Publication date: Jul 26, 2025

This study investigated social determinants of cardiovascular disease mortality (CVD) and effect modification by race/ethnicity, age, and sex, before and during the COVID-19 pandemic, in Californians aged ≥18 years. The Healthy Places Index (HPI) is a composite of 23 indicators of neighborhood economic conditions, education, transportation, housing, social capital, environmental pollution, built-environment, and access to health care. In this cross-sectional study, 615,295 CVD deaths were aggregated to 2010 census tracts from death certificates and populations from U. S. census, 2015-2021. Death rates were age-adjusted and stratified by HPI deciles, sex, and race/ethnicity, and segmental regression was used to describe HPI-CVD dose-response. CVD mortality rates in 2015 to 2019 were inversely associated with HPI and declined 5. 4% per HPI decile. The rate ratio between the 1 and 10 decile (reference) was 1. 77 (CI: 1. 71-1. 83) for all CVD, 2. 24 (CI: 2. 12-2. 36) for ischemic heart disease, 2. 01 (CI: 1. 84-2. 2) for hypertensive heart disease, and 1. 41 (CI: 1. 30-1. 52) for stroke. The pre-pandemic HPI-CVD mortality gradient was unaltered in the pandemic period (2020-2021). Differences in mortality rates between the highest and lowest HPI decile within race/ethnicity groups were larger than differences between race/ethnicity groups. The HPI-attributable fraction of CVD mortality was 0. 28. The pandemic did not change pre-existing disparities in CVD mortality associated with social determinants of health. There are untapped opportunities to integrate area-based socioeconomic measures in public health surveillance and population health monitoring in healthcare, and to reinforce policies and programs that reduce CVD health inequities.

Semantics

Original Article