Psychosocial Pathways

Indicator Profile

Psychosocial pathways are the ways in which social, cultural, and environmental factors influence an individual’s mind and behavior.^1,2 This concept focuses on the intersection and interaction of individual-level factors such as mental well-being and stress, with social factors such as social networks and support systems.

Psychosocial factors, such as occupational stress, social support or isolation, sleep quality, and mental health, are shaped by racial, economic, and other societal structures. For example, unemployment and loss of income may lead to increased stress and feelings of worthlessness, which then affect health through lifestyle or behavioral changes (e.g., less healthy eating, increased drinking or smoking) or through neurological changes. Psychosocial pathways refer to both the indirect influence of psychosocial factors on health through behavior modifications and the direct impact on health via psychoneuroendocrine changes.³

Table of Contents

Indicators

Case Example

References

Indicators

This document provides guidance for measuring seven indicators related to psychosocial pathways that influence risk for developing or the ability to manage cardiovascular disease (CVD). The seven psychosocial pathway indicators are measured at different levels of analysis, including individual, census tract, county, and state.

Access to Mental Health Care

Why is this indicator relevant?

Health care access is a public health issue, because many Americans lack the physical or financial resources to receive the health care services they need. Mental health care access is challenging due to the scarcity of mental health services and the social stigma associated with mental health.⁴ One indicator of mental health care access is the extent to which mental health care is available in a geographic area.

In the United States, more than half of Americans are diagnosed with a mental illness or disorder during their lifetime, yet nearly 30% of the population live in a county designated as a Mental Health Professional Shortage Area (MHPSA).^5,6 MHPSAs are areas where the ratio of mental health providers (e.g., psychiatrists, clinical social workers, therapists) to residents is 1 to 30,000 or less.⁷ A National Violent Death Reporting System study between 2005 and 2010 (n = 57,877 suicides) compared adult decedents who received any or no mental health treatment within 2 months before death. Results suggest that having access to mental health services improves diagnosis and may prevent deaths by suicide.⁸ Low availability of mental health services at the county level is also linked to negative health outcomes. Mental health shortage areas have higher county-level suicide rates, and individuals with serious mental illnesses living in shortage areas are more likely to be admitted to the hospital.^9,10

Mental disorders play a role in multiple aspects of the pathogenesis of CVD and other chronic noncommunicable diseases. They independently confer an adverse prognosis for CVD mortality and death from all causes and directly impair quality of life.¹¹

This indicator can be assessed by the following measure. Click on the measure to learn more:

Measure 1: City and County Minimum Wage
Definition	The population size compared with the number of mental health providers. It represents the number of individuals one physician serves in a county, if the population were equally distributed across physicians. The value on the right side of the ratio is always 1 or 0. A 1 indicates that there is at least one mental health provider in the county; 0 indicates that there are no registered mental health providers in the county.
Data Availability	County, state Subgroups: Gender
Data Source(s)	County Health Rankings & Roadmaps (CHR&R): CHR&R is a program of the University of Wisconsin Population Health Institute. The CHR&R program provides data, evidence, guidance, and examples to build awareness of the multiple factors that influence health and support leaders in growing community power to improve health equity. CHR&R uses the Centers for Medicare & Medicaid Services (CMS) National Provider Identification (NPI) data to provide county-level estimates of the ratio of a population to mental health providers. The ratio represents the number of individuals served by one mental health provider in a county, if the population were equally distributed across providers. Users can access this measure under Ranked Measures > Health Factors > Clinical Care > Mental Health Provider. Data are downloadable as an Excel workbook, and years of data availability vary by state.
Additional Measurement Considerations	This measure does not consider availability of telehealth psychological services. Mental health care availability metrics should be interpreted alongside mental health care needs. It is important to consider the level of need in a community as some unhealthy areas may have high health care availability due to high need for health services.

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Adverse Childhood Experiences (ACEs)

Why is this indicator relevant?

