Impacts of Financial Hardship on Cardiovascular Health; Implications of Debt, Socioeconomic Status, and Social Dynamics/Ethnicity

Introduction 

Cardiovascular Diseases (CVDs) were the leading causes of death from 1990 to 2015, with an estimated 17.9 million deaths worldwide [1]. CVDs consist of all diseases that affect the heart, including coronary heart disease, heart failure, angina, and stroke. Diabetes and physical inactivity are commonly known risk factors for CVDs, along with excessive smoking and poor diet. Psychosocial studies have uncovered associations between everyday aspects of life and physical health, especially relating to depression and stress. Social dynamics cause stress to be experienced in different ways, leading to a variety in physical manifestations. Research has shown that depression is a risk factor for CVDs [2], but the individual experiences that have a possibility of causing poor mental health were not explored, limiting these findings. This review will cover research on the impacts of socioeconomic status, debt, social dynamics, and ethnicity on cardiovascular health, as these are correlated with detrimental cardiovascular health issues. This research is needed to provide evidence for future policies in order to reduce CVD mortality in high-risk populations. 

Socioeconomic Status

Socioeconomic status (SES) is a term used by sociologists to describe a person’s income, job, and education, and has been correlated with CVD risk [3]. Within the United States, wage inequality is steadily increasing, with the top 90% of earners having 13.53 times more income than the bottom 10% of earners [4]. Abdalla et al. analyzed the prevalence of CVDs by income in 2010 from the National Health and Nutrition Examination Survey (NHANES) for participants aged 20 years and older. The researchers found that a higher income and access to resources predicted a lower prevalence of CVD mortality and a lower risk of chronic heart failure and stroke [5]. As the prevalence of stroke and heart attack decrease within the highest-resources population, the risk of CVD mortality in the lower-resources population increases [5]. Thus, the trends in CVDs are not the same for all groups. Similarly, Hassen et al. analyzed data from the SHARE (Survey of Health, Ageing and Retirement in Europe) study of adults in Belgium and France aged 50 and older between the years 2011 and 2017. The data from this study showed that being classified as high income had a percent outcome of 7.0% of CVD. Adults who were classified as having middle or lower income had outcomes of 10.3% and 12.1% for CVD, respectively [6]. As income decreased, the risk of CVD increased, as indicated by CVD frequency in lower income earners. Both Hassen et al. and Abdalla et al. show that despite analysis of different age ranges, income is inversely proportional to CVD risk and mortality. Therefore, due to the visible effect income and SES have on CVD risk, this issue should be targeted by community representatives in the health sector by promoting reputable finance management companies along with providing equitable resources for income relief for those in need.

Education

In addition to the findings about income, education level is inversely proportional to the likelihood of CVD, especially when there is an absence of a high school or general education diploma [5]. Therefore, further research is being conducted to analyze the effects of educational level on heart health. Educational level can provide greater access to higher paying wages, in turn increasing access to health resources, such as quality health insurance, while decreasing the risk of mortality [7]. Ge et al. utilized data from China Patient-centred Evaluative Assessment of Cardiac Events-Prospective Heart Failure Study (China PEACE 5p-HF Study) to explore the association of education with heart failure mortality in hospitals. Low education is classified as being below primary school, while high education is above the high school level. Patients who were classified as being in the low educational level had a heart failure (HF) mortality rate of 20.2%, while those in the high educational level had a mortality rate of 13.7% after hospital admission. Hospital readmission was also the highest for the patients with a lower income (less than ¥10,000 annually) and low education [8]. Both studies indicate that across different countries and populations, higher educational levels decrease the risk of CVDs and mortality. Moreover, low education levels reduce job accessibility and health status education, potentially preventing patients from managing their overall health and accessing quality healthcare.

