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Chapter Summary

This chapter discusses societal and individual-level social determinants of cardiovascular health. Understanding these social determinants of cardiovascular health is important for improving the outcomes among individuals and the community through better prevention and treatments for ischemic heart disease (IHD). Epidemiological studies have reported that populations in rural and underserved urban locations have greater cardiovascular events and mortality than urbanites in developed and developing countries. This risk is mediated through location-based disparities in health care, lower educational status (a marker of lower socioeconomic status), and lower availability and affordability of medicines (see Fuster and Hurst’s Central Illustration). Policy-level interventions that focus on each of these three factors are needed to improve quality of health systems and health care in these underserved locations. Essential to this improvement is the requirement for novel health financing mechanisms to provide comprehensive universal primary and secondary health care, especially in developing countries. High-quality and free universal health care are crucial for improving access and use of proven medicines and other interventions, and promotion of lifelong adherence can lead to substantially better cardiovascular health.

eFig 15-01 Chapter 15: Location and Level of Care, Education, Availability of Medicines, and Cardiovascular Mortality


Healthy lifestyles are crucial in the prevention of cardiovascular disease (CVD) and mortality. Pharmacological measures are also needed among those with cardiovascular risk factors and established disease. Healthy lifestyle in individuals and populations, type of health care, and access to medications are, however, determined by social and economic factors that are in turn influenced by multiple social, economic, and cultural circumstances. These factors, collectively known as social determinants of health, are increasingly being identified as important in health and also in causation and treatment of CVDs.1,2 Physicians have known for centuries that social factors such as poor living conditions and poverty are associated with poor health and higher all-cause mortality.3 It is also well known that cardiovascular conditions such as rheumatic heart disease and other infection-related conditions (tubercular pericarditis, Chagas disease) and nutritional deficiency cardiomyopathies are more common among the poor and those living in crowded conditions.4 Until the middle of the 20th century, diseases such as ischemic heart disease (IHD) and stroke and their risk factors—hypertension, diabetes, hypercholesterolemia, and unhealthy lifestyles—were more prevalent among richer individuals in developed countries. This has changed and poor individuals in these countries currently have higher incidence and mortality from IHD and stroke.5,6 Similar trends are emerging in developing countries.6

The World Health Organization (WHO) has defined social determinants of health as the conditions in which people are born, grow, live, work, and age.7 These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. Key concepts that influence the ...

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