Research over the past decade has pointed to the cumulative and long-lasting impact of childhood experiences and early life factors on adult health status. ACEs refer to traumatic events and severe or chronic stress occurring during childhood (ages 0–17), including abuse (physical, emotional, and sexual), neglect (emotional and physical), and household dysfunction (parental mental health illnesses, household substance abuse, violence between parents or caregivers, incarcerated family member, and parental separation or divorce).¹² Exposure to stressful and traumatic events during childhood disrupts normal psychosocial development and may lead to the development of mental health disorders and negative coping strategies such as smoking, overeating, and physical inactivity, all of which are risk factors for CVD.^13,14 Moreover, prolonged stress in childhood alters biological functioning in stress regulatory pathways, leading to negative stress responsivity in adulthood.¹⁵

Low social economic status, early life stress, and ACEs are linked to the development of poor health behaviors, hypertension, and increased risk for ischemic heart disease and CVD.1^6,17,18,19 A seminal CDC-Kaiser Permanente study on ACEs found a strong dose–response relationship between childhood exposure to abuse, neglect, and dysfunction and multiple risk factors for several of the leading causes of death, including alcoholism, smoking, drug abuse, severe obesity, and physical inactivity.²⁰ The study also found a graded relationship between ACEs and conditions such as ischemic heart disease, cancer, chronic lung disease, and liver disease.²¹

The life course perspective has been increasingly incorporated into cardiovascular health strategies. In a scientific advisory, the American Heart Association stated that “cardiovascular health is being lost from childhood through young adulthood” and declared that “we must improve the distribution of cardiovascular health levels across the population by preserving cardiovascular health from childhood and by treating health risk behaviors to help more individuals improve their cardiovascular health into older ages.”²²

Adverse childhood experiences (ACEs) are traumatic events and severe or chronic stress that occur during childhood (ages 0–17), including abuse (physical, emotional, and sexual), neglect (emotional and physical), and household dysfunction (parental mental health illnesses, household substance abuse, violence between parents or caregivers, incarcerated family member, and parental separation or divorce). This indicator can be assessed by the following measure. Click on the measure to learn more:

Measure 1: City and County Minimum Wage
Definition	Potentially traumatic events that occur in childhood (before age 18) and include abuse, neglect, as well as parental mental illness, substance use, divorce, incarceration, and domestic violence.
Data Availability	Individual, State
Data Source(s)	Behavioral Risk Factor Surveillance System (BRFSS): CDC’s BRFSS is a state-level, multistage-cluster sampling telephone survey of U.S. residents that collects data on self-reported demographics, health behaviors, and preventive health practices. The ACE module is an optional module (states elect to add optional modules to the state questionnaire) that assesses child abuse, neglect, and household challenges. The ACE questionnaire was adapted from the original CDC-Kaiser Permanente ACE study.²³ The ACE module was added in 2009, and years of data availability will vary by state. Questionnaires and data are available for download. Example Survey Instrument The following survey instrument is available to measure ACEs: Family Health History Questionnaire The Family Health History Questionnaire was used to collect information on child abuse and neglect, household challenges, and other sociobehavioral factors in the original CDC-Kaiser Permanente ACE Study. The landmark ACE study was conducted at Kaiser Permanente from 1995 to 1997 across 17,000 health maintenance organizations. The study questionnaire assesses childhood experiences in two dimensions (abuse/neglect and household stressors) and captures 10 categories of ACE: emotional, physical, and sexual abuse; physical and emotional neglect; parental separation or divorce; and household substance abuse, mental illness, domestic violence, and criminal activity. The full questionnaire has more than 64 questions and is available through CDC’s Violence Prevention website. Search for “Study Questionnaire” at the link below. Link: https://www.cdc.gov/violenceprevention/aces/about.html ACE Questionnaire for Adults The ACE Questionnaire for Adults is a screening tool designed to help primary care clinicians assess risk for toxic stress and guide effective responses to ACE. The screening tool captures 10 different categories of ACE by asking respondents 10 yes or no questions. The screener was adapted from the original CDC-Kaiser Permanente ACE study²⁴ by the Office of the California Surgeon General and Department of Health Care Services in consultation with the California Surgeon General’s Clinical Advisory Subcommittee. The full questionnaire is available in 17 languages through the ACEs Aware website. Link: https://www.acesaware.org/learn-about-screening/screening-tools/screening-tools-additional-languages/

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Mental Health Disorders

Why is this indicator relevant?

