Social and community context determinants of health

The social determinants of health (SDoH) are factors that influence an individual’s health such as the conditions in the places and environments in which people are born, live, learn, work, play and age that ultimately affect people’s health and quality-of-life outcomes and risks.

What are the SDoH?

The SDoH include a diverse array of factors, for example, safe housing, employment status and job opportunities, access to physical activity opportunities, air and water pollution, literacy skills, and discrimination and violence. Various models exist that help to explain and group the SDoH. One of the most common models used to explore the SDoH is Dahlgren and Whitehead’s 1991 model which maps out SDoH at various levels, showing the relationship between one’s health and individual characteristics (both relating to lifestyle and biology); social and community factors; living and working conditions; and wider socio-economic, cultural and environmental conditions. The US Department of Health and Human Sciences groups the SDoH into 5 domains: economic stability, education access and quality, health care access and quality, neighbourhood and built environment, and social and community context.

What is the evidence for using the SDoH?

It is difficult and often misleading to estimate how much of an influence the social determinants of health have, both in relation to each other and in relation to other determinants such as medical care or genetics. Nonetheless, various estimates exist which in general agree that the majority of health determinants are related to the SDoH, as opposed to medical care and biology.

The SDoH provide us with a framework for understanding the broad factors that affect our health, outside of the clinical setting and beyond our biology and genetics, that might be the root cause of health disparities and inequities. For example, if people do not have access to healthy foods (perhaps due to shops not stocking healthy foods, or healthy foods being more expensive than unhealthy foods), they are less likely to have good nutrition, which increases their risk of certain health conditions, such as diabetes and heart disease. Trying to encourage healthy choices is unlikely to eliminate these disparities, but addressing the barriers to healthy food access (the SDoH) could have more success.

How to address the SDoH?

Since the SDoH covers a wide range of health determinants, addressing the SDoH also requires a wide range of activities and policies. A Health in All Policies (HIAP) approach is vital in addressing the SDoH since the health system is often not best placed to address some determinants. For example, health actors can work with the education sector to impact education-related determinants, with the environment sector to address air pollution, or the housing sector to improve the safety of living conditions

Rahul Singh, MD,1 Zulqarnain Javed, PhD, MBBS, MPH,2 Tamer Yahya, MD,3 Javier Valero-Elizondo, MD MPH,4,5 Isaac Acquah, MD, MPH,3 Adnan A. Hyder, MD, MPH, PhD,6 Muhammad Haisum Maqsood, MD,7 Zahir Amin,8 Sadeer Al-Kindi, MD,9 Miguel Cainzos-Achirica, MD, MPH, PhD,3,4,5 and Khurram Nasir, MD, MPH, MSc3,4,5

Rahul Singh

1Department of Cardiology, University of Minnesota, Minnesota, US

Find articles by Rahul Singh

Zulqarnain Javed

2Division of Health Equity & Disparities Research, Center for Outcomes Research, Houston Methodist, Houston, Texas, US

Find articles by Zulqarnain Javed

Tamer Yahya

3Center for Outcomes Research, Houston Methodist, Houston, Texas, US

Find articles by Tamer Yahya

Javier Valero-Elizondo

4Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA

5Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist, Houston, Texas, US

Find articles by Javier Valero-Elizondo

Isaac Acquah

3Center for Outcomes Research, Houston Methodist, Houston, Texas, US

Find articles by Isaac Acquah

Adnan A. Hyder

6George Washington University, Washington, DC, US

Find articles by Adnan A. Hyder

Muhammad Haisum Maqsood

7Lincoln Medical Center, New York, New York, US

Find articles by Muhammad Haisum Maqsood

Zahir Amin

8University of Houston, Houston, Texas, US

Find articles by Zahir Amin

Sadeer Al-Kindi

9Case Western Reserve University School of Medicine, Cleveland, Ohio, US

Find articles by Sadeer Al-Kindi

Miguel Cainzos-Achirica

3Center for Outcomes Research, Houston Methodist, Houston, Texas, US

4Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA

5Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist, Houston, Texas, US

Find articles by Miguel Cainzos-Achirica

Khurram Nasir

3Center for Outcomes Research, Houston Methodist, Houston, Texas, US

4Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA

5Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist, Houston, Texas, US

Find articles by Khurram Nasir

Author information Article notes Copyright and License information Disclaimer

1Department of Cardiology, University of Minnesota, Minnesota, US

2Division of Health Equity & Disparities Research, Center for Outcomes Research, Houston Methodist, Houston, Texas, US

3Center for Outcomes Research, Houston Methodist, Houston, Texas, US

4Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA

5Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist, Houston, Texas, US

6George Washington University, Washington, DC, US

7Lincoln Medical Center, New York, New York, US

8University of Houston, Houston, Texas, US

9Case Western Reserve University School of Medicine, Cleveland, Ohio, US

Zulqarnain Javed: gro.tsidohtemnotsuoh@devajz

CORRESPONDING AUTHOR: Zulqarnain Javed, PhD, MBBS, MPH Houston Methodist Hospital, Houston, Texas, US gro.tsidohtemnotsuoh@devajz

Received 2021 Apr 5; Accepted 2021 Aug 18.

Copyright : © 2021 The Author(s)

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.

Abstract

Disease prevention frameworks and clinical practice guidelines in the United States (US) have traditionally ignored upstream social determinants of health (SDOH), which are critical for reducing disparities in cardiovascular disease (CVD)—the leading cause of death in the US. Existing evidence demonstrates a protective effect of social support, social cohesion, and community engagement on overall health and wellbeing. Increasing community and social support is a major objective of the Healthy People 2030 initiative, with special provisions for vulnerable populations. However, to date, existing evidence of the association between community and social context (CSC)—an integral SDOH domain—and CVD has not been reviewed extensively. In particular, the individual and cumulative impact of CSC on CVD risk and the pathways linking CSC to cardiovascular outcomes are not well understood. In this review, we critically appraise current knowledge of the association between CSC and CVD, describe potential pathways linking CSC to CVD, and identify opportunities for evidence-based policy and practice interventions to improve CVD outcomes.

