RUHS Journal of Health Sciences, Volume 5 Number 2, April–June 2020 Review Article

Social Determinants of Cardiovascular Diseases: An Indian Perspective

Rajeev Gupta1, Indu Mohan2 1Chairman, Academic Research Development Unit, Rajasthan University of Health Sciences, and Department of Preventive Cardiology and Internal Medicine, Eternal Heart Care Centre and Research Institute; 2Assistant Professor, Department of Community Medicine, Mahatma Gandhi Medical College, Jaipur, Rajasthan, DOI:10.37821/ruhsjhs.5.2.2020.317

ABSTRACT increased. The average per capita income has increased many-folds. Some Indians are among the richest persons of Socioeconomic factors are the major determinants of the world. The World Bank has reclassified the country health. Role of these factors has been known for centuries from low-income to low-middle income group of nations. in context of general well being. However, their importance This indicates increase in gross national income, per capita in context of non-communicable disease, specifically, income and expenditure, and economic development cardiovascular diseases has not been highlighted until indices. recently. These factors include social disorganization, adverse early life events, poor life course social gradient, unemployment, stressful environment at work, low social support and cohesion, unhealthy dietary habits, poverty, illiteracy, social exclusion, and individual health behavi- ours including smoking. In the developed countries studies on social factors started in middle of last century and presently, they are recognised as factors of fundamental importance. In this review, we list socioeconomic factiors of importance, describe association of social factors with chronic illnesses and focus on social determinants of cardiovascular risk factors and diseases. We also Figure 1: Social and economic “development” and rise and summarize studies in India that have highlighted role of fall of cardiovascular diseases. social factors, especially low education status, with increasing cardiovascular diseases. And finally, we suggest Health parameters have also changed- Indians are living measures to build a healthy society to tackle the epidemic longer, maternal, neonatal and infant mortality rates have of cardiovascular diseases in our country. declined significantly, childhood vaccination rates have INTRODUCTION increased, and some infectious diseases such as smallpox and poliomyelitis have been eliminated. Concurrently, the India is changing rapidly. In the last seventy years, there disease patterns have also changed. From predominantly has been a significant change in social, economic and communicable, nutritional, maternal, and childhood political scenario in the country. Societies have changed for causes of morbidity and mortality in the last century, there the better; there is more egalitarianism and better has been a shift to preponderance of non-communicable inclusiveness. Societal fabric of the country has evolved diseases as major causes of disability and deaths.1 Major from predominance of feudalism to democracy. non-communicable diseases which are important causes of Marginalised groups are moving towards the mainstream. mortality are cardiovascular diseases, chronic respiratory Economic prosperity and societal well-being has also diseases, cancer, diabetes, and injuries. Depression and 105 RUHS Journal of Health Sciences, Volume 5 Number 2, April–June 2020

Table 1: Important socioeconomic factors in chronic diseases Macro-level factors - Index of social/human development - Social status and societal disparities - Social support systems - Measures of income inequality and disparities - Area based measures (urban, rural, slums, etc) - Measures of living conditions - Healthcare service delivery Micro-level individual factors - Individual level social gradient - Life span social class - Social exclusion - Stress - Early life events - Employment status and working conditions - Unemployment - Social support - Addiction including tobacco and alcohol - Food - Transport - Education - Cardiovascular risk factors Smoking, abnormal lipid levels, hypertension, diabetes - Adherence to lifestyles and other treatments - Secondary and tertiary prevention treatments availability and compliance cardiovascular diseases are major causes of morbidity.1 improvement in social conditions in which people live and Emergence of non-communicable diseases as major causes decline of communicable and nutritional diseases. This of mortality and morbidity is due to social and economic review shall focus on social determinants of chronic changes that cause disease transition from communicable diseases, mainly cardiovascular diseases (coronary heart to these diseases. Similar changes occurred in countries of disease and stroke). We shall summarize the substantial Europe and North America more than fifty years ago. We international data on this subject and present data from hypothesised that these changes are “price-to-pay” of only a few Indian studies available on this subject. socioeconomic development although better development Implications of social determinants of cardiovascular leads to decline in these diseases as has happened in many diseases on healthcare policies, health economics, and high income countries in Europe and North America inpatient care are also highlighted. 2 (Figure 1). Social Factors: Health and Chronic Illnesses Social determinants of health are crucial for population Multiple social factors are involved in well-being of the health. Long before scientific advances are made and reach society and individual.3 These are listed in table 1. The the general public, social changes are important causes of factors range from macro-level social issues such as disease rise and fall. For example, tuberculosis decline national and state level policies to individual or micro-level predated development of effective chemotherapy by factors such as education and health literacy. All these decades and was due to better incomes and living factors lead to greater illnesses among low socioeconomic conditions. Rheumatic heart disease decline in the western status subjects. These include social disorganization, world happened long before the advent of penicillin (for adverse early life events, poor life course social gradient, treatment of streptococcal chest infection) or cardiac unemployment, stressful environment at work, poor public surgery (for treatment of established valvular heart transport, low social support and cohesion, unhealthy disease). There is a significant relationship between