Mental health refers to emotional, psychological, and social well-being; mental health disorders refers to conditions affecting cognition, emotion, and behavior (e.g., schizophrenia, depression, autism).²⁵

Certain racial/ethnic groups, women, and individuals who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual, or other sexual orientations (LGBTQIA+) are disproportionately affected by mental health issues due to greater exposure to several risk factors, including lack of access to mental health care services, discrimination, poverty, and unemployment. Although the prevalence of clinical depression is lower among Black/African American persons (24.6%) and Hispanic/Latino persons (19.6%) than among White persons (34.7%), depression is more likely to be persistent and debilitating in these groups.^26,27 Furthermore, these differences are partially due to Black/African American and Hispanic/Latino American persons being less likely to seek clinical help, and providers being less likely to identify and diagnose culturally different presentations of mental health disorders. Therefore, it is speculated that clinical prevalence of depression is underestimated for these groups and the true depression prevalence is higher for Black/African American and Hispanic/Latino persons than for White persons.²⁸ Moreover, people who identify as multiracial are most likely to report mental illness within the past year compared with other racial/ethnic groups. American Indians/Alaskan Native persons report higher prevalence of post-traumatic stress disorder (PTSD) and substance use disorders than any other group.²⁹ LGBTQIA+ youth are four times more likely to attempt suicide than their heterosexual/cisgender counterparts.³⁰

Mental health and cardiovascular health have a well-established relationship. Specifically, studies show that depression, anxiety, and PTSD are associated with negative CVD outcomes.³¹ Patients with CVD are three times more likely to be depressed than those without CVD. The American Heart Association recommends that depression be recognized as a major risk factor for heart disease and heart disease mortality. Despite this, many patients are rarely assessed for mental health problems, and mental health disorders are often undiagnosed.³²

Mental health refers to emotional, psychological, and social well-being; mental health disorders refer to conditions affecting cognition, emotion, and behavior (e.g., schizophrenia, depression, autism). This indicator can be assessed by the following measures. Click on each measure to learn more:

Measure 1: City and County Minimum Wage
Definition	The average number of mentally unhealthy days self-reported in the past 30 days, in response to the question, “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”
Data Availability	State, County Subgroups: Age, education, gender, income, race
Data Source(s)	County Health Rankings & Roadmaps (CHR&R): CHR&R is a program of the University of Wisconsin Population Health Institute. The CHR&R program provides data, evidence, guidance, and examples to build awareness of the multiple factors that influence health and support leaders in growing community power to improve health equity. CHR&R uses Behavioral Risk Factor Surveillance System (BRFSS) data to provide county-level estimates of the average number of mentally unhealthy days reported in the last 30 days (age-adjusted). Data may be disaggregated by age, gender, race/ethnicity, education, and income. Users can access this measure under Health Outcomes > Quality of Life > Poor Mental Health Days. Data are downloadable as an Excel workbook, and years of data availability vary by state.

Measure 1: City and County Minimum Wage
Definition	Percentage of individuals in each area diagnosed with anxiety. People with anxiety disorders respond to situations and things with fear and dread and may experience physical signs of anxiety, such as a pounding heart and sweating. Anxiety disorders involve more than temporary fear or stress and interfere with the ability to function.³³
Data Availability	Individual
Data Source(s)	Example Survey Instrument The following survey instrument is available to measure presence of anxiety: NIH Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety Instruments PROMIS is an NIH-funded initiative to develop and validate patient-reported outcomes for clinical research and practice. PROMIS Anxiety instruments measure emotional distress caused by hyperarousal, fear, stress, and related somatic symptoms within a 7-day time frame and using a 5-point rating scale that ranges from 1 (“Never”) to 5 (“Always”). The PROMIS Anxiety instruments for the general adult population include a full item bank of 29 questions (PROMIS Item Bank v1.0–Anxiety) and short forms of 4, 6, 7, and 8 questions (PROMIS Short Form v1.0 – Anxiety 4a, 6a, 7a, and 8a, respectively). To access the questionnaires and scoring guidance, users can use the first link below and enter the following search terms: “Age = Adult, Category = Mental Health, Domain = Anxiety/Fear, Language = English, Measure System = PROMIS.” The second link provides details on score interpretation. Links: https://www.healthmeasures.net/search-view-measures https://www.healthmeasures.net/score-and-interpret/interpret-scores/promis/promis-score-cut-points