Keywords: community, social context, cardiovascular disease, social determinants of health

Introduction

Cardiovascular disease (CVD) affects more than 480 million people annually worldwide.1 In the United States (US) alone, nearly 655,000 Americans die each year of CVD.2 It is known that traditional clinical risk factors such as diabetes, hypertension, and obesity, and modifiable risk behaviors including insufficient physical activity, poor diet, smoking, and alcohol consumption, account for over 80% of all CVD.3 Yet, most lifestyle CVD interventions focus on addressing downstream risk factors for disease, often failing to address the “causes of the causes.”4,5 Disease prevention frameworks and clinical practice guidelines have historically ignored upstream social determinants of health (SDOH), which are critical toward achieving primary prevention and reducing health disparities in CVD.6,7 In this context, a recent joint American College of Cardiology (ACC)/American Heart Association (AHA) clinical practice guideline emphasized the need to address SDOH to inform delivery of care and achieve primary prevention.6

Healthy People 2030 is a key initiative of the US Department of Health and Human Services’ Office of Disease Prevention and Health Promotion. Designed to improve the nation’s health and wellbeing, Healthy People 2030 sets forth specific objectives to create social and physical environments that help achieve optimal population health.8 Improved community and social support—a key SDOH—is a major objective, with special provisions for vulnerable populations including children/adolescents, racial/ethnic minorities and the lesbian, gay, bisexual, and transgender population.8 Existing evidence suggests a protective effect of social support, social cohesion, community engagement, and other community and social context (CSC) subdomains on overall health and wellbeing.8,9 However, relatively few studies have examined the impact of CSC on CVD risk or the possible pathways linking CSC to CVD outcomes, both of which merit further research. This review is intended to (1) critically appraise current knowledge of the association between CSC and CVD, (2) elucidate potential pathways and mechanisms through which CSC may predict adverse CVD outcomes, and (3) identify opportunities for evidence-based interventions to improve CVD outcomes and reduce disparities.

Community and Social Context: An Integral Part of SDOH

Widely used SDOH models, such as the Healthy People and Kaiser Family Foundation models, provide critical domain-based frameworks for greater understanding of SDOH and design of evidence-based interventions to address SDOH.8,10 Community and social context is defined as “the context in which individual, societal, and cultural factors interact to impact health outcomes,”11 and it is an integral part of SDOH. SDOH are broadly classified into six major domains: economic stability, education, food, CSC, neighborhood and physical environment, and healthcare system.8,10 Each SDOH domain is linked to others via multiple pathways, with major CSC-SDOH interlinkages outlined in Figure 1.

Open in a separate window

Figure 1

Community and social context: interlinkages with other social determinants of health (SDOH) domains.

We identified four recurring themes in available literature on CSC and accordingly divided the domain into four distinct subdomains: social support, social cohesion/social networks, discrimination, and community engagement and civic participation (Figure 1).10,11,12,13 The following section discusses the impact of individual CSC subdomains on cardiovascular health using evidence from existing literature. Different measures used to define CSC subdomains, as reported in the literature and referenced herein, are listed in Table 1.14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38

Table 1

Community and social context subdomain measures.14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38

Open in a separate window

Social Support

Context

Social support is a multifaceted construct that encompasses information and resources available to an individual to deal with a wide spectrum of life’s challenges and stressors.13 It is often classified as emotional (empathy, love, trust), instrumental (tangible goods), informational (information provided to cope with stressful situations), and appraisal (affirmative support related to self-evaluation).10 Social support is built around a bidirectional “positive emotional exchange” between an individual and his/her social networks, with positive effects on health outcomes.12

Current Evidence

Social support is linked to physical and mental wellbeing, increased ability to cope with stress, and improved self-care and overall health-related quality of life in individuals with CVD.13,39 Gallagher and colleagues14 found that older adults with high levels of social support were more likely to consult with a health professional for weight gain, adhere to medication, and exercise regularly compared with those with medium or low levels of social support; these pathways improve overall cardiovascular health and survival.

Through multiple pathways, social support has been shown to improve self-care in patients with heart failure.15 For example, findings from a study of social support and survival in patients with heart failure found that patients experiencing both lack of social support and medication nonadherence had a 3.5-times increased risk of adverse cardiac events relative to patients with medication adherence and higher social support.15 In the same study, the authors reported a mediation effect of medication adherence, highlighting a possible mechanism through which social support may impact cardiovascular health. Similarly, lack of emotional support has been associated with a significantly increased risk of mortality after hospitalization for myocardial infarction (MI).17

In a unique 19-year retrospective cohort study of more than 3,000 men and women, Thurston et al.40 found nearly twice the increased risk of incident coronary artery disease associated with experiences of loneliness. Further, it has been reported that individuals without a spouse or close confidant have lower survival rates compared with those who were married, have a confidant, or both.18

Despite the evidence documenting a protective effect of social support on cardiovascular health, relatively few studies have evaluated the effectiveness of social support interventions in the context of CVD. In the Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial—the largest study of social support interventions in CVD patients to date—Lett and colleagues41 demonstrated that higher levels of perceived social support with cognitive behavioral therapy were associated with improved cardiac outcomes (time to death and reinfarction), but only in patients without elevated depression, suggesting the relevance of psychological wellbeing to the CSC-CVD association. Greater evidence is needed to improve current understanding of the effectiveness of existing interventions and inform future interventions on a population level.