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Figure 2: Social determinants as underlying causes of all non-communicable diseases dietary habits, poverty, social exclusion, and individual unstable migration, better incomes, and also provides health behaviours other than smoking. Indeed social coping abilities. Educational status has been used the most determinants are the major underlying causes of all non- in cardiovascular epidemiological studies as marker of communicable diseases.4,5 socioeconomic status as it is stable after early childhood Multiple parameters could be used to assess socio- and least influenced by social changes or illness in 6 economic status. These include trans generational factors adulthood. We have previously reported that in India (genetic and epigenetic factors), in-utero factors, tracking educational level correlates significantly with occupation, 7 of standard risk factors beginning from infancy to housing, neighbourhood measures, and social status. adulthood and others.3 Education is a summary measure of Similar associations have been reported in other studies 3,4,8-10 early life experiences as higher parental education from India and other low income countries. In the India promotes maternal dietary adequacy and child literacy, Heart Watch study, we reported a significant relationship of leads to better and stable occupation, less chances of highest attained educational levels with self-perceived

Figure 3: All-cause mortality in US population according to household income (1972-1989).

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Figure 4: Relative inequalities in the rate of death from any cause in men and women in selected European countries. Y-axis shows relative risk of all cause mortality in lowest v/s highest education quintile. socioeconomic status (Kendall's tau-B, men=0.15, mortality as compared to countries with high inequalities women=0.15, p<0.001), as well as occupational class (tau- (e.g., Lithuania, Poland, and Hungary). The trends were B, men= 0.35, women= 0.31, p<0.001).11 similar for men and women.12 Social class as the most important determinant of all-cause Po and Subramanian13 reported relationship of household mortality has been highlighted in many studies in high income quintiles and all-cause mortality in Indian Human income countries. Issacs and Schroeder10 reported that Development Survey, 2004-2005 (Figure 4). More than when US population was classified according to household 217,000 individuals were prospectively studied. Indivi- income quintiles, the adjusted odds ratios for all-cause duals were classified into quintiles of household income. mortality were three times greater for subjects with income At every age-group, the mortality was greater in the bottom <15,000 US$ as compared to income >70,000 US$ (Figure quintile of income as compared to the highest. Similar 2). In Europe, countries were classified according to degree relationship was found with other measures of income such of social inequality and educational and occupational as household wealth and monthly consumption. status (Figure 3). Those with low inequalities (e.g., Pednekar et al14 reported association of educational status Sweden, Norway, and Denmark) had lower all-cause (as a marker of socioeconomic status) with all-cause 108 RUHS Journal of Health Sciences, Volume 5 Number 2, April–June 2020

