Understanding the social determinants of cardiovascular health in Asian Americans

American Heart AssociationSep 16 2024

Numerous social and structural factors, including immigration status, socioeconomic position and access to health care, contribute to differences in cardiovascular health and heart disease risk for Asian Americans, and these factors affect Asian ethnic subgroups in different ways, according to a new scientific statement published today in the American Heart Association's journal, Circulation.

This AHA scientific statement, "Social Determinants of Cardiovascular Health in Asian Americans," highlights the evidence for the role of social determinants of health in cardiovascular health among Asian American adults and identifies future directions for research to advance health equity for the Asian American population and reduce health disparities in these communities.

Asian Americans are the fastest growing racial group in the United States, with a population projected to reach up to approximately 46 million by 2060. According to the U.S. Census Bureau, Asian Americans will represent more than 10% of the total U.S. population at that time.

However, Asian Americans remain persistently underrepresented as participants in medical research. Previous studies have found that Asian Americans are less willing to participate in health research compared to other racial/ethnic groups. Research conducted exclusively in English may also result in underrepresentation of Asian American individuals with lower English proficiency from different Asian ethnic subgroups.

"Due to the small numbers of Asian Americans recruited in research studies, even when Asian American participants are included, they are frequently combined into a single 'Asian' category or grouped with Native Hawaiian and Pacific Islander communities, which results in the masking of clinically relevant differences in health among subgroups of people of Asian descent," said Chair of the statement writing group Nilay S. Shah, M.D., M.P.H., FAHA, an assistant professor of cardiology and preventive medicine at Northwestern University's Feinberg School of Medicine in Chicago.

As of 2021, the six largest Asian origin ethnic groups in the U.S. were Chinese, Indian, Filipino, Vietnamese, Korean and Japanese Americans. People of other Asian ethnic groups, such as Pakistani, Thai or Cambodian descent, are less often identified in research studies, limiting understanding of health status in these populations.

Asian American ethnic groups should be individually identified, since each sub-group represents a unique population with distinct social, cultural and health characteristics. There are several social factors that uniquely influence health behaviors and disease risk in individual Asian ethnic groups, including reasons for immigration, socioeconomic position and differences in health care access and utilization."

Nilay S. Shah, M.D., M.P.H., FAHA, assistant professor of cardiology and preventive medicine, Northwestern University's Feinberg School of Medicine

Immigration status and structural racism

Immigration policy, citizenship status and legal documentation are widely recognized as important social determinants of health for people immigrating to the U.S. including people from Asia.

Historically, Asian American immigrants have faced structural racism and anti-Asian prejudice resulting in policies restricting immigration into the U.S. The 1882 Chinese Exclusion Act restricted immigration and citizenship based solely on national origin, and Executive Order 9066 led to the unjust, forced incarceration of Japanese Americans during World War II in 1942.

Differences in histories and reasons for migration and resettlement may contribute to suboptimal heart health. For example, Bhutanese, Burmese, Cambodians, Hmong, Laotians and Vietnamese people have frequently arrived in the U.S. as refugees. Refugees are more likely to experience chronic stress due to being exposed to war, violence, hunger and trauma, which may worsen heart health. Real and perceived discrimination may also influence cardiovascular health by leading to increased stress, poor sleep habits, and other suboptimal health behaviors.

Asian Americans without documented immigration status often lack employer-based health insurance. Non-U.S. citizens also have limited access to federal and state health insurance programs, which may contribute to disparities in health outcomes. In addition, lack of health insurance and concerns about immigration status can limit access to timely health care and may also deter individuals from seeking preventive care for cardiovascular risk factors.

Socioeconomic and social factors

Due to the socioeconomic diversity of Asian communities, there are substantial differences in the physical and social characteristics of neighborhoods in which Asian Americans live. The complex interplay of social determinants of health, including social support, neighborhood walkability and access to nutritious foods, influence cardiovascular health and contribute to differences across ethnic groups.

While the Asian American population overall is relatively a high-income group, there are significant differences within individual ethnic groups. In 2019, median annual household income ranged from approximately $44,000 per year in Burmese Americans to $119,000 per year among Indian Americans (compared to the average of $85,800 for all Asian Americans).

Employment status in the U.S. is frequently related to health insurance coverage, residence in resource-rich neighborhoods and housing stability. A nationally representative survey of Asian Americans from 10 ethnic backgrounds found that adults who were employed were more likely to report having better health.

In addition, Asian Americans with less than a high school education were 73% less likely to have ideal heart health compared to those with college degrees. A potential explanation is that people employed in low-wage occupations, such as in the service and food industries, may experience greater discrimination and have fewer benefits and employee protections.

Previous research has found that food insecurity, defined as limited or uncertain access to adequate amounts of food, and nutrition security, which refers to the availability, accessibility and affordability of healthy foods, are associated with increased overweight and obesity, type 2 diabetes and cardiovascular mortality in all communities. In the wake of the COVID-19 pandemic, estimates for food insecurity increased by approximately 25% for Vietnamese American adults and 53% for Filipino American adults.

Acculturation, or the process of adapting to a different culture, also affects heart disease risk factors in people who immigrate to the U.S. For example, greater availability and consumption of processed and fast foods and more sedentary lifestyles are known risk factors associated with higher rates of obesity.

Differences in health access and literacy

Asian Americans, especially those not born in the U.S., often experience difficulty in accessing health care services, inadequate health communication between clinicians and patients, cultural differences in health-related beliefs and discrimination in the health care system.

Prior research suggests that gaps in health insurance coverage within some Asian American subgroups, such as Korean and Vietnamese Americans, may be attributable to high rates of employment in occupations that less often provide health insurance coverage, such as jobs in the construction, maintenance or transportation industries, working for a small business or being a small business owner.

English proficiency varies considerably among Asian ethnic groups in the U.S. Limited English proficiency may impact cardiovascular health by preventing patients from adequately reporting symptoms or health concerns. In addition, insufficient use of interpretation/translation services may prevent health care professionals from adequately understanding and addressing health concerns in Asian Americans with limited English proficiency.

Health literacy, or knowledge about health services, also varies across Asian American ethnic groups. Limited health literacy can negatively affect the use of preventive care and/or following medical instructions and taking medications as prescribed. Asian immigrants may also gravitate towards traditional, complementary or alternative medicine practices common in Asian countries, such as acupuncture or herbal therapies.

Shah said, "All of these social determinants of health are likely interrelated, and the cumulative impact of these structural and social risk factors contributes to suboptimal cardiovascular health in Asian Americans. There is an urgent need to understand these challenges and address them with effective prevention strategies to help improve their long-term cardiovascular health. Achieving health equity in this rapidly growing population will require multi-level interventions that target the key factors influencing cardiovascular health and account for the unique experiences within individual Asian subgroups."

The scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association's Prevention Science Committee of the Council on Epidemiology and Prevention and the Council on Cardiovascular and Stroke Nursing; the Council on Hypertension; the Council on Lifestyle and Cardiometabolic Health; the Council on Basic Cardiovascular Sciences; the Council on Clinical Cardiology; the Council on Peripheral Vascular Disease; and the Council on Quality of Care and Outcomes Research. American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association's official clinical practice recommendations.

Co-authors are Vice Chair Stella Yi, Ph.D., M.P.H.; Namratha R. Kandula, M.D., M.P.H.; Yvonne Commodore-Mensah, Ph.D., M.H.S., R.N., FAHA; Brittany N. Morey, Ph.D., M.P.H.; Shivani A. Patel, Ph.D., M.P.H.; Sally Wong, Ph.D., R.D., FAHA; and Eugene Yang, M.D., M.S.