Social Cohesion

Context

Social cohesion is an important measure of the strength of an individual’s ties to his/her community and is defined by Kawachi and Berkman42 as “the extent of connectedness and solidarity among groups in a society.” A cohesive society allows mutual sharing of the community’s collective energy and support system via availability of social capital, which is in turn made available through social networks. Social networks are webs of societal relationships—quantified by their range, density, boundedness, and individuals’ characteristics/homogeneity—that act as antecedents of social support.43,44 Social cohesion may protect cardiovascular health through multiple pathways, including improved health behaviors, positive psychological and physical health effects, and improved coping ability.13,45,46

Current Evidence

Findings from a large, prospective study of > 5,000 participants suggest that neighborhood social cohesion may predict 22% lower risk of MI, independent of sociodemographic and clinical predictors.20 These results are corroborated by findings from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study, which showed nearly 50% lower odds of hypertension associated with high neighborhood cohesion.21

Berkman and colleagues44 posit that social networks influence health behaviors and, ultimately, health outcomes by providing social support, influencing social engagement/attachment, and increasing access to material goods and resources. In their study of > 2,700 participants from the Framingham Heart Study, Strully et al.47 demonstrated that men had nearly 50% higher odds of taking aspirin if a male friend had also been recently taking aspirin; furthermore, women were nearly three times as likely to take aspirin if a female friend recently experienced a cardiovascular event. Similarly, using data for > 23,000 adults from the National Health Interview Survey, Quinn and colleagues22 reported that higher social cohesion was associated with 22%, 13% and 14% increased odds of meeting aerobic guidelines, strength guidelines, and combined aerobic and strength guidelines, respectively.

Social isolation has been shown to be a strong risk factor for CVD. A meta-analysis of 16 longitudinal studies found that poor social relationships were associated with 29% increased risk of coronary heart disease and 32% increased risk of stroke.48 Prior evidence suggests that socially isolated individuals may experience higher rates of smoking and obesity and are less likely to be physically active relative to those with stronger social bonds.48,49 In addition, social isolation and loneliness may lead to chronic stress, which in turn contributes to CVD.50 In one of the largest reported prospective studies of social network in CVD, Kawachi and colleagues16 followed 32,624 male health professionals over a 4-year period and found that those who were socially isolated had a 90% increased risk for cardiovascular mortality and 121% increased risk of incident stroke compared with those with the highest level of social networks.

Poor social networks/lack of social cohesion may have disproportionate effects on disadvantaged populations, including racial/ethnic minorities. For example, findings from a diverse prospective study of > 5,000 adults suggest that the effects of neighborhood segregation were more prominent in non-Hispanic Blacks (NHBs) than non-Hispanic Whites (NHWs), while no effects were observed in Hispanics.51 Conversely, increasing neighborhood social cohesion is associated with a corresponding decrease in interleukin-6 (IL-6) levels, with the strongest association reported in the NHB population (15-point decrease per unit increase in social cohesion).3,52 While there is considerable variation in the measurement and operationalization of social cohesion, widely used and validated scales such as the Neighborhood Cohesion Instrument.23 Social Cohesion Scale,24 and the psychosocial and lifestyle questionnaire from the Health Retirement Survey25 assess various aspects of trust, type/strength of social bonds (eg, friendships, exchange of resources), perceived helpfulness/practical help, common values, loyalty, and tolerance (Table 1).

Discrimination

Context

The Institute of Medicine defined discrimination as “differences in care that result from biases, prejudices, stereotyping, and uncertainty in clinical communication and decision making.”53 While there are multiple forms of discrimination related to race, gender, weight, national origin, religion, and other sociodemographic factors, this review focuses on racial/ethnic discrimination. Most population-level racial/ethnic disparities are linked to structural or institutional racism, which manifests as disparities in employment opportunities, residential segregation, and access to material resources, among others.54 In turn, such differential treatment55 restricts access to health care and affects quality of care for disadvantaged populations.

Major mechanisms of the discrimination-CVD association include internalized racism and adverse psychological effects, unhealthy coping behaviors, and cumulative psychological and physiological effects of acute and chronic stress.13,56 In addition, insufficient cultural competence training and implicit provider bias toward racial/ethnic minorities increases the risk of bias in clinical decision making and affects the quality of the physician-patient relationship, with implications for patients’ trust in the healthcare system.57,58

Current Evidence

A large population-based study of > 6,000 adults (The Multi-Ethnic Study of Atherosclerosis) found that during a median follow-up of over 10 years, lifetime discrimination experience in two or more domains predicted a 6% to 28% increased risk of CVD.26 Similarly, during a 13-year follow-up of participants from the Jackson Heart Study, Forde and colleagues27 found that lifetime discrimination was associated with a 50% increased risk of hypertension.

Institutional racism contributes to disparities in both healthcare access and quality.56 Existing evidence suggests that racial/ethnic minorities receive lower quality of care compared to NHWs.59 For example, it has been previously documented that NHBs with hypertension are less likely to receive psychosocial support and rapport-building statements from physicians and more likely to experience shorter clinic visits compared with their NHW counterparts with similar CVD risk profiles.60 In turn, such differential treatment can create gaps in physician-patient communication and compromise the overall quality of care.56

Provider-level disparities in adherence to clinical guidelines, medication prescribing, and use of invasive therapies based on patients’ race/ethnicity have been noted in prior studies.59 A survey-based study of > 700 physicians found that providers were less likely to refer NHB patients to the cardiac catheterization laboratory compared with NHW patients.28 Similarly, NHB patients with MI are less likely to be admitted to facilities with resources for revascularization procedures.29 In addition, NHBs who are taken to the catheterization lab have lower odds of door-to-balloon time < 90 minutes and longer revascularization times compared with NHWs.61

Unfortunately, knowledge of discrimination in health care and its resulting disparities is still low among cardiologists. Findings from a web-based survey of nearly 350 cardiologists found that only one-third of providers agreed that racial disparities existed in cardiac care, merely 12% felt that it was present in their institution, and just 5% felt that their patients were affected by it. Interestingly, physicians caring for NHB and Hispanic patients had an even lower perception of the existence of healthcare disparities.62 Feelings of implicit bias and provider discrimination among the NHB population have been documented to lower their trust in the healthcare system, leading to missed doctor appointments.63

Discrimination is a strong correlate of health and wellness among those who are incarcerated. CVD is the second-leading cause of death in the incarcerated64 population, with a disproportionate impact on racial/ethnic minority populations. Prior evidence suggests worse CVD outcomes in the incarcerated population relative to the nonincarcerated and higher CVD risk in NHBs compared with NHWs.30 However, current knowledge of the long-term impact of incarceration on the cardiovascular health of racial/ethnic minorities is limited and mandates further study.

