favorable CVH among Hispanics/Latinos is only present when a composite CVH score is used as opposed to individual CVH components, suggesting that previously documented positive associations between volunteerism and individual CHV components may not extend across all racial/ethnic populations. Finally, this is the first study to demonstrate that the association between volunteerism and favorable CVH among Hispanics/Latinos differs by years lived in the US (a commonly used proxy measure of acculturation). Such finding suggests that Hispanics/Latinos living in the US ten years or more (representing more acculturated individuals) may benefit the most from disease prevention and health promotion efforts that foster volunteerism.

Our finding on the prevalence of volunteerism (14.5%) for the overall sample corroborates previous estimates reported by the US Department of Labor indicating a volunteerism prevalence of 15.5% in Hispanic/Latino adults.⁴² The volunteerism prevalence in the present study was lower than those previously reported for other populations, including African Americans (19.3%),⁴² Asians (17.9%),⁴² non-Hispanic whites (26.4%),⁴² Mexican-American adults in California (29.8%),⁴³ and a representative sample of adults in Mexico (66%).⁴⁴ The finding on the relatively small proportion of US Hispanic/Latino adults reporting volunteerism highlights the need for increasing civic and social engagement opportunities. They may also highlight socioeconomic disparities and/or engagement in other activities (such as caregiving and family responsibilities) that reduce opportunities for volunteerism among Hispanics/Latinos. Findings that volunteerism is associated with higher income and education, but not with sex or employment status, are consistent with previous research among Mexican Americans living in California.⁴³

We found that volunteerism is associated with higher odds of favorable overall CVH profile. This finding is consistent with a study that found an association of volunteerism with lower odds of a composite score of the metabolic syndrome in middle-aged and older adults.²³ Interestingly, the association between volunteerism and overall CVH profile persisted after adjustment for lifestyle and psychological factors. This is a notable finding given that the mechanisms underlying volunteerism and health associations remain largely unexamined. It has been suggested that volunteerism may be important for health via engagement in healthy lifestyles and by buffering against the detrimental health effects of psychological distress.^29,33,45 Our results suggest that lifestyle and psychological factors do not play an important role (as either confounders or mediators) in the associations of volunteerism and favorable CVH in this population. However, we are not able to formally evaluate the mechanistic pathways linking volunteerism to CVH using cross-sectional data and adjusting for covariates is not the ideal method (although it can provide preliminary evidence). Alternatively, other potential mechanisms such as sense of purpose in life, social support, and social capital may be driving these associations.⁴⁶ Future research should be conducted using prospective designs to determine temporality and elucidate the mechanistic pathways linking volunteerism and CVH.

The associations we found between volunteerism and favorable CVH are only evident when considering all factors as opposed to individual components. Similarly, researchers of the Health and Retirement Study showed that there was no association between volunteerism and individual CVD risk factors in African Americans, but there was an association between volunteerism and individual CVD risk factors among non-Hispanic white volunteers.²⁴ Nevertheless, the reasons for the null findings on the associations of volunteerism and each CVH factor are unclear. Our findings, along with such previous research, suggest that the associations between volunteerism and individual CVH components may differ across racial/ethnic populations. A plausible explanation for discrepancies across racial/ethnic groups is that “context matters”⁴⁷ for volunteerism and health. As such, some populations may be benefiting from specific contextual factors of the settings where they volunteer. For instance, the community psychology field has long recognized the community-based settings that promote well-being and empowerment are more likely to contribute to overall health than those without a such attribute.⁴⁷ Previous research has documented that moderate-levels of volunteerism (compared to low) have the most benefits for health.⁴⁸ It is also possible that volunteers from disadvantaged groups are able to volunteer a lower number of hours than non-Hispanic whites.

This is the first study to demonstrate that the association between volunteerism and favorable CVH among Hispanics/Latinos differs by acculturation status (as measured by years lived in the US). Number of years in the US is an acculturation proxy commonly used to assess the length of time a person is exposed to potentially deleterious conditions.⁹ Studies typically find that Hispanic/Latino immigrants to the US become to more exposed to harmful and stressful conditions the longer they live in the US while also losing some of the protective cultural resources (particularly at 10 years and after).⁴⁹ In light the social capital model¹¹ and previous evidence, our finding on effect modification by acculturation could be partially explained by distinctions between the types of social capital that are accessed through volunteerism across acculturation groups. For example, more acculturated volunteers may have higher access to bridging social capital (referring to links to people of higher socioeconomic status), which, in turn, is strongly associated with positive health outcomes.^50-53 In contrast, the null association for the less acculturated group may be because volunteerism is fostering bonding social capital (links between people of similar socioeconomic status) which does not necessarily translate to health benefits.^50-53 Additional potential explanations include that the health benefits associated with volunteerism were offset by multiple commitments experienced by recent immigrants.⁵⁴ Further, there may be differences in the types of organizations (religious vs. school-based), activities (mentoring vs. cleaning a street), and the reasons (self-directed altruistic vs. community-level expectations) for volunteerism between recent immigrants and more acculturated Hispanic/Latino adults. The process of acculturation is complex and deserves further investigation in Hispanics/Latinos.