Debt

High amounts of debt and financial stress affect both physical and mental health, and are significantly correlated with the possibility of CVD in high-risk groups. Unsecured debt, like car or home loans, often have higher interest rates because of the high risk for the lender, which increases the stress of repayment for the loanee. According to the 2021 Experian data, between 23-25% of Americans are debt free, with mortgage and student loans being the top two sources of debt [9, 10]. Batomen et al. analyzed the data from the PSID survey and identified relationships between education, unsecured debt, and incident of death from CVDs. Participants with a high school diploma or lower had higher amounts of unsecured debt, accounting for wealth and income. Furthermore, participants within the highest quartile of unsecured debt had a 54% and 69% increase in death and occurrence of hypertension/coronary heart disease (CHD) respectively [11]. Similarly, Frech et al. discussed how unsecured debt increases the prevalence of inflammation, pain interference (PI), and stiffness. PI is a measure of how much pain impacts everyday activities (physical, emotional, cognitive, and social). The occurrence of PI and stiffness was logged for participants from the National Longitudinal Study of Youth, and the data showed a strong correlation with unsecured debt. Respondents at age 50 who had unsecured debt for a significant amount of their life reported more pain than those who did not have debt [12]. Both studies detailed the effects of unsecured debt on physical health through the analysis of prevalence of disease or pain. Additionally, researchers in both studies acknowledge the effects that chronic stressors, such as debt, have on mental health. Batomen et al. shows that household debt is a predictor of worse psychological health, which in turn relates to Frech et al.’s statement that worrying about repayment would increase anxiety and mental health problems [11, 12]. High financial burden can lead to depressive symptoms and poor mental health, affecting the physical health of participants in these studies. Debt is correlated to an array of effects on physical health and emotional stress, supporting the data that points to stress and CVD being especially prevalent in marginalized groups.

Student Debt 

Financial strain is not limited to mortgage, credit, or auto debt, as student debt has also been seen to be correlated to cardiovascular health. Recent research has aimed to analyze the effect of student debt on cardiovascular health in adults within the United States. Student debt has more than tripled in the past 15 years, increasing an approximate 211% according to the U.S Department of Education. In the Federal Student Aid Portfolio Summary, the total student loan debt in 2007 was $516 billion and increased to $1620.9 billion in Q1 of 2024 [13]. The effects of this stark increase in student debt can be seen in the cardiovascular health of Americans today. Using data from the National Longitudinal Study of Adolescent to Adult Health, Lippert et al. 2022 assessed CVD risk and C-reactive protein (CRP) assay scores from participants of the study. CRP assay scores numerically visualize inflammation and chronic stress and indicate possible disease within the body. Individuals who consistently had student debt had higher CVD risk scores than those who never had debt, whereas respondents who paid off their debt had lower risk scores than those who never had debt [14]. Additionally, CRP values for respondents who took on debt or were in continuous debt were significantly higher than other respondents who either paid their debt or never had debt [14]. This data indicates that there are both cardiovascular benefits and disadvantages associated with acquiring student debt. CVD risk and inflammation is exacerbated by loans and lower education, which agrees with the previously mentioned study done by Abdalla et al. However, student debt can also be acquired by pursuing higher education, where degree completion can lead to better accessibility to higher wages and better health education/insurance. Yet, unfavorably, this student debt accumulation adds a significant amount of mental stress, in turn affecting heart health and increasing CVD occurrence in the economically disadvantaged. 

Social Dynamics and Ethnicity

Even after taking into account confounding variables, an increase in CVD mortality is seen across different racial/ethnic, age, and education groups globally, providing researchers with more questions about potential influences on heart health. Socially isolated populations show an increase in CVD as a result of social behaviors related to SES. Social behaviors like isolation and job stress can be influenced by SES due to not having enough time outside of work to connect with others in their community or family. A lack of social relationships is shown to have negative effects on health, including an increase in inflammation and decrease in mental health [15]. The effects of social behaviors on the cardiovascular health of individuals, especially in high-risk populations, is a problem that is seen internationally. In both Belgium and France, older adults were found to have decreased social networks and support compared to their younger counterparts. The evidence showed that a lower supportive environment is correlated with CVD risk in older participants [6] and although old age is a determinant for CVD, it can also be seen in younger populations. Vasan et al. found that higher loneliness in young adults is associated with arterial stiffness, an indicator that accompanies poor cardiovascular health [16]. Similarly, Moran et al. provided evidence that a low SES is tied to self-isolation (due to a lack of financial resources) which in turn increases CVD mortality [17]. Comparably, Ge et al. found that those with an unpartnered status had a higher mortality rate than partnered individuals. Despite this finding, researchers noted that the effects of partner status on CVD mortality is lower in China than in Western countries due to cultural differences. Multiple generations can be living in one household, providing additional support to CVD patients and limiting the effect of a deficit in spousal and social support [8]. Social relationships impact a CVD patient’s ability to recover, and lead to a lower risk of readmission and mortality.