Community Engagement and Civic Participation

Context

Community engagement encourages community members to plan, design, and implement public health interventions and is an established tool to reduce disparities and inequities in health and health care.65 The concept of civic participation means participating in a variety of community-level activities that foster societal relationships, strengthen social bonds and networks, and improve health and wellbeing—both on individual and community levels.66 Both community engagement and civic participation have beneficial effects on cardiovascular health.

Current Evidence

In the Community Outreach and Cardiovascular Health (COACH) trial, patients with CVD, type 2 diabetes, or hypercholesterolemia were randomized to either enhanced usual care (control arm) or to the intervention arm, which included CVD risk factor management with a nurse practitioner/community health worker.67 The intervention group had significantly higher improvements in total cholesterol, LDL cholesterol, triglycerides, systolic and diastolic blood pressures, and hemoglobin A1c.

The HONU (Heart of New Ulm) is a population-level CVD prevention project that engages a variety of community stakeholders to reduce CVD risk in the community through heart-health screenings, community weight-loss interventions, community health challenges, and a phone counseling program for high-risk residents. The project’s multipronged approach to community engagement over the course of 5 years yielded a significant improvement in a variety of CVD risk factors, including physical activity and daily fruit and vegetable intake.33 Compared with matched controls from a similar community over the span of 7 years, the community at New Ulm had higher rates of blood pressure control, lower triglyceride levels, higher medication compliance (lipid medication and aspirin), and smaller increases in atherosclerotic CVD risk scores.31

Health advocacy by barbers, coupled with medication management by pharmacists, has been shown to be helpful in improving health behaviors in the NHB community.31 In a cohort of 319 NHB males with systolic blood pressure (SBP) ≥ 140 mm Hg, 139 barbershop patrons were assigned to an intervention involving medication management by a pharmacist in the shop (cases) and 180 patrons received lifestyle modification tips and encouragement to set up doctor appointments (controls). At the end of 6 months, mean SBP dropped by 27 mm Hg in cases compared with 9.3 mm Hg in the control group.31,34

Local churches have also been successful in improving community health behaviors. Findings from the Healthy Body Healthy Spirit trial of > 1,000 individuals recruited across 16 churches showed that a combination of standard educational materials, nutritional/physical activity resources, and motivational interviewing (via telephone counseling calls) significantly increased both fruit and vegetable consumption and physical activity.32

Civic participation, such as volunteering, voting, and a variety of group recreational and sporting activities (eg, hockey, soccer, gardening, cleaning, etc.), strengthens existing social networks, increases social cohesion, creates a common sense of goals and purpose, and improves overall health and wellbeing.68 A study of > 7,000 middle-aged and older adults found that greater participation in volunteering activities was associated with 22% lower odds of central adiposity and 26% lower odds of lipid dysregulation. Similarly, another study of > 5,600 middle-aged and older men and women documented a 20% lower risk of hypertension and lower blood pressure levels overall among individuals who reported volunteering.35 Civic participation may also improve overall CVD risk profile by improving physical activity and expanding/strengthening social networks, as documented in a study of Hispanic individuals that found that increased civic participation promoted physical activity, regardless of the size of social networks and awareness of physical activity resources.69

Pathways from CSC to CVD

The theoretical foundations of social support and all four subconstructs are grounded in the social comparison, social exchange, and social competence theories.70 The positive impact of each type of support is facilitated by social networks, social cohesion/community engagement, and the overall psychosocial climate of an individual’s environment.70 These pathways are summarized in Figure 2.

Open in a separate window

Figure 2

Pathways from community and social context (CSC) to cardiovascular disease (CVD). SDOH: social determinants of health.

It is posited that a positive psychosocial climate, including attributes of helpfulness and protection, helps develop social competence, which in turn positively reinforces self-esteem, psychological wellbeing, and the ability to cope with stress.70,71 Social competence further enhances the positive, bidirectional, mutually rewarding association between an individual and the networks that provide social support, ensuring overall “social health”—an important determinant of psychological wellbeing.70,72

Social support and associated constructs influence health outcomes via both physiological and psychological stress response as well as health behaviors.44 Lack of social cohesion and trust have been associated with poor mental health outcomes, and limited social support or weak/small social networks—largely prevalent among disadvantaged groups—are associated with negative emotional states.73 Similarly, the effects of poor social support and/or community engagement might be mediated by poor health behaviors, such as smoking, excessive alcohol consumption, and low physical activity levels.74

The psychological and behavioral responses to unfavorable community/social exposures potentiate harmful physiological responses, such as activated hypothalamic-pituitary-adrenal (HPA) axis and raised levels of inflammatory markers.75,76 For example, acute stress is documented to be associated with raised IL-6 levels in women with low self-reported social support.76 Social isolation and low social support are linked to increased heart rate, blood pressure, and cortisol levels in preclinical studies.77,78 Similarly, poor social support is linked to increased HPA axis reactivity and associated effects, such as increased heart rate and blood pressure.79

Major mechanisms of the discrimination-CVD association include internalized racism and adverse psychological effects (negative emotional state, heightened anticipatory vigilance, psychological distress, etc.), unhealthy coping behaviors, and cumulative psychological and physiological effects of acute and chronic stress.13,54,56 These contribute to elevated blood pressure, decreased insulin sensitivity, and increased coronary artery calcium.80,81 Additional factors at the healthcare level include lack of cultural competence training and implicit provider bias toward racial/ethnic minorities and other disadvantaged population subgroups, with implications for quality of care for marginalized populations and patient trust in the healthcare system.57,58

Additional evidence is needed to understand potential intersectionality among different CSC subdomains. Future studies should also assess how CSC effects are potentially modified via socioeconomic and demographic pathways.

Conclusions

Community and social context affect cardiovascular health via multiple subdomains and diverse pathways. Social support, social cohesion, discrimination, and community engagement and civic participation uniquely determine social networks and social capital, ability to seek and/or provide help, ability to cope with stress, neighborhood trust and strength of social bonds, bias and prejudice, and overall sense of goals and common purpose. In turn, these and related CSC factors shape one’s susceptibility to illness and access to helpful resources, thereby determining individual-, community-, and population-level health outcomes.