Measure 1: City and County Minimum Wage
Definition	Percentage of individuals in each area diagnosed with depression.
Data Availability	County, state, individual
Data Source(s)	PolicyMap: PolicyMap is a data warehouse of more than 50,000 indicators on demographics, income and spending, housing, lending, quality of life, economy, education, health, and federal regulations. A free (basic) subscription provides access to measures developed using publicly available data sources via a single-layer mapping tool. A paid (standard) subscription provides access to multilayer mapping, analysis tool, and data downloads (CSV format). PolicyMap uses the CMS data to present the percentage of Medicare fee-for-service beneficiaries who are diagnosed with depression. Users who want to view the depression diagnoses prevalence for the general population can overlay the map with state or county-level demographic information and/or download the data. Users can access this measure under Health > Health Conditions > Chronic Conditions > Depression (which falls under Medicare Population). Data for this measure are available for 2007–2018. Example Survey Instrument The following survey instrument is available to measure presence of depression: NIH Patient-Reported Outcomes Measurement Information System (PROMIS) Depression Instruments The PROMIS is an NIH-funded initiative to develop and validate patient reported outcomes for clinical research and practice. PROMIS Depression instruments measure negative affect, mood, self-image, and social interaction within a 7-day time frame and using a rating scale that ranges from 1 (“Never”) to 5 (“Always”). The PROMIS Depression instruments for the general adult population include a full item bank of 29 questions (PROMIS Item Bank v1.0–Depression) and short forms of 4, 6, and 8 questions long (PROMIS Short Form v1.0–Depression 4a, 6a, 8a, and 8b, respectively). To access the questionnaires and scoring guidance, users can use the first link below and enter the following search terms: “Age = Adult, Category = Mental Health, Domain = Depression/Sadness, Language = English, Measure System = PROMIS.” The second link provides details on score interpretation. Links: https://www.healthmeasures.net/search-view-measures https://www.healthmeasures.net/score-and-interpret/interpret-scores/promis/promis-score-cut-points

Measure 1: City and County Minimum Wage
Definition	Percentage of individuals whose primary cause of mortality is self-harm.
Data Availability	County, state, region, division Subgroups: Age, gender, race/ethnicity, rurality/urbanization
Data Source(s)	CDC Web-based Injury Statistics Query and Reporting System (WISQARS): CDC’s WISQARS is an interactive, online database that provides fatal and nonfatal injury, violent death, and cost of injury data. The Fatal Injury Reports on WISQARS provide estimates on the number of suicide deaths per 100,000 people at state, regional, and national levels from 1981 to 2020. Data are also available by age, race/ethnicity, and gender. To obtain suicide data from WISQARS, navigate to the provided link and select “Suicide” under Intent or manner of injury drop-down menu. CDC Wonder’s Underlying Cause of Death Database (WONDER): CDC’s WONDER manages nearly 20 collections of public-use data for U.S. births, deaths, cancer diagnoses, environmental exposures, and vaccinations, among other topics. Users can create tables, maps, and charts; export data; and obtain descriptive statistics such as frequency counts. Specifically, the Underlying Cause of Death database contains mortality and population counts for all U.S. counties. For this measure, users can access data on intentional self-harm by first reading and agreeing to the data use restrictions and then submitting a request form that groups results by 15 Leading Causes of Death, or Cause of Death for a more detailed breakdown, for a given geographical level (county, state, region, or division) and/or level of urbanization (non-core, micropolitan, small metro, medium metro, large central metro, or large fringe metro). Data are based on death certificates for U.S. residents. Data can be disaggregated by age, race/ethnicity, and gender. Data are available for 1999–2020.

Measure 1: City and County Minimum Wage
Definition	A set of painful mental and physical symptoms that may be part of normal fluctuations of mood or may indicate the beginning of serious mental illness.³⁴ Serious psychological distress includes mental health problems severe enough to cause moderate to serious impairment in social, occupational, or school functioning and to require treatment.
Data Availability	Individual
Data Source(s)	Example Survey Instrument The following survey is available for assessing psychological distress and serious mental illness: Kessler Psychological Distress Scale Two Kessler Psychological Distress Scales, K10 and K6, were developed for the National Health Interview Survey (NHIS).³⁵ Both scales are measures of psychological distress used to screen for serious mental illness based on questions about level of nervousness, agitation, psychological fatigue, and depression in the past 30 days. K10 and K6 assess the frequency of nonspecific psychological distress and how it affects functional impairment, using a five-point Likert scale. K10 is a 10-item self-reported measure and K6 is the short-form scale with six questions. For K10, the scores for the 10 items are added up, yielding a minimum possible score of 10 (no distress) and a maximum possible score of 50 (severe distress). For K6, the six items are added up to yield a final score between 0 and 24; a score of 13 or above is considered to indicate a serious mental illness.³⁶ The measure and scoring are available through the Harvard Medical School’s National Comorbidity Survey website. Link: https://www.hcp.med.harvard.edu/ncs/k6_scales.php

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Sleep Health

Why is this indicator relevant?

