In 2016, the National Heart, Lung, and Blood Institute (NHLBI) released the NHLBI Strategic Vision as a result of collaborative input on the future of Institute-driven research over the next 10 years. From this, the NHLBI’s Division of Cardiovascular Sciences (DCVS) developed an implementation plan that emphasizes six key priority areas related to the mission and goals of the Division. On March 27-28, 2019, DCVS convened a core group of experts focused on one of the key areas of the DCVS Strategic Implementation plan, Addressing Social Determinants of Cardiovascular Health and Heath Disparities, to develop a framework for developing a series of virtual workshops planned for 2019-2020. The goal of these future virtual workshops includes discussion about the state of the science and remaining gap areas, as relevant to cardiovascular and cardiometabolic diseases.
Social determinants of health refer to those circumstances in which people are born, grow, live, work, and age that influence health. The distribution of health and illness cluster at the intersections of social, economic, environmental, and interpersonal forces. Healthy People 2020 has identified five key areas for social determinants of health, including: 1) Economic Stability, 2) Education, 3) Social and Community Context, 4) Health and Health Care, and 5) Neighborhood and Built Environment as foci for one of the four overarching goals for the decade-- to “create social and physical environments that promote good health for all."1
These social determinants create significant health disparities by race, sex, sexual orientation and gender identity, geography, poverty, and other social and environmental factors. For example, research suggests that lower levels of educational attainment are associated with a higher prevalence of cardiovascular risk factors, higher incidence of cardiovascular events, and higher cardiovascular mortality, independent of other sociodemographic factors; these associations have appeared to widen over time.2,3 However, significant gaps in knowledge on the relationship of social determinants of health with cardiometabolic disease remain. Thus, the DCVS Strategic Vision Implementation internal staff working group on Social Determinants of Health and Health Disparities is planning a series of virtual workshops to discuss the gaps in the science relevant to cardiovascular and cardiometabolic diseases.
- Achieve consensus on the definitions and types of social determinants most closely linked to cardiovascular health and disease
- Identify core questions and/or issues that pertain to each social determinant of cardiovascular health and disease
- Identify priority areas/themes for further, in-depth exploration via the subsequent virtual workshops
Discussion and Emerging Themes
The presentations were organized into multiple sessions. The opening session included an overview of current related work across NIH and HHS as well as the American Heart Association. Topics included: 1) plans for analysis of the existing DCVS funding portfolio in this area; 2) a review of the Healthy People 2020 Framework and Domains for Social Determinants of Health; 3) an update on the work of the PhenX Toolkit Social Determinants of Health Working Group; 4) discussion of the American Heart Association’s scientific statement on Social Determinants of Risk and Outcomes for Cardiovascular Disease; and 5) summaries of the NHLBI-sponsored workshop on Social Determinants of Health: Contributions of Early Life Adversity to Cardiovascular Disparities in Adulthood and the NIH Office of Behavioral and Social Sciences Research (OBSSR) led workshop on Screening and Referral for Social Determinants of Health: Innovative Health Care Applications and Future Directions.
Following this overview, each participant presented a brief perspective on specific domains of social determinants of health within their area of expertise by 1) providing a brief overview and/or definitions of the social determinant; 2) discussing the current evidence about the association of the social determinant to health outcomes in general, and cardiovascular and cardiometabolic health/disease outcomes specifically; 3) identifying the gaps in knowledge for understanding the role of this social determinant on cardiometabolic disease and the barriers/challenges/facilitators for addressing these gaps; and 4) recommendations for future directions.
Several themes emerged from the discussion and are presented in detail below:
Broad scope of social determinants. Although the workshop used the Healthy People 2020 Framework as a starting point, the working group acknowledged that there were many domains and concepts of social determinants of health (Table). The body of literature exploring mechanisms, associations, and interventions on the relationship of a particular social determinant with cardiometabolic health is vast and heterogenous. Some domains have extensive evidence and are ripe for interventional studies, whereas some domains are earlier in development.