The effects of individual CSC subdomains manifest via both upstream (eg, material resources, access/quality of care) and downstream (eg, unhealthy coping behaviors) factors. These constructs impact CVD risk via multiple physiologic, psychosocial, and emotional pathways, including the role of stress as a mediator of increased CVD risk and poor disease outcomes.

The findings of this review are intended to increase awareness of the impact of social and environmental conditions on cardiovascular health and serve as a resource for healthcare providers and health equity champions, both on practice and policy levels. Given the country’s current social and political climate, we are confident that the evidence presented herein will stimulate future discussion on addressing CSC-related inequities in CVD morbidity and mortality, with particular implications for socially disadvantaged communities.

Key recommendations to address major knowledge gaps in the field and advance current understanding of the pathways, mechanisms, and overall effects of CSC were presented in Table 2. Future efforts should focus on developing strategies to incorporate CSC into clinical risk-prediction algorithms and informing CVD prevention and management guidelines and practices.

Table 2

Subdomain-specific research and policy recommendations. CSC: community and social context; CVD: cardiovascular disease; SDOH: social determinants of health.

• Conduct large-scale population-based studies to further elucidate pathways from CSC to CVD.

• Inform community-level social support interventions using evidence from both observational and experimental studies.

• Increase focus on social support-CVD link in disadvantaged populations, including racial/ethnic minorities.

• Develop validated, generalizable measures of social support.

• Future study should focus on increasing understanding of potential moderating effects of race/ethnicity on the social cohesion-CVD relationship.

• Future research should improve understanding of pathways linking social cohesion/networks and CVD, including the role of health behaviors and psychological wellbeing.

• Investigate possible intersectional effects of race/ethnicity and other SDOH, on CVD outcomes.

• Define and develop tools to measure/analyze discrimination and bias in health care.

• Elucidate major physiologic, psychological, and behavioral pathways from perceived discrimination to CVD.

• Improve current understanding of the effects of internalized racism and health behaviors in marginalized populations.

• Develop evidence-based interventions to address health system factors contributing to racial/ethnic disparities in CVD, such as implicit bias and lack of cultural competence.

• Design and implement community-level CVD prevention interventions: identify community leaders and engage relevant stakeholders.

• Document potential variation in civic participation by different sociodemographic factors, including sex and race/ethnicity.

• Describe pathways linking civic participation to improved CVD outcomes.

• Increase representation and participation of underserved communities in community-based CVD prevention programs.

Open in a separate window

Key Points

• Individual and societal relationships are key determinants of health and wellbeing, and high social cohesion is documented to have a strong protective effect on cardiovascular health. Conversely, poor social bonds and weak social networks predict poor cardiovascular health, with a disproportionate impact on vulnerable communities.

• Evidence for a positive effect of social support on cardiovascular disease (CVD) outcomes—including the long-term impact of social support interventions—is lacking and merits greater research, as does evidence to develop a standardized social support measurement tool.

• Racial/ethnic discrimination is linked to both cardiovascular risk factors and adverse CVD outcomes, including hypertension, stroke, and coronary heart disease. Although various pathways explain the link between discrimination and CVD, existing understanding is limited and merits further study.

• Current evidence suggests that community engagement and civic participation promote positive behavioral changes, strengthen social bonds/networks, and exert a protective effect on cardiovascular health.

• Greater civic engagement and representation of marginalized populations in community engagement initiatives is essential to maximizing the benefits of such interventions and improving health outcomes on a population level.

• Medical training must acknowledge and address issues such as cultural competence with the aim of reducing implicit provider bias in clinical decision making.

Funding Statement

Dr. Nasir is on the advisory board of Amgen, Novartis Medicine Company, and his research is partly supported by the Jerold B. Katz Academy of Translational Research.

Funding information

Dr. Nasir is on the advisory board of Amgen, Novartis Medicine Company, and his research is partly supported by the Jerold B. Katz Academy of Translational Research.

Competing Interests

The authors have no competing interests to declare.

References

1. Virani SS, Alonso A, Benjamin EJ, et al. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation. 2020.Mar3;141(9):e139–e596. doi: 10.1161/CIR.0000000000000757 [PubMed] [CrossRef] [Google Scholar]

2. CDC.gov [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; c2021. Heart Disease facts; 2020.Sep8 [cited 2021 Sep 3]. Available from: https://www.cdc.gov/heartdisease/facts.htm#:~:text=Heart%20disease%20is%20the%20leading,1%20in%20every%204%20deaths

3. Rubinstein A, Colantonio L, Bardach A, et al. Estimation of the burden of cardiovascular disease attributable to modifiable risk factors and cost-effectiveness analysis of preventative interventions to reduce this burden in Argentina. BMC Public Health. 2010.Oct20;10:627. doi: 10.1186/1471-2458-10-627 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

4. WHO.int [Internet]. Geneva, Switzerland: World Health Organization; c2021. Global status report on noncommunicable diseases 2014; 2014.Oct26 [cited 2021 Sep 2]. Available from: https://www.who.int/publications/i/item/9789241564854

5. Angermayr L, Melchart D, Linde K. Multifactorial lifestyle interventions in the primary and secondary prevention of cardiovascular disease and type 2 diabetes mellitus--a systematic review of randomized controlled trials. Ann Behav Med. 2010;40(1):49–64. [PubMed] [Google Scholar]

6. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation; 2019.Sep10;140(11):e596–e646. doi: 10.1161/CIR.0000000000000678 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

7. CDC.gov [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; c2021. State Heart Disease and Stroke Prevention Program in Health Care Settings to Prevent Heart Disease and Stroke; 2014.Jul22 [cited 2021 Sept 3]. Available from: https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_state_healthcare.htm

8. Health.gov [Internet]. Washington, DC: US Department of Health and Human Services; c 2021. HealthyPeople 2030: Social Determinants of Health; 2021. [cited 2021 Sep 3]. Available from: https://health.gov/healthypeople/objectives-and-data/social-determinants-health