Sleep health is commonly recognized as comprising several measurable dimensions, including sleep duration (total amount of sleep per 24-hour day), sleep continuity or efficiency (ease of falling asleep and returning to sleep), timing (placement of sleep within the 24-hour day), alertness/sleepiness (ability to maintain attentive wakefulness), and satisfaction/quality (subjective assessment of “good” or “poor” sleep).³⁷ These dimensions are associated with physical, mental, and neurobehavioral well-being. Moreover, sleep is an important modulator of cardiovascular health; sleep deprivation is linked to hypertension, congestive heart failure, and stroke.^38,39

Historically, sleep duration in the United States has declined steadily from the 1960s onward, plateauing in the early 21st century to an average of 6 hours, which is below CDC’s and National Sleep Foundation’s minimum recommendation of at least 7 hours per day. Certain racial/ethnic groups, including Black/African American persons, multiracial persons, Native Hawaiian persons, Pacific Islander persons, American Indians/Alaska Native persons, and immigrant groups have worse sleep outcomes, averaging less sleep and lower quality of sleep than their White person counterparts.^40,41 For instance, the CDC Behavioral Risk Factor Surveillance System (BRFSS) found that 46.3% of Native Hawaiian and Pacific Islander persons, 45.8% of Black/African American persons, 44.3% of multiracial persons, and 40.4% of American Indians/Alaska Native persons reported getting less than 7 hours of sleep per day, compared with 33.4% of White persons.⁴² Other studies found significantly less slow-wave sleep and more self-reported daytime fatigue among Black/African American persons compared to White persons.⁴³Hypothesized contributors to racial/ethnic sleep inequities include competing demands (e.g., occupational and financial considerations), environmental exposures (e.g., air pollution), and psychosocial stressors (e.g., perceived discrimination and acculturation).^44,45

Current sleep research studies have an increased focus on investigating the relationship between sleep and other disparities certain groups experience. Many researchers consider sleep health indicators, including sleep duration, sleep-disordered breathing, and insomnia, as prominent contributing factors to CVD outcome disparities.⁴⁶ Increasing awareness of sleep-mediated causes of disease risk, funding for research into underlying sleep disparity causes, and public education on the importance of sleep health, may lead to cardiovascular and overall health improvements.

Sleep health is commonly recognized as comprising several measurable dimensions, including sleep duration (total amount of sleep per 24-hour day), sleep continuity or efficiency (ease of falling asleep and returning to sleep), timing (placement of sleep within the 24-hour day), alertness/sleepiness (ability to maintain attentive wakefulness), and satisfaction/quality (subjective assessment of “good” or “poor” sleep). This indicator can be assessed by the following measure. Click on the measure to learn more:

Measure 1: City and County Minimum Wage
Definition	Percentage of adults who self-report sleeping less than 7 hours per night on average.
Data Availability	Individual, county, census tract Subgroups: Age, gender, race, education, income
Data Source(s)	County Health Rankings & Roadmaps (CHR&R): CHR&R is a program of the University of Wisconsin Population Health Institute. The CHR&R program provides data, evidence, guidance, and examples to build awareness of the multiple factors that influence health and support leaders in growing community power to improve health equity. CHR&R uses Behavioral Risk Factor Surveillance System (BRFSS) data to provide county-level estimates of the percentage of adults who report fewer than 7 hours of sleep on average, adjusted by age to account for counties with different age distributions. Data may be disaggregated by age group, gender, race, education, and income. Users can access this measure under Additional Measures > Health Behaviors > Insufficient Sleep. Data are downloadable as an Excel workbook and years of data availability vary by state. PLACES: Local Data for Better Health: PLACES is the expansion of the original 500 Cities Project, covering the entire United States—50 states and the District of Columbia—at county, place, census tract, and ZIP Code Tabulation Area (ZCTA) levels. The CDC Division of Population Health’s Epidemiology and Surveillance Branch provides the estimates. Users can access data on insufficient sleep using the “Health Risk Behaviors > Sleeping less than 7 hours among adults aged 18 years or older” measure. The model-based estimates specific to this measure used BRFSS data. Data since 2016 are published through a public, interactive website that allows users to view, explore, and download data by county, place, census tract, and ZCTA. Because the small area model cannot detect effects due to local interventions, users are cautioned against using these estimates for program or policy evaluations. Example Survey Instrument The following survey instrument is available to measure sleep health: Pittsburgh Sleep Quality Index (PSQI) The PSQI is a self-rated questionnaire that identifies “good” and “poor” sleepers by assessing the sleep quality and the sleep disturbance presence over 1 month.⁴⁷ The PSQI comprises 19 survey items that capture seven components of sleep quality, including subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, sleep medication use, and daytime dysfunction. The instrument and scoring details are available from the University of Pittsburgh’s Center for Sleep and Circadian Science. Link: https://www.sleep.pitt.edu/instruments/