Table: Domains of Social Determinants of Health
Neighborhood and Built environment
Homelessness, segregation, crowding, neighborhood, physical environment, built environment, geography/geographic variation/place, urban-rural, occupational/environmental exposures
Low income, unemployment, poverty, lack of liquid assets, socioeconomic status (SES), Temporary Assistance for Needy Families (TANF), food insecurity, food availability, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), food stamps, food desert
Low education, language proficiency, SES, illiteracy
Social and Community Context
Social isolation, social support, social engagement, social disadvantage, faith-based, community, family, social context, social gradients, acculturation; Incarceration, justice, criminal justice, health policy, crime/violence; Discrimination, bias, implicit bias, sexism, racism, injustice, inequity
Health and Health Care
Medical care, health care, access to health care, health literacy, uninsured, Medicaid
Issues related to measurement were recognized across all social determinants of health domains. For some domains, a large number of measures exist and there is substantial variation across studies. However, for other domains, although strong conceptual definitions exist, there are challenges in operationalizing these definitions in research studies. Other common issues included: 1) the lack of standardized definitions; 2) the lack of standardized and/or validated instruments for assessing social determinant constructs in clinical and/or research settings; 3) a need for evidence-based consensus on the appropriate context for use of a given measure if multiple measures exist; 4) an understanding of the benefits and limitations of objective vs. subjective (i.e., self-reported) measures and traditional vs. more novel measures; 5) a better understanding of measures at the individual vs. broader levels; and 6) an improved understanding of response bias influenced by the environment (e.g., who is administering an instrument) and other factors.
Current state of the evidence
Stress describes the body's reaction to environmental or psychological threats which results in stimulation of highly interconnected biological systems including the autonomic nervous system and hypothalamic-pituitary-adrenal (HPA) axis. Chronic activation of the stress response is purported to be the means by which social determinants may impact cardiometabolic health. Social determinants of health could be characterized as either physiologic (e.g., environmental toxins, gender affirming hormone replacement therapy) or psychological/behavioral (e.g., experiences of discrimination, health behavior changes).
For some social determinants, there is strong and robust evidence linking them to health in general and cardiometabolic conditions in particular, such as the association of socioeconomic status (SES) with cardiovascular outcomes. Other domains of social determinants lack this information because they are difficult to measure, or existing measures are novel and may be missing key data on validity and reliability, or they have been studied more extensively for other outcomes and not cardiovascular outcomes.
Across all domains of social determinants of health, participants noted that the patterns of exposure to social determinants is important. For example, experiences could be characterized as distal (e.g., external to the individual, such as acts of prejudice and discrimination) vs. proximal (e.g., subjective interpretations of one’s own identity or experience, such as fear of rejection or internalized bias/stigma). Patterns of exposure should also be considered including intensity, frequency, and timing of the exposure (e.g., during early life vs. later in adulthood).
Furthermore, social determinants of health often are tightly linked with each other, and with certain demographic features, e.g., a disproportionate number of poor may also be homeless, involved in the criminal justice system, and/or live in high crime neighborhoods. Intersectionality, which describes the synergistic nature of social group identities (e.g., race, class, and gender), may also reflect the complex and cumulative impact of disproportionate exposure to particular social determinants of health. This complexity makes it difficult to assess the independent association of many social determinants with cardiometabolic health and/or disease. Social determinants of health may render their impact directly, as mediators along a causal pathway, or as effect modifiers. Several populations disproportionately impacted by social determinants of health (e.g., homeless, gender/sexual minorities) and that have been more extensively studied for other conditions (e.g., HIV, substance use); research on social determinants among these populations should be leveraged to study cardiometabolic disease.
Research evaluating social determinants of cardiometabolic health has consisted largely of observational studies. Although there are more questions that can be addressed with additional observational studies, particularly longitudinal investigations, there is also a paucity of intervention studies that address social determinants of health, both in population and healthcare/clinical settings. At the population level, the intervention studies that do exist focus on delivering an existing intervention in a disparity population (e.g., racial/ethnic or gender minority). In the healthcare setting, interventions are primarily focused on how consideration of social determinants of health may improve risk assessment and therefore better stratify individuals for current or novel risk reduction efforts. A new cluster of health care-based interventions aims to improve patients’ social conditions by strengthening linkages with community-based social services and/or to adjust medical care based on an understanding of social risk factors. Research on the added value of these health care-based interventions is at an early stage.