9. Reblin M, Uchino BN. Social and emotional support and its implication for health. Curr Opin Psychiatry. 2008.Mar;21(2):201–5. doi: 10.1097/YCO.0b013e3282f3ad89 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

10. KFF.org [Kaiser Family Foundation]. San Francisco, CA: Kaiser Family Foundation; c2021. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity; 2018.May10 [cited 2021 Sep 3]. Available from: https://www.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/

11. CDC.gov [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; c2021. Social Determinants of Health. Know What Affects Health; 2021.May6 [cited 2021 Sep 3]. Available from: https://www.cdc.gov/socialdeterminants/index.htm

12. HealthyPeople.gov [Internet]. Washington, DC: US Department of Health and Human Services; c2021. Social Determinants of Health: Explore Resources Related to the Social Determinants of Health; 2021. [cited 2021 Sep 3]. Available from: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources

13. Havranek EP, Mujahid MS, Barr DA, et al. Social Determinants of Risk and Outcomes for Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation. 2015.Sep1;132(9):873–98. doi: 10.1161/CIR.0000000000000228 [PubMed] [CrossRef] [Google Scholar]

14. Gallagher R, Luttik M-L, Jaarsma T. Social support and self-care in heart failure. J Cardiovasc Nurs.Nov-Dec2011;26(6):439–45. doi: 10.1097/JCN.0b013e31820984e1 [PubMed] [CrossRef] [Google Scholar]

15. Wu JR, Frazier SK, Rayens MK, Lennie TA, Chung ML, Moser DK. Medication adherence, social support, and event-free survival in patients with heart failure. Health Psychol. 2013.Jun;32(6):637–46. doi: 10.1037/a0028527 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

16. Kawachi I, Colditz GA, Ascherio A, et al. A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA. J Epidemiol Community Health. 1996.Jun;50(3):245–51. doi: 10.1136/jech.50.3.245 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

17. Berkman LF, Leo-Summers L, Horwitz RI. Emotional support and survival after myocardial infarction: a prospective, population-based study of the elderly. Ann Intern Med. 1992.Dec15;117(12):1003–9. doi: 10.7326/0003-4819-117-12-1003 [PubMed] [CrossRef] [Google Scholar]

18. Williams RB, Barefoot JC, Califf RM, et al. Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease. JAMA. 1992.Jan22-29;267(4): 520–4. [PubMed] [Google Scholar]

19. Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA. 2003.Jun18;289(23):3106–16. doi: 10.1001/jama.289.23.3106 [PubMed] [CrossRef] [Google Scholar]

20. Kim ES, Hawes AM, Smith J. Perceived neighbourhood social cohesion and myocardial infarction. J Epidemiol Community Health. 2014.Nov;68(11):1020–26. [PMC free article] [PubMed] [Google Scholar]

21. Lagisetty PA, Wen M, Choi H, Heisler M, Kanaya AM, Kandula NR. Neighborhood social cohesion and prevalence of hypertension and diabetes in a South Asian population. J Immigr Minor Health. 2016.Dec;18(6):1309–16. doi: 10.1007/s10903-015-0308-8 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

22. Quinn TD, Wu F, Mody D, et al. Associations Between Neighborhood Social Cohesion and Physical Activity in the United States, National Health Interview Survey, 2017. Preventing chronic disease. 2019.Dec19;16. doi: 10.5888/pcd16.190085 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

23. Buckner JC. The development of an instrument to measure neighborhood cohesion. Am J Comm Psych. 1988;16(6):771–791. [Google Scholar]

24. Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violent crime: A multilevel study of collective efficacy. Science. 1997.Aug15;277(5328):918–24. doi: 10.1126/science.277.5328.918 [PubMed] [CrossRef] [Google Scholar]

25. Smith J, Ryan L, Sonnega A, Weir D. Psychosocial and lifestyle questionnaire 2006–2016. Ann Arbor, MI: Survey Research Center, Institute for Social Research. 2017.Jul. [Google Scholar]

26. Everson-Rose SA, Lutsey PL, Roetker NS, et al. Perceived Discrimination and Incident Cardiovascular Events: The Multi-Ethnic Study of Atherosclerosis. Am J Epidemiol. 2015.Aug1;182(3):225–34. doi: 10.1093/aje/kwv035 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

27. Forde AT, Sims M, Muntner P, et al. Discrimination and hypertension risk among African Americans in the Jackson heart study. Hypertension. 2020.Sep;76(3):715–723. doi: 10.1161/HYPERTENSIONAHA.119.14492 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

28. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999.Feb25;340(8):618–26. doi: 10.1056/NEJM199902253400806 [PubMed] [CrossRef] [Google Scholar]

29. Popescu I, Cram P, Vaughan-Sarrazin MS. Differences in admitting hospital characteristics for black and white Medicare beneficiaries with acute myocardial infarction. Circulation. 2011.Jun14;123(23):2710–6. doi: 10.1161/CIRCULATIONAHA.110.973628 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

30. Wang EA, Pletcher M, Lin F, et al. Incarceration, incident hypertension, and access to health care: findings from the coronary artery risk development in young adults (CARDIA) study. Arch Intern Med. 2009.Apr13;169(7):687–93. doi: 10.1001/archinternmed.2009.26 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

31. Victor RG, Lynch K, Li N, et al. A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops. N Engl J Med. 2018.Apr5;378(14):1291–1301. doi: 10.1056/NEJMoa1717250 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

32. Resnicow K, Jackson A, Blissett D, et al. Results of the healthy body healthy spirit trial. Health Psychol. 2005.Jul;24(4):339–48. doi: 10.1037/0278-6133.24.4.339 [PubMed] [CrossRef] [Google Scholar]

33. Benson G, Sidebottom AC, Sillah A, et al. Population-level changes in lifestyle risk factors for cardiovascular disease in the Heart of New Ulm Project. Prev Med Rep. 2019.Jan31;13:332–340. doi: 10.1016/j.pmedr.2019.01.018 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