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Social Support

Why is this indicator relevant?

Social support refers to the benefits provided through relationships with family members, friends, spouses, colleagues, and acquaintances (e.g., emotional, instrumental, and informational support). Social support and social integration are predictive of mortality for a number of conditions, including CVD.^{48,49,50,51,52} Lack of social support and poor social integration are linked to increased inflammation, which is a risk factor for CVD.^53,54 Social support also buffers the negative effects of discrimination on health outcomes. Specifically, social support mitigates the adverse health consequences of discrimination. Researchers posit that emotionally supportive environments allow people to better cope with unfair treatment.⁵⁵ For instance, a study in California showed that Hispanic/Latino immigrants who reported discriminatory experiences and low social support were more likely to report poor health than those who reported discriminatory experiences and high levels of social support.⁵⁶ Another study found that peer support interventions that community health workers delivered, including barbershop and beauty parlor interventions, were associated with decreases in CVD risk factors.⁵⁷ Other studies, however, found no association between social support and CVD outcomes overall, or detected effects in only one gender after adjusting for age and other characteristics.^58,59,60,61 Therefore, further research is warranted to elucidate the effect of social support on CVD risk and whether it may serve as a buffer for the negative health consequences of discrimination.

Measure 1: City and County Minimum Wage
Definition	Degree of structural and functional support. Structural support refers to social connectedness, such as social network size and/or density. Functional support refers to how interpersonal relationships may serve different functions, such as emotional, instrumental, or instructional support.
Data Availability	Individual
Data Source(s)	NIH Patient-Reported Outcomes Measurement Information System (PROMIS) Battery of Short Form Social Support Measures: PROMIS is an NIH-funded initiative to develop and validate patient-reported outcomes for clinical research and practice; it includes a battery of tests that vary in length (four, six, and eight questions) and measure emotional social support (PROMIS Short Form V2.0–Emotional Support 4a, 6a, 8a), informational social support (PROMIS Short Form V2.0–Informational Support 4a, 6a, and 8a), instrumental social support (PROMIS Short Form V2.0–Instrumental Support 4a, 6a, and 8a), and social isolation (PROMIS Short Form V2.0–Social Isolation 4a, 6a, and 8a). They can be used with the general population and with individuals living with chronic conditions. A complete list of PROMIS social support measures and scoring guidance, as well as computer adaptive test versions of these measures are searchable within Northwestern University’s Health Measure database. Users can use the link below and enter the following search terms: “Category = Social Health, Domain = Relationships/Social Support, Type= Fixed Length Short Form, Language = English, System = PROMIS.” Lubben Social Network Scale (LSNS): The LSNS is a self-report measure of social engagement, including family and friends, and correlates with mortality, all cause hospitalization, health behaviors, depressive symptoms, and overall physical health. The scale has two versions: the short, 6-item scale (LSNS-6) and the 12-item scale (LSNS-R). The short version has been validated among European and multiethnic populations in the United States.^62,63 The total score is calculated by summing the response scores to all items. For the LSNS-6, the score ranges from 0 to 30, with a higher score indicating more social engagement. Before using this scale, researchers are asked to fill out this permission form. The LSNS-6 is available at the Boston College School of Social Work website. Social Network Index (SNI): The Berkman-Syme SNI is a self-reported 12-item measure of social isolation and integration based on an individual’s number of social ties and focused on four types of social connections: marriage or partnership, frequency of contact with friends and family, frequency of religious participation, and group membership.⁴⁸