Workshop participants also discussed the utility of intervening on a particular social determinant at an individual versus broader (e.g., neighborhood or community) level, while recognizing that multi-level interventions are likely ideal but logistically challenging. Many individual-level or community-level interventions focus on changing individual behaviors (including behaviors to enhance resilience and/or coping strategies), with fewer studies targeting a change in the environment or context.
Challenges and Barriers to Conducting Research
A number of challenges and barriers to understanding the role of social determinants of health were identified. The lack of standardization around definitions, measures, and context for the use of social determinant assessment instruments was recognized across many domains of social determinants of health. In addition, many researchers are not aware of ways to consider social determinants of health in the provision of clinical care or the conduct of research. Furthermore, there are ethical challenges for conducting randomized clinical trials to explore the relationship of social determinants to cardiometabolic health (e.g., randomizing groups to receive or not receive housing or income). Budgetary and time limits of funding create logistical challenges to research in this area as the impact of interventions targeting social determinants of health may require significant resources and extended follow-up times. Additionally, the trans-disciplinary research needed in this arena requires coordination across a variety of research disciplines (e.g., social science, health, economics) and research-funding agencies with varying missions and priorities. Policies that impact health (e.g., medication access, housing, and education policies) are often not evaluated for their impact on health outcomes, underscoring the need for more natural experiments in this area of research.
Considerations for Future Research
A comprehensive model of mechanisms by which social determinants get “under the skin” to impact subsequent cardiometabolic risk needs to be developed. It should utilize a lifespan approach to identify the most vulnerable developmental periods associated with cardiometabolic risk. The perspective of social determinants of health research should be broadened from a risk assessment model to an intervention-based model focused on enhancing resilience.
Although multiple measures may be needed for a comprehensive assessment of the complex, multi-level relationship of a social determinant with health outcomes, many studies do not include any measures of social determinants of health at all. Therefore, identifying some basic consensus measures of social determinants of health that may be integrated into current research on cardiometabolic health could be an initial step forward. Despite the challenges related to measurement previously described, research incorporating multilevel factors (i.e., individual behaviors and contextual factors, and the interaction between both) should be a priority. In addition, the multiple dimensions of the social determinant should be considered (e.g., evaluation of SES may include measures for individual economic deprivation and area level poverty). The development and integration of physiologic and environmental sensors and other innovative technologies could also contribute to improved measurement of some social determinants of health in research.
Large population studies and natural experiments should also be leveraged for study. Workshop participants supported capitalizing on innovative datasets, such as social media and data from app developers and technology companies.
The trans-disciplinary nature of this research will require the development of a network of researchers and community collaborators to develop translational research programs. There was particular interest in computer and data scientists who could lead the mining, integration, and interpretation of data from disparate sources to generate datasets with multi-level measures of social determinants of health. New research should leverage the health care sector’s growing engagement around addressing adverse social conditions as part of health care delivery to improve health. In addition, federal agencies that support research and delivery of social services should be engaged in research on the impact of their programs and policies on health outcomes.
Following the presentations, several topics emerged that should be considered for further exploration in the proposed virtual workshop series. Logistical considerations for conducting the workshop series were also discussed. Participants recommended each virtual workshop follow a common structure and address several areas that were applicable across several domains as follows:
1) Measurement: This may include discussion of commonly used measures, individual level vs. broader level assessment of cardiovascular health and/or disease effects, the pattern of exposure with regard to intensity/severity and frequency/chronicity, and timing of assessment during the lifespan. In addition, some constructs may be evaluated using objective/extrinsic measures (e.g., exposure to poverty or acts of discrimination) or subjective/intrinsic measures (e.g., perceived discrimination, internalized stigma).
2) State of the evidence and research gaps: Discussion may focus on the state of the evidence along the translational spectrum in terms of how observational data have informed the development and evaluation of interventions, and the subsequent implementation and dissemination of effective interventions. Discussion could also review the degree to which interventions address multiple levels, i.e., individuals and communities.
3) Challenges and Opportunities: Methodologic issues, legal and policy limitations, and ethical issues may impede advancing the science in understanding the association of social determinants with cardiometabolic conditions. Engaging diverse stakeholders and/or developing a workforce with the necessary expertise to address research gaps may be required. Discussion could also include the identification of existing assets and resources that could be leveraged to advance research.