34. Sidebottom AC, Sillah A, Vock DM, et al. Assessing the impact of the heart of New Ulm Project on cardiovascular disease risk factors: A population-based program to reduce cardiovascular disease. Prev Med. 2018.Jul;112:216–221. doi: 10.1016/j.ypmed.2018.04.016 [PubMed] [CrossRef] [Google Scholar]

35. Burr JA, Tavares J, Mutchler JE. Volunteering and hypertension risk in later life. J Aging Health. 2011.Feb;23(1):24–51. doi: 10.1177/0898264310388272 [PubMed] [CrossRef] [Google Scholar]

36. Driscoll A. Carnegie’s community-engagement classification: Intentions and insights. Change: The Magazine of Higher Learning. 2008;40(1):38–41. [Google Scholar]

37. CDC.gov [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; c2021. Agency for Toxic Substances and Disease Registry: Principles of Community Engagement - Second Edition; 2015.Jun25 [cited 2021 Sep 3]. Available from: https://www.atsdr.cdc.gov/communityengagement/index.html

38. Ahmed SM, Palermo A-G S. Community engagement in research: frameworks for education and peer review. Am J Public Health. 2010.August;100(8):1380–7. doi: 10.2105/AJPH.2009.178137 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

39. Cobb S. Presidential Address—1976. Social support as a moderator of life stress. Psychosom Med.Sep-Oct1976;38(5):300–14. doi: 10.1097/00006842-197609000-00003 [PubMed] [CrossRef] [Google Scholar]

40. Thurston RC, Kubzansky LD. Women, loneliness, and incident coronary heart disease. Psychosom Med. 2009.Oct;71(8):836–42. doi: 10.1097/PSY.0b013e3181b40efc [PMC free article] [PubMed] [CrossRef] [Google Scholar]

41. ClinicalTrials.gov [Internet]. Bethesda, MD: US National Library of Medicine; c 2021. Enhancing Recovery in Coronary Heart Disease (ENRICHD) Patients; 2016.Apr14 [cited 2021 Sep 3]. Available from: https://clinicaltrials.gov/ct2/show/study/{"type":"clinical-trial","attrs":{"text":"NCT00000557","term_id":"NCT00000557"}}NCT00000557

42. Kawachi I, Berkman L. Social cohesion, social capital, and health. In: Berkman LF, Kawachi I, editors. Social Epidemiology. New York, NY: Oxford University Press; 2000. p. 147–190. [Google Scholar]

43. HealthyPeople.gov [Internet]. Washington, DC: US Department of Health and Human Services; c2021. Social Cohesion; 2021. [cited 2021 Sep 3]. Available from: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/social-cohesion

44. Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium. Soc Sci Med. 2000.Sep;51(6):843–57. doi: 10.1016/s0277-9536(00)00065-4 [PubMed] [CrossRef] [Google Scholar]

45. Choi YJ, Matz-Costa C. Perceived neighborhood safety, social cohesion, and psychological health of older adults. Gerontologist. 2018.Jan18;58(1):196–206. doi: 10.1093/geront/gnw187 [PubMed] [CrossRef] [Google Scholar]

46. Fan C, Jiang Y, Mostafavi A. Emergent social cohesion for coping with community disruptions in disasters. J R Soc Interface. 2020.Mar;17(164):20190778. doi: 10.1098/rsif.2019.0778 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

47. Strully KW, Fowler JH, Murabito JM, Benjamin EJ, Levy D, Christakis NA. Aspirin use and cardiovascular events in social networks. Soc Sci Med. 2012.Apr;74(7):1125–9. doi: 10.1016/j.socscimed.2011.12.033 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

48. Lauder W, Mummery K, Jones M, Caperchione C. A comparison of health behaviours in lonely and non-lonely populations. Psychol Health Med. 2006.May;11(2):233–245. doi: 10.1080/13548500500266607 [PubMed] [CrossRef] [Google Scholar]

49. Shelton RC, McNeill LH, Puleo E, Wolin KY, Emmons KM, Bennett GG. The association between social factors and physical activity among low-income adults living in public housing. Am J Public Health. 2011.Nov;101(11):2102–2110. doi: 10.2105/AJPH.2010.196030 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

50. Valtorta NK, Kanaan M, Gilbody S, Ronzi S, Hanratty B. Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart. 2016.Jul1;102(13):1009–16. doi: 10.1136/heartjnl-2015-308790 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

51. Kershaw KN, Osypuk TL, Do DP, De Chavez PJ, Diez Roux AV. Neighborhood-level racial/ethnic residential segregation and incident cardiovascular disease: the multi-ethnic study of atherosclerosis. Circulation. 2015.Jan13;131(2):141–8. doi: 10.1161/CIRCULATIONAHA.114.011345 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

52. Neergheen VL, Topel M, Van Dyke ME, et al. Neighborhood social cohesion is associated with lower levels of interleukin-6 in African American women. Brain Behav Immun. 2019.Feb;76:28–36. doi: 10.1016/j.bbi.2018.10.008 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

53. Smedley BD, Stith AY, Nelson AR, editor. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; c2003. doi: 10.17226/12875 [CrossRef] [Google Scholar]

54. Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med. 2009.Feb;32(1):20–47. doi: 10.1007/s10865-008-9185-0 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

55. Yearby R. The impact of structural racism in employment and wages on minority women’s health. Hum Rts. 2018.Mar18;43(3):21. [Google Scholar]

56. Brewer LC, Cooper LA. Race, discrimination, and cardiovascular disease. Virtual Mentor. 2014.Jun1;16(6):270–4. doi: 10.1001/virtualmentor.2014.16.06.stas2-1406 [PubMed] [CrossRef] [Google Scholar]

57. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017.Mar1;18(1):19. doi: 10.1186/s12910-017-0179-8 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

58. Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc. 2008.Nov;100(11):1275–85. doi: 10.1016/s0027-9684(15)31505-4 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

59. Mody P, Gupta A, Bikdeli B, Lampropulos JF, Dharmarajan K. Most important articles on cardiovascular disease among racial and ethnic minorities. Circ Cardiovasc Qual Outcomes. 2012.Jul1;5(4):e33–41. doi: 10.1161/CIRCOUTCOMES.112.967638 [PubMed] [CrossRef] [Google Scholar]

