So many things go into making up “population well-being” — healthy or unhealthy behaviors, physical and social environment, financial security, access to green spaces, readily available healthy food…the list goes on. Public health researchers, using validated holistic measures, have shown strong associations of population well-being with health outcomes, lower rates of hospitalizations and emergency department and hospital use, and greater use of preventive services.
But is population well-being associated with cardiovascular disease mortality?
Indeed it is, according to a cross-sectional study of 514,971 participants conducted by Erica Spatz, M.D., and colleagues from Yale. In fact, the association was independent of structural factors, such as socioeconomic status, and population health metrics, such as rates of hypertension, diabetes, obesity, and physical inactivity. Moreover, population well-being mediated the association of structural factors with cardiovascular disease mortality.
Erica Spatz, M.D., M.H.S.
In the study, the primary outcome was the county-level rate of total cardiovascular disease mortality; secondary outcomes were mortality rates for stroke, heart failure, coronary heart disease, acute myocardial infarction and total heart disease.
Areas with higher measures of community, social, financial, and “sense of purpose” well-being, and with greater life satisfaction had lower rates of cardiovascular death. The association held for each well-being element and for five types of CVD mortality, although the primary associations were with death from heart disease.
Mortality rates for CVD declined from a mean of 499.7 deaths per 100,000 people in counties in the lowest quintile of population well-being to 438.6 in those with the highest population well-being. Secondary outcomes showed similar patterns. After adjusting for structural factors and structural-plus-population health factors, the association was “attenuated but still significant,” with 73 fewer deaths per 100,000 people for each 1-point increase in well-being.
The most significant elements of well-being were financial and community health, the researchers found.
“We know that CVD mortality is associated with individual level socioeconomic status, cardiometabolic risk factors, and positive and negative psychological attributes,” say Spatz and colleagues.
But those individual-level factors don’t account for all the variation in cardiovascular disease outcomes in a population. A broader view of the population’s well-being that is not “merely the absence of negative factors but also the facilitation of positive factors,” they note, “can open up opportunities for communities to improve cardiovascular outcomes through the promotion of well-being.”
Higher well-being is a “measurable, modifiable, and meaningful outcome,” Spatz and colleagues argue, and the fact that it was associated with lower CVD mortality indicates that well-being may be a focus of advancing cardiovascular health.