Socioeconomic
Indicator Profile
Socioeconomic status refers to the absolute or relative levels of economic resources, power, and prestige closely associated with wealth of an individual, community, or country. Socioeconomic status is a multidimensional construct comprising multiple factors, such as income, education, employment status, and other factors.
Low socioeconomic status is associated with higher risk of developing and dying from cardiovascular disease (CVD). Specifically, the American Heart Association notes that income level, educational attainment, and employment status at the individual and neighborhood level are consistently associated with CVD in high-income countries. Socioeconomic factors can affect health status directly at the individual level and can also influence broader household, neighborhood, or community-level characteristics, which can then affect health.
Socioeconomic factors affect one’s ability to engage in health activities, afford medical care and housing, and manage stress. For example, employment provides income, which enables access to housing, education, childcare, food, medical care, and other needs. At the community level, lower-income neighborhoods are less likely to have access to high quality health care.
Socioeconomic factors can also interact with or confound relationships between other variables and health. For example, the combined effects of socioeconomic status and race/ethnicity or sex can influence health differently across different groups.
Indicators
This document provides guidance for measuring five indicators related to socioeconomic factors that are associated with differential risks of developing CVD. The five socioeconomic indicators are measured at different levels of analysis, including city, county, and state.
Education
Why is this indicator relevant?
Education is strongly associated with life expectancy and morbidity. Research has shown that by the age of 25, a college graduate is expected to live a decade longer than a high school dropout. Many studies, including a meta-analysis of hypertension research, have observed that lower levels of education are associated with a greater risk of CVD than higher levels of education are. For instance, one study showed that for men who completed graduate school, the likelihood of developing heart disease was 42%, compared with 59% for men who completed grade school only (the difference was statistically significant). Among women, the likelihood of developing heart disease was 28% for those who completed graduate studies, compared with 50% for women completing grade school only. Similarly, low educational attainment is an independent predictor of adverse outcomes for patients with coronary artery disease. Moreover, persistent racial disparities in educational attainment contribute to racial differences in heart disease mortality.
Education plays an important role in health through its influence on multiple socioeconomic factors, such as employment, income, and other economic opportunities. Individuals with lower levels of educational attainment are more likely to lack sociopolitical power and economic resources, leading to adverse occupational, residential, and recreational conditions associated with negative health consequences. These adverse conditions lead to differential exposures to stressors (e.g., unemployment, crime, violence) and fewer resources (e.g., recreation, physical activities) to cope with the accumulation of stressors that contribute to a greater risk of hypertension.
School policies and exclusionary discipline practices, such as suspensions and expulsions, are applied unfairly by educators and have been shown to have a disproportionately negative impact on Black/African American children’s academic achievement. Exclusionary school discipline practices hinder educational attainment and exacerbate socioeconomic and health inequities. In addition to hindering academic achievement, expulsions and suspensions are correlated with substance use and worse mental health and social connectivity, which are risk factors for adverse health behaviors among adolescents, such as early sexual initiation; alcohol, tobacco, and drug use; violent behaviors; and gang involvement. These adverse health behaviors in turn increase the risk of adverse health outcomes, including CVD.
Employment Status
Why is this indicator relevant?
Employment status (whether an individual is working to earn wages) is consistently identified as an indicator of socioeconomic status strongly associated with health outcomes. Employment status affects health through both physical and psychosocial pathways. Employees may be exposed to hazardous physical, chemical, or biological agents from the occupational setting. Unstable employment can lead to loss of compensation and employee benefits (e.g., health insurance), creating psychosocial stress. In the United States, health care is accessed through predominantly employer-sponsored health insurance plans. Loss of employment results in loss of health care insurance coverage. The short-term unemployed tend to experience the greatest barriers to health care access, as they may not be able to take advantage of public benefits. Even in cases where individuals may qualify for public insurance assistance through the Consolidated Omnibus Budget Reconciliation Act (COBRA) or other public programs, the copayments and deductibles are often too costly for those with reduced or no steady income. The long-term unemployed and those not able to work may be eligible for Medicaid. Those who are self-employed also experience barriers to health care, as individual insurance plans are often not as comprehensive as employer-sponsored plans. Barriers to health care access due to loss of employer-sponsored health coverage are associated with reduced health care utilization and unfavorable health outcomes, including CVD.
