Social and Psychosocial Determinants of Racial and Ethnic Differences in Cardiovascular Health in the United States Population

Abstract

Background: Social and psychosocial factors are associated with cardiovascular health (CVH). Our objective was to examine the contributions of individual-level social and psychosocial factors to racial and ethnic differences in population CVH in the NHANES (National Health and Nutrition Examination Surveys) 2011 to 2018, to inform strategies to mitigate CVH inequities.

Methods: In NHANES participants ages ≥20 years, Kitagawa-Blinder-Oaxaca decomposition estimated the statistical contribution of individual-level factors (education, income, food security, marital status, health insurance, place of birth, depression) to racial and ethnic differences in population mean CVH score (range, 0-14, accounting for diet, smoking, physical activity, body mass index, blood pressure, cholesterol, blood glucose) among Hispanic, non-Hispanic Asian, or non-Hispanic Black adults compared with non-Hispanic White adults.

Results: Among 16 172 participants (representing 255 million US adults), 24% were Hispanic, 12% non-Hispanic Asian, 23% non-Hispanic Black, and 41% non-Hispanic White. Among men, mean (SE) CVH score was 7.45 (2.3) in Hispanic, 8.71 (2.2) in non-Hispanic Asian, 7.48 (2.4) in non-Hispanic Black, and 7.58 (2.3) in non-Hispanic White adults. In Kitagawa-Blinder-Oaxaca decomposition, education explained the largest component of CVH differences among men (if distribution of education were similar to non-Hispanic White participants, CVH score would be 0.36 [0.04] points higher in Hispanic, 0.24 [0.04] points lower in non-Hispanic Asian, and 0.23 [0.03] points higher in non-Hispanic Black participants; P<0.05). Among women, mean (SE) CVH score was 8.03 (2.4) in Hispanic, 9.34 (2.1) in non-Hispanic Asian, 7.43 (2.3) in non-Hispanic Black, and 8.00 (2.5) in non-Hispanic White adults. Education explained the largest component of CVH difference in non-Hispanic Black women (if distribution of education were similar to non-Hispanic White participants, CVH score would be 0.17 [0.03] points higher in non-Hispanic Black participants; P<0.05). Place of birth (born in the United States versus born outside the United States) explained the largest component of CVH difference in Hispanic and non-Hispanic Asian women (if distribution of place of birth were similar to non-Hispanic White participants, CVH score would be 0.36 [0.07] points lower and 0.49 [0.16] points lower, respectively; P<0.05).

Conclusions: Education and place of birth confer the largest statistical contributions to the racial and ethnic differences in mean CVH score among US adults.

Keywords: cardiovascular health; ethnicity; psychosocial factors; racial groups; social factors.

Figure 1.. Decomposition of the net difference in mean cardiovascular health score between racial and ethnic group among males

CVH: Cardiovascular health, NHW: Non-Hispanic White. Values above/below 0 indicate the amount the mean CVH score would be higher/lower (respectively) if the distribution of the individual-level factor was equivalent to that of non-Hispanic White males. Factors represented in the bar graphs statistically significantly contributed to the explained component of the net difference in mean CVH between racial and ethnic group compared with non-Hispanic White males (p<0.05). Factors not included in each respective bar did not significantly contribute to the explained component of the difference in mean CVH between racial and ethnic group compared with non-Hispanic White males. Net difference in CVH between racial and ethnic groups is shown in Table 1. The sum of the decomposed effects displayed that are associated with each factor may not equal the overall net difference in mean CVH, because the unexplained component of racial and ethnic differences also contributes to differences in mean CVH between racial and ethnic groups. Quantitative results showing the unexplained component of the difference in mean CVH between racial and ethnic groups is shown in Table 3. Corresponding quantitative results showing the explained component of the difference in mean CVH between racial and ethnic groups is shown in Supplemental Table S3.

Figure 2.. Decomposition of the net difference in mean cardiovascular health score between racial and ethnic group among females

CVH: Cardiovascular health, NHW: Non-Hispanic White. Values above/below 0 indicate the amount the mean CVH score would be higher/lower (respectively) if the distribution of the individual-level factor was equivalent to that of non-Hispanic White females. Factors represented in the bar graphs statistically significantly contributed to the explained component of the net difference in mean CVH between racial and ethnic group compared with non-Hispanic White females (p<0.05). Factors not included in each respective bar did not significantly contribute to the explained component of the difference in mean CVH between racial and ethnic group compared with non-Hispanic White females. Net difference in CVH between racial and ethnic groups is shown in Table 1. The sum of the decomposed effects displayed that are associated with each factor may not equal the overall net difference in mean CVH, because the unexplained component of racial and ethnic differences also contributes to differences in mean CVH between racial and ethnic groups. Quantitative results showing the unexplained component of the difference in mean CVH between racial and ethnic groups is shown in Table 3. Corresponding quantitative results showing the explained component of the difference in mean CVH between racial and ethnic groups is shown in Supplemental Table S3.