Figure 5: Household income quintiles and all-cause mortality in India Human Development Survey (2004-05). There is a significant direct correlation of mortality with increasing poverty at all age-groups; differences are most marked in the younger age-groups. mortality. In this prospective study of more than 148,000 subjects compared to the middle and high socioeconomic subjects, the age-adjusted all-cause mortality was 45-50% subjects.5,6,9,18 In India, specific social and economic groups lower in men and women with the highest educational who are more vulnerable to greater chronic disease, status as compared to the illiterate (Figure 5). especially cardiovascular disease, mortality need further Association of low socioeconomic status with mortality studies. and morbidity from other chronic non-communicable Social Determinants and Cardiovascular Risks diseases such as cancer and chronic respiratory diseases are also well reported in the high and middle income countries In socioeconomically primitive societies, chronic disease although data from India are sparse.15 In the Million Death risk factors such as smoking, physical inactivity, obesity, Study performed in all regions of India by the Registrar hypertension, hypercholesterolemia, and diabetes are more 3 General of India, cancer mortality was significantly greater in high socioeconomic status. With social and economic in low income states and regions (central India and the development and ongoing epidemiological transition in north-east) as compared to others.16 Tobacco related these countries, the risk factors became more prevalent 4 cancers of mouth and oesophagus were the largest group among the lower socioeconomic status subjects. For and were predominantly observed in low socioeconomic example, in UK at middle of the twentieth century groups. Similar data have also been reported for chronic cardiovascular diseases and cardiovascular risk factors respiratory disease mortality in India.17 were more common in upper and middle social classes as compared to the lower. Reduction of risk factors among the A very large body of data are available from high and higher social classes, mostly due to greater awareness and middle income countries and consistently show that better treatments, led to decline in cardiovascular disease mortality from non-communicable chronic diseases is two- incidence and mortality in these groups. In the lower to three-times greater among the low socioeconomic status

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Figure 6: Age-adjusted hazard rates of all cause mortality with increasing educational status in Mumbai. In this prospective study of more than 148,000 men and women, a significant decline is observed with increasing educational status in both men and women. socioeconomic groups, the risk factors did not change, prospective studies in North America, Western Europe, and decline of cardiovascular mortality was absent or slow and other high income countries.6,18 5 cardiovascular diseases became more common. Myriad of studies from high and middle income countries Inverse association of multiple socioeconomic factors with have reported greater prevalence of smoking, non-smoked cardiovascular disease mortality as well as cardiovascular tobacco use, obesity, hypertension, and hypercholes- risk factors has been well described from Europe and North terolemia in low socioeconomic status subjects.6,21,22 America.6 One of the first descriptions of the inverse Educational status has been the most frequently used association of socioeconomic status with incidence of criteria in USA and it was repeatedly demonstrated that low coronary mortality was reported from Evans County Heart educational status subjects had not only greater cardio- Study in the US in late 1960's. In this cross sectional study, vascular risk factors but also greater cardiovascular the prevalence of coronary heart disease was similar in all morbidity and mortality.6 In USA, time trends in the socioeconomic groups but in the prospective phase the cardiovascular mortality patterns show that cardiovascular 7-year incidence of coronary mortality among labourers disease based disparities are increasing among the less and unemployed workers was twice of the professionals.19 educated subjects.10 The rate of decline of cardiovascular The Whitehall study among London civil servants mortality was significantly greater among the most literate evaluated relationship of employment status with cardio- subjects as compared to the least literate. Reasons for this vascular events in 1980's.20 Coronary heart disease difference include issues of access, affordability, mortality was 3.6 times higher in the lowest than in the top compliance to treatments, greater smoking and unhealthy grades. Similar findings have been reported from large diets, and lower rates of physical activity. 110 RUHS Journal of Health Sciences, Volume 5 Number 2, April–June 2020

Figure 7: Cardiovascular Framingham Risk Score among men and women in different educational status groups (ES) in Jaipur. Risk scores are significantly greater in low and middle educational groups (men p=0.045, women p=0.011).

Evidence in India Delhi (1980's), it was reported that metabolic cardio- vascular risk factors such as obesity, hypertension, high Influence of socioeconomic status on non-communicable cholesterol, and diabetes were greater in higher socio- disease risk factors, especially cardiovascular risk factors, economic groups as compared to the poor.23,24 The magni- has not been well studied in India. Epidemiological studies tude of excess was about 1.5-2.0 times greater in high v/s in mid- and late twentieth century reported greater low socioeconomic groups. These and other contemporary cardiovascular risk factor prevalence among the higher studies, also reported higher prevalence of smoking and social classes. In studies from Chandigarh (1960's) and tobacco use among low socioeconomic groups, the overall

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Figure 8: Case-control studies of educational status or socioeconomic status and incident acute coronary syndromes in India. Studies from urban locations (Bangalore, Delhi, INTERHEART) reported that acute coronary events were 2-5 times more frequent in those at lowest educational quartile as compared to the highest. 11121 RUHS Journal of Health Sciences, Volume 5 Number 2, April–June 2020

