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Unlike previous chapters that have primarily focused on clinical factors and proximal determinants of heart disease, this chapter tackles the broader societal and social forces that influence this health condition at the population level. As outlined in the final report of the World Health Organization (WHO) Commission on Social Determinants of Health, "heart disease is caused not by a lack of coronary care units but by the lives people lead, which are shaped by the environments in which they live…the main action on social determinants of health must therefore come from outside the health sector."1 The chapter is divided into three parts. First, we will analyze how societal factors influence heart disease, with particular reference to socioeconomic development and socioeconomic gradients of heart disease and related behavioral risk factors. Then, we will examine the role of social factors including social organization, social relations, and chronic stress, including work stress. Finally, we will discuss prevention strategies to reduce heart disease and the socioeconomic gradient of heart disease at the population level.

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The influence of societal factors on heart disease is supported by at least two major categories of scientific evidence: The epidemic change in response to socioeconomic development that profoundly affected standards of living and habits; the socioeconomic gradients of heart disease and related behavioral risk factors varied according to the stage of socioeconomic development.

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Socioeconomic Development and Heart Disease (Across Societies)

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As underlined in the WHO report on social determinants of health, despite the existing epidemiologic differences between rich and poor countries, the causes of heart diseases are the same wherever these diseases occur. The emergence of heart diseases in both developed and developing countries is largely associated with the advent of industrialization and urbanization that improved socioeconomic conditions and changed the way of living.2,3 Evidence shows that the diffusion and decline of this health condition vary according to the stage of socioeconomic development of a country, especially in the context of the epidemiologic transition from infectious to chronic diseases. Although heart disease has often been regarded as a disease of affluent societies, the rapid socioeconomic changes that transformed patterns of consumption and lifestyle have rapidly affected developing countries, especially in the last decades. Rates of coronary heart disease are still low in the poorest regions of the world, including sub-Saharan Africa and the rural areas of South America and South Asia. But they have become more common in regions characterized by increasing wealth, longevity, and lifestyle changes in diet, exercise, and smoking, such as India and Latin America. Rates are declining in Western Europe, North America (excluding some parts of Mexico), Australia, and New Zealand as changes in the way of living delay ischemic heart disease and stroke to more advanced ages.4

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Whereas the epidemic in affluent societies increased and declined over the course of a century, the transition in the developing world has been compressed into a few ...

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