Aside from social relationships, the risk of heart attack and coronary heart disease within the United States has been shown to vary by ethnic group. Researchers O’Rand and Hamil-Luker analyzed data from the Health and Retirement Study (HRS) between 1999 and 2014, grouping participants based on generation. The researchers used data from two cohorts in the HRS panel to compare the risk of heart attack between White and Black interviewees. The study found that Black Boomers (born between 1946 and 1964) had a high positive association of heart attack with household and unsecured debt, while their White counterparts had a lower risk of heart attack as housing debt increased [18]. Moreover, the results from the HRS study showed that despite controlling for SES factors, household debt did not equally affect heart attack percentages in Black and White participants. Despite acquiring similar amounts of debt, 57% and 65% of Black participants in the respective Prewar and Baby Boomer cohort were taking blood pressure medication, compared to 36% and 42% of White respondents in the same cohorts [18]. Moreover, not only do Black Americans have a higher risk of heart attack, but they also have an increased risk of coronary heart disease (CHD) which is a common form of CVD. Moran et al. used data from the longitudinal Jackson Heart Study and assessed financial stress and the occurrence of CHD. Participants in this study who had moderate to high amounts of financial stress had a higher incidence of CHD when assessing socioeconomic status [17]. Both O’Rand and Hamil-Luker 2020 and Moran et al. 2019 support the conclusion that CVD risk is uniquely affected by financial stress and strain within the African American community. They also both provide evidential support for future interventions that aim to educate about loan types and forgiveness programs to mitigate the effects of psychological stress correlated with finances within high-risk populations. 

Conclusion 

The purpose of this review was to examine the effects of financial stress on the physical body, using data that considers socioeconomic factors like income, education, debt, and ethnicity. Current research has shown that SES variables and debt are associated with an increase in inflammation correlated with the stress of financial hardship. Moreover, data has shown that individuals that are at a high risk of diminished cardiovascular health by financial hardship are more prominent in minority groups like the African-American population and those without social support. The studies used in this review were observational, so causation was not concluded from the data. Future studies could strengthen the correlation by initiating a study in which CVD prevalence is assessed in medically high-risk populations within income, education, and job type. Research analyzing the effects of financial support programs on cardiovascular health would be beneficial in supporting future policies that aim to lower CVD mortality.

About the Author: Idara Mfon Udoisa

Idara is a 3rd year Human biology major interested in pursuing a career in medicine and patient advocacy. Her minor in public health exposed her to the variety of focuses that are within medicine. Cardiovascular disease and debt are matters that impact the community she grew up in, furthering her interests in the connection between mental and physical health. She hopes to tie in her experience as a Certified Nursing Assistant for high risk populations and this review of cardiovascular health to create a source for community members and advocate for public health policies that support loan forgiveness and financial relief programs. She also recently joined UC Davis’ Imani Clinic in order to further give back to a local community, and focus on patient outreach and health literacy.

Author's Note

I wrote this review article as an assignment for my UWP 102B class. At first I did not know which topic to choose, but my interest in public health and advocacy lead me to look towards issues that affect the communities that I grew up in. Cardiovascular disease and student debt are not matters I thought would have any connection with each other, but the more I looked into how mental health is affected by outside factors, the more I became interested in how recent research about financial hardship has looked into the long-term influences on physical health. I hoped to provide a source for both community members and advocate for public health policies that support loan forgiveness and financial relief programs!

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