Figure 9: The causal chain of cardiovascular diseases. Social factors such as income and education are important upstream determinants of cardiovascular pathophysiological pathway. impression was greater prevalence of risk factors, cardiovascular risk factors (smoking, non-smoked tobacco especially cardio-metabolic, among the high socio- use, alcohol, and hypertension) among the illiterate economic groups.23-25 No studies were available that subjects in India was in rural Rajasthan.7 In this study, 1982 evaluated cardiovascular mortality among different rural adult men and women were evaluated for prevalence socioeconomic groups. of various cardiovascular risk factors. Socioeconomic Studies at the turn of twentieth century reported greater status was judged according to level of education, which is prevalence of smoking, hypertension, and in some studies, important marker of social status and correlated well with 7 hypercholesterolemia among the illiterate and subjects better occupation and better living conditions. It was with low socioeconomic (educational) status. One of the observed that illiterate men had greater prevalence of first studies that reported greater prevalence of multiple smoking and hypertension while obesity was more among

Figure 10: 30-day risk-factor adjusted cardiovascular mortality according to socioeconomic status in the CREATE registry in India. RUHS Journal of Health Sciences, Volume 5 Number 2, April–June 2020

Figure 11: Interventions to modify social determinants of health are the basis for all prevention activities (primordial, primary, and secondary) in cardiovascular diseases. the more literate. Biochemical factors were not evaluated. risk factors such as smoking, non-smoked tobacco use, and Another study among Indian industrial populations from high visible fat intake was greater in low educational status eight locations reported greater prevalence of multiple subjects, but cardio-metabolic risk factors such as low behavioural cardiovascular risk factors (smoking, non- HDL cholesterol, high triglycerides, and metabolic syn- 11 smoke tobacco use, low fruits and vegetables consumption, drome also were more in low educational status subjects. and alcoholism) among the less literate subjects while These studies indicate an ongoing epidemiological metabolic risk factors (obesity, high cholesterol, and transition in India and suggest that in the near future the risk diabetes) were more in the higher educational groups.26 factor transition that has occurred in high and middle

Studies in Jaipur urban population reported similar income countries shall also happen in India. The cardio- findings.27 Jaipur Heart Watch-2 study also reported higher vascular risk factors (both behavioural and cardio- Framingham Risk Score (composite of age, smoking, metabolic) shall become more frequent among low socio- hypertension, hypercholesterolemia, and diabetes) among economic classes and cardiovascular diseases shall be a the illiterate and low educational status subjects disease of the poor. (Figure 6).28 Case-control studies in urban populations in India have More recent studies, one in rural Andhra Pradesh (Andhra reported greater incidence of acute coronary syndromes Pradesh Rural Health Initiative)29 and another large among those at lower end of educational quintiles as nationwide study in urban middle-class populations in 11 compared to the highest (Figure 8). The first study that 11 reported such an association was a small case-control study cities (India Heart Watch), have also reported greater 30 prevalence of behavioural risk factors in low socio- in Bangalore in early 1990's. Subsequently larger studies economic groups (classified according to socioeconomic in Delhi and the INTERHEART-South Asia study reported 31,32 scale, education or occupation). The Andhra Pradesh study similar findings. The association was not significant in 33 reported greater prevalence of cardio-metabolic risk rural Maharashtra patients. A case-control study at factors in the more literate subjects.29 The India Heart Bikaner among the premature coronary heart disease Watch in urban subjects reported that not only behavioural patients also did not report significant differences in