Finally, we did not find evidence of effect modification by sex in the association between volunteerism and favorable CVH. A finding that is inconsistent with a study that reported an association between volunteerism and lower CVD risk factor burden in women, but not in men.¹⁷ There was no evidence of effect modification in the association of volunteerism and favorable CVH by age when comparing across strata of younger versus middle-aged and older adults. Our null finding on effect modification by age is inconsistent with previous evidence showing benefits of volunteerism among middle-aged and older adults, but not among younger adults in relation to self-perceived health²⁶ and depression symptoms.^21,25 These inconsistent findings may be because the prevalence of favorable CVH in Hispanic/Latino adults is small or it may be that the previously documented sub-groups associations also differ across race/ethnicity populations. Overall, results from stratified analysis should be interpreted with caution given the relatively smaller sample size in some of the cells; additional research is needed to confirm our results.

Limitations and Strengths

This study has some limitations that warrant attention, while providing potential directions of future studies. First, the cross-sectional study design does not allow us to determine causality. For instance, it is unknown whether volunteerism leads to changes in favorable CVH or whether those with favorable CVH are able to engage in volunteerism because they are healthier than those without favorable CVH. Regardless of causality, promoting volunteerism among Hispanics/Latinos has important implications for improving community and individual health. Likewise, in this cross-sectional study, we were not able to examine the mechanisms that may help to explain the association between volunteerism and favorable CVH. For instance, social capital constructs, such as social support and community cohesion, may help to explain the relations under study; however, these components of social capital were not included in our study. While we adjusted our models for lifestyle and psychological factors, more research is needed to confirm whether they are confounders or meditators of these associations. As such, future research should aim to examine directionality and elucidate the mechanistic pathways linking volunteerism and CVH among Hispanics/Latinos. Second, while various different measures of acculturation exist (eg, SASH acculturation scale, language preference, and age at migration), the single measure of acculturation we used in our study (ie, duration of time in the US) may inadequately capture the multidimensional process of acculturation. Nevertheless, the present study expands findings from previous research showing the role of acculturation, as measured by years lived in the US, on CVH.⁹ Third, we are unable to evaluate the frequency of engagement in volunteer activities (such as number of hours per week). Yet, there may be a dose-response in these relations. Finally, volunteerism prevalence may have been under-reported if some participants were engaged in forms of civic engagement not perceived as volunteerism, such as informal activism and community health promotion programs (“promotoras”). This is important because previous research has documented that a strong sense of place among community members of Hispanic/Latino ethnic enclaves is characterized, in part, by neighbors helping one another and organizing to improve their communities.⁵⁵

However, regardless of limitations, we contribute to the literature by highlighting the need for more research on volunteerism, including the use of comprehensive measures. Researchers could use the findings of this study as preliminary evidence for future studies. An important strength of our study was that the HCHS/SOL used probability sampling within pre-selected diverse regions which is superior to the convenience samples that are often used in epidemiological cohort studies. Furthermore, we captured a comprehensive picture of volunteerism prevalence in Hispanic/Latino adults living in four US urban areas. Finally, objective measures of CVD risk factors and medication use were included and collected using robust protocols for quality control.

IMPLICATIONS FOR POLICY AND HEALTH BEHAVIOR

As the Hispanic/Latino population is rapidly growing, it is important to better understand the potential benefits of volunteerism for individual- and community-level health. The social capital model suggests that civic engagement and volunteerism can promote the growth of social networks in one’s community and beyond, which can promote access to resources, as well as more opportunities and social power.¹¹ Public health policies can promote civic engagement by fostering and enabling community action at the local level. At the policy level, government funding sources can promote strategies to increase civic participation among adults. Funding should also be allocated to support the Healthy People 2020 social determinants of health topic area on social and community context. Health behaviors programs can be designed to foster volunteerism, while also improving health outcomes such as body mass index and smoking. A well-recognized example of an intervention to promote volunteerism and health is the Experience Corps program, designed to promote volunteerism and physical among older adults.⁵⁶ Finally, at the clinical level, it has been proposed that health care professionals could prescribe volunteerism to patients while assisting patients and families in harnessing the potential health effects.⁵⁷