4) Recommendations: Each virtual workshop should provide a core set of recommendations for consideration.
Several specific topics/domains of social determinants were prioritized for consideration for the initial virtual workshops including: 1) geography and neighborhood, which may include discussion of rural and urban disparities, housing, neighborhood segregation, and the built environment; 2) economics and education, which may focus on poverty, literacy, health literacy, educational attainment and/or achievement, and SES; 3) health care settings for social risk screenings and interventions; 4) crime and violence, which may include discussion of interpersonal trauma and criminal justice system involvement; and 5) bias and discrimination with an emphasis on the experiences of women, racial/ethnic minorities, and gender and sexual minorities.
Additional topics for consideration include: 1) development of a comprehensive model for designing multi-level intervention research of social determinants of cardiometabolic health; 2) harnessing natural experiments to evaluate cardiometabolic outcomes as a result of local and federal level policies that impact social determinants; and 3) leveraging novel data sources, such as wearable sensors, apps, and social service provider data to study social determinants of cardiometabolic health.
NHLBI Staff Contacts
- Nicole Redmond, MD, PhD, MPH; Division of Cardiovascular Sciences, NHLBI
- Erin Iturriaga, DNP, RN; Division of Cardiovascular Sciences, NHLBI
Working Group members
- Laura Gottlieb MD, MPH; University of California-San Francisco
- Mahasin S. Mujahid, PhD, MS, FAHA; University of California-Berkeley
Non-Federal Workshop Participants and Speakers
- Travis P. Baggett, MD, MPH; Harvard Medical School and Massachusetts General Hospital
- Seth Berkowitz, MD, MPH; University of North Carolina, Chapel Hill
- Billy Caceres, PhD, RN, AGPCNP-BC; Columbia University
- David Chae, ScD, MA; Auburn University
- Stephanie L Fitzpatrick, PhD; Kaiser Permanente Northwest
- Cheryl Dennison Himmelfarb, PhD, RN, ANP, FAAN, FAHA, FPCNA; Johns Hopkins University
- Peter James, MHS, ScD; Harvard Medical School
- Kiarri Kershaw, PhD, MPH; Northwestern University
- Tene Lewis, PhD; Emory University
- Gina Lovasi, PhD; Drexel University
- Tiffany Veinot, MLS, PhD; University of Michigan
- Melicia Whitt-Glover, PhD; Winston-Salem State University
- Qian Xiao, PhD, MPH; University of Iowa
NIH/HHS Invited Workshop Participants
- Nancy Breen, PhD; National Institute of Minority Health and Health Disparities (NIMHD)
- David Goff, MD, PhD; Director, Division of Cardiovascular Sciences (DCVS), NHLBI
- Ayanna Johnson, MSPH; Office of Disease Prevention and Health Promotion, US Department of Health and Human Services
- Leslie MacDonald, MS, ScD; National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention
- Tiffany Powell-Wiley, MD, MPH, FAHA; Division of Intramural Research, NHLBI
NHLBI Staff Workshop Organizers
- Alison Brown, MS, PhD; Clinical Applications and Prevention Branch, DCVS, NHLBI
- Rebecca Campo, PhD; Clinical Applications and Prevention Branch, DCVS, NHLBI
- Patrice Desvigne-Nickens, MD; Heart Failure and Arrhythmias Branch, DCVS, NHLBI
- Erin Iturriaga, DNP, RN; Atherothrombosis & Coronary Artery Disease Branch, DCVS, NHLBI
- Nicole Redmond, MD, PhD, MPH; Clinical Applications and Prevention Branch, DCVS, NHLBI
- Catherine Stoney, PhD; Clinical Applications and Prevention Branch, DCVS, NHLBI
1. Healthy People 2020 [Internet]. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion [May 1, 2019]. Available from: https://www.healthypeople.gov/
2. Kaplan, G. A., & Keil, J. E. (1993). Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation, 88(4), 1973-1998.
3. Mensah, G. A., Mokdad, A. H., Ford, E. S., Greenlund, K. J., & Croft, J. B. (2005). State of disparities in cardiovascular health in the United States. Circulation, 111(10), 1233-1241.