60. Cené CW, Roter D, Carson KA, Miller ER, Cooper LA. The effect of patient race and blood pressure control on patient-physician communication. J Gen Intern Med. 2009.Sep;24(9):1057–64. doi: 10.1007/s11606-009-1051-4 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

61. Cavender MA, Rassi AN, Fonarow GC, et al. Relationship of race/ethnicity with door-to-balloon time and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: findings from Get With the Guidelines-Coronary Artery Disease. Clin Cardiol. 2013.Dec;36(12):749–56. doi: 10.1002/clc.22213 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

62. Lurie N, Fremont A, Jain AK, et al. Racial and ethnic disparities in care: the perspectives of cardiologists. Circulation. 2005.Mar15;111(10):1264–9. doi: 10.1161/01.CIR.0000157738.12783.71 [PubMed] [CrossRef] [Google Scholar]

63. Greer TM. Perceived racial discrimination in clinical encounters among African American hypertensive patients. J Health Care Poor Underserved. 2010.Feb;21(1):251–63. doi: 10.1353/hpu.0.0265 [PubMed] [CrossRef] [Google Scholar]

64. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison—a high risk of death for former inmates. N Engl J Med. 2007.Jan11;356(2):157–65. doi: 10.1056/NEJMsa064115 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

65. O’Mara-Eves A, Brunton G, Oliver S, Kavanagh J, Jamal F, Thomas J. The effectiveness of community engagement in public health interventions for disadvantaged groups: a meta-analysis. BMC Public Health. 2015.Feb12;15:129. doi: 10.1186/s12889-015-1352-y [PMC free article] [PubMed] [CrossRef] [Google Scholar]

66. Abbott S. Social capital and health: The role of participation. Soc Theory Health. 2010;8(1):51–65. doi: 10.1057/sth.2009.19 [CrossRef] [Google Scholar]

67. Allen JK, Dennison-Himmelfarb CR, Szanton SL, et al. Community Outreach and Cardiovascular Health (COACH) Trial: a randomized, controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers. Circ Cardiovasc Qual Outcomes. 2011.Nov1;4(6):595–602. doi: 10.1161/CIRCOUTCOMES.111.961573 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

68. Kim S, Kim C-y, You MS. Civic participation and self-rated health: a cross-national multi-level analysis using the world value survey. J Prev Med Public Health. 2015.Jan;48(1):18–27. doi: 10.3961/jpmph.14.031 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

69. Marquez B, Gonzalez P, Gallo L, Ji M. Latino Civic Group Participation, Social Networks, and Physical Activity. Am J Health Behav. 2016.Jul;40(4):437–45. doi: 10.5993/AJHB.40.4.5 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

70. Langford CPH, Bowsher J, Maloney JP, Lillis PP. Social support: a conceptual analysis. J Adv Nurs. 1997.Jan;25(1):95–100. doi: 10.1046/j.1365-2648.1997.1997025095.x [PubMed] [CrossRef] [Google Scholar]

71. Integrating Social Support in Nursing Integrating Social Support in Nursing M. j. Stewart SAGE 246pp £12.95 0-8039-4274-5. Nurs Stand. 1994.Jul20;8(43):40. doi: 10.7748/ns.8.43.40.s57 [PubMed] [CrossRef] [Google Scholar]

72. Stevens ES. Reciprocity in social support: An advantage for the aging family. Fam Soc. 1992;73(9):533–541. 10.1177/104438949207300903 [Google Scholar]

73. Wang J, Mann F, Lloyd-Evans B, Ma R, Johnson S. Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review. BMC Psychiatry. 2018.May29;18(1):156. doi: 10.1186/s12888-018-1736-5 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

74. Steptoe A, Kivimäki M. Stress and cardiovascular disease. Nat Rev Cardiol. 2012.Apr3;9(6):360–70. doi: 10.1038/nrcardio.2012.45 [PubMed] [CrossRef] [Google Scholar]

75. Uchino BN, Cacioppo JT, Kiecolt-Glaser JK. The relationship between social support and physiological processes: a review with emphasis on underlying mechanisms and implications for health. Psychol Bull. 1996.May;119(3):488–531. doi: 10.1037/0033-2909.119.3.488 [PubMed] [CrossRef] [Google Scholar]

76. Puterman E, Epel ES, O’Donovan A, Prather AA, Aschbacher K, Dhabhar FS. Anger is associated with increased IL-6 stress reactivity in women, but only among those low in social support. Int J Behav Med. 2014.Dec;21(6):936–45. doi: 10.1007/s12529-013-9368-0 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

77. Shively CA, Clarkson TB, Kaplan JR. Social deprivation and coronary artery atherosclerosis in female cynomolgus monkeys. Atherosclerosis. 1989.May;77(1):69–76. doi: 10.1016/0021-9150(89)90011-7 [PubMed] [CrossRef] [Google Scholar]

78. Sapolsky RM, Alberts SC, Altmann J. Hypercortisolism associated with social subordinance or social isolation among wild baboons. Arch Gen Psychiatry. 1997.Dec;54(12):1137–43. doi: 10.1001/archpsyc.1997.01830240097014 [PubMed] [CrossRef] [Google Scholar]

79. Steptoe A, Owen N, Kunz-Ebrecht SR, Brydon L. Loneliness and neuroendocrine, cardiovascular, and inflammatory stress responses in middle-aged men and women. Psychoneuroendocrinology. 2004.Jun;29(5):593–611. doi: 10.1016/S0306-4530(03)00086-6 [PubMed] [CrossRef] [Google Scholar]

80. Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet. 2007.Sep22;370(9592):1089–100. doi: 10.1016/S0140-6736(07)61305-1 [PubMed] [CrossRef] [Google Scholar]

81. Panza GA, Puhl RM, Taylor BA, Zaleski AL, Livingston J, Pescatello LS. Links between discrimination and cardiovascular health among socially stigmatized groups: A systematic review

What does social and community context mean?

Which topics are key issues in social and community context as a social determinant of health?

What are the determinants of community health?

What are the social factors that influence community health?