Beyond the impact of employment status on access to health insurance, employment type may directly affect the risk for heart disease. In a recent meta-analysis, shift work, including rotational and night shift work, was associated with a 26% increased risk of coronary heart disease (CHD) morbidity and an approximately 20% increased risk of CHD and CVD mortality. Increased risk develops after 5 years of shift work and increases 7.1% for every 5 additional years of shift work. The association seems to be strongest for rotating shift schedules (i.e., people work a mix of irregular day and night hours) rather than fixed day- or night-only shifts. Causal factors include disruptions to circadian rhythms and poor health behaviors associated with shift work.
Income
Why is this indicator relevant?
The relationship between income and health is well established. Households with incomes below the federal poverty level (annual income thresholds set by the federal government to determine financial eligibility criteria) have high levels of illness and premature mortality. Individuals with lower incomes lack economic resources, resulting in social disadvantage, poor education, poor working conditions, housing insecurity, and residence in unsafe neighborhoods. These negative environmental and psychosocial factors affect behavioral and physiological pathways that have proximal effects on health, including increased morbidity and mortality. The United States has experienced a rise in income inequality, with widening racial gaps in wealth. For every dollar of wealth that White households have, Asian, Hispanic/Latino, and Black/African American households have 83 cents, 7 cents, and 6 cents, respectively. It is estimated that in the United States, the gap in life expectancy between the top 1% of wage earners and the bottom 1% is 14.6 years for men and 10.1 years for women. Moreover, over the past few decades’ life expectancy has increased among the wealthiest 20%, while the remaining 80% have not experienced any gains in life expectancy.
A growing body of evidence points to income-based disparities in CVD. One study found that the richest 20% of study participants had healthier levels of biomarkers for cardiovascular disease, including body mass index, systolic blood pressure, and high-density lipoproteins relative to the poorest 80% of participants. Individuals with lower incomes are more likely to experience adverse psychosocial factors that can induce a physiological stress response, resulting in higher circulating levels of catecholamines, higher cortisol levels, and increased blood pressure, which are all risk factors for CVD.
Food Insecurity
Why is this indicator relevant?
Food insecurity, defined as the disruption of food intake or eating patterns due to insufficient financial resources and other resources, is closely related to income and unemployment and is widely recognized as a risk factor for chronic diseases, such as hypertension, coronary heart disease (CHD), hepatitis, stroke, cancer, asthma, diabetes, arthritis, chronic obstructive pulmonary disease (COPD), and kidney disease. In 2020, it was estimated that 10.5% of U.S. households experienced food insecurity, and the prevalence of food insecurity was notably higher for single-parent households and Black/African American and Hispanic/Latino households.
Food insecurity negatively affects health and increases the risk for CVD through three pathways: unhealthy nutrition; monetary trade-offs; and psychological distress. First, food insecurity is associated with poorer diet quality, which may lead to metabolic dysregulation, fat accumulation, or insulin resistance. Second, relieving and mitigating food insecurity often involves monetary trade-offs between purchasing food or medication that may severely limit people’s ability to manage chronic conditions properly. Third, food insecurity is strongly associated with psychological distress, lower self-efficacy, and depressive symptoms, triggering physiological stress responses (e.g., elevated cortisol levels) and unhealthy coping behaviors (e.g., excessive drinking, smoking, drug use).
Housing Insecurity
Why is this indicator relevant?
Housing insecurity is commonly defined as high housing cost relative to income, but it also has been used as an umbrella term to describe multiple housing issues, such as poor housing quality, unstable occupancy, overcrowding, and unsafe neighborhoods. Housing-insecure adults are more likely to delay medical care and utilize emergency care, have poorer health care access, experience adverse mental health outcomes, and have higher prevalence of substance use than individuals with stable housing do.
Eviction and foreclosure are associated with exposure to violence, depression, anxiety, increased alcohol use, psychological distress, and suicide. Housing insecurity can be linked to CVD risk and related mortality due to downstream consequences of psychological distress and competing stressors (i.e., spending on housing rather than medical care). Increased exposure to secondhand smoke is common in low-income and public housing. Secondhand smoke interferes with the normal functioning of the heart, blood, and vascular systems; damages the lining of blood vessels; and causes blood platelets to become stickier, which increases the risk of heart attacks, strokes, and development of coronary heart disease. Cardiotoxic air pollutants from poor-quality homes are also associated with increased risk for CVD.
Homeownership offers stable housing and is a protective factor for mental health. Homeowners report higher self-esteem and happiness than renters and people experiencing housing insecurity, results that could reduce stress, a common risk factor for cardiovascular health. Homeownership is also associated with better psychosocial health, such as reduced burden of depression.
All information obtained on this page is from the Centers for Disease Control and Prevention.