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Figure 12: Suggested interventions for tackling social determinants of . various educational groups.34 included more than 20,000 patients from 89 centres in 38 Mumbai Cohort Study was conducted in late 1990's and India, mostly urban. The prospective data showed that early 2000's. In this study more than 148,000 men and one-month mortality was significantly greater among the women were recruited at baseline and then followed up for low socioeconomic classes (Figure 10). Among the poor as 5 years for all-cause and cardiovascular mortality.14 compared to the risk, the risk factor unadjusted 30-day Cardiovascular mortality was significantly greater in the mortality was 1.6 times greater while the risk factor lower educational classes (socioeconomic groups). adjusted mortality was 1.5 times (socioeconomic classi- Cardiovascular mortality was 40-60% lower in men and fication was based on a physician validated socioeconomic women with the highest educational status as compared to score). The difference in mortality was almost entirely illiterate and those with less than primary level of explained by lower use of more expensive investigations education. Similar trends were reported in the nationwide (blood biomarkers) and medical therapies (thrombolysis Million Death Study.35 and drugs such as statins or ACE inhibitors) and surgical interventions. This study shows that low socioeconomic WHO has included markers of socioeconomic status subjects are at increased risk of dying after an acute (education and income) as critical mediators in coronary syndrome mainly due to low use of treatments. cardiovascular disease pathophysiology (Figure 9).36 There Delayed access to care was also an important finding in this are multiple pathways through which these social factors study. increase the cardiovascular (coronary heart disease) risk. These include influence on smoking, tobacco, alcohol and Thus, the current evidence shows that social factors are fat intake, physical activity, and overweight. All these important determinants of cardiovascular risk factors as factors influence more proximate cardiovascular risk well as coronary heart disease and cardiovascular mortality factors such as blood pressure, cholesterol, and . In urban as well as rural populations, behavioural and lead to increased ischemic heart disease. Other cardiovascular risk factors such as smoking, non-smoked important determinants of increased risk of mortality are tobacco use, low fruits and vegetables intake, and high access to medical care as well as poorer quality of care visible fat intake are more in low socioeconomic status 37 subjects. In urban populations, the cardio-metabolic risk among the low socioeconomic classes. factors are more among the lower socioeconomic classes. The CREATE registry of acute coronary syndromes There is evidence that cardiovascular mortality (especially 114 RUHS Journal of Health Sciences, Volume 5 Number 2, April–June 2020 coronary heart disease) is more in low socioeconomic class in focus from curative to promotive health is required. subjects. In metropolitan cities, such as Mumbai, those There has to be amalgamation and proper overview of with low educational status (low socioeconomic status) public (governmental) and private (non-governmental) have greater cardiovascular mortality. However, there is sectors of healthcare services for any significant impact on still a dearth of data on association of socioeconomic status the overall health and cardiovascular health of the country. with cardiovascular risk factors, incidence and mortality in Similar interventions have been suggested by the US most regions of India. Studies are also required to Institute of Medicine.43 determine associations of specific social characteristics Conclusion with cardiovascular risks and outcomes. Social determinants are the most important factors in Building a Healthy Society health and disease. In India, non-communicable diseases There is convincing evidence that interventions to improve such as cardiovascular diseases and cancer are emerging as the social determinants of health are essential for control of important problems. Factors such as social disorgani-- cardiovascular diseases.5,36,39 Also in India40,41 horizontal zation, adverse life course social gradient, unemployment, integration of policies to influence human and social stressful environment at work, social exclusion, low social development indices is essential and a strong political will support and cohesion, unhealthy dietary habits and is required to change (Figure 11). smoking, and poverty are important factors. Social policies The WHO Commission of Social Determinants of Health directed to alleviate poverty, illiteracy and social published its final report in 2008.36 The Commission's disparities are also important. Population wide interven- overreaching recommendations were (i) improve living tions are the “best-buy” for improving cardiovascular conditions, (ii) tackle the inequitable distribution of power, health of the country. Studies in India show that cardio- money and resources; and (iii) measure and understand the vascular diseases and risk factors are rapidly increasing problem and assess the impact of action. Three principles and all socioeconomic classes are vulnerable. Lack of of action were suggested: public funded preventive and curative healthcare has placed low socioeconomic groups at greater risk of morta- 1. Improve the conditions of daily life- the circumstances 37,39 in which people are born, grow, live, work, and age; lity from chronic diseases. There is need to focus on social factors to improve health, especially cardiovascular 2. Tackle the inequitable distribution of power, money, health. More multidimensional pathophysiological, opera- and resources- the structural drivers of those condi- tional and outcomes-research is required in this area. tions of daily life- globally, nationally and locally; 3. Measure the problem, evaluate action, expand the REFERENCES know-ledge base, develop a workforce that is trained 1. India State Level Disease Burden Collaborators. Nations in the social determinants of health, and raise public within a nation: Variations in epidemiological transition awareness about the social determinants of health. across the states in India 1990-2016, in the Global Burden of Disease Study. Lancet. 2017; 390:2437-60. We have listed a large number of items that are required to tackle the social determinants of cardiovascular disease in 2. Gupta R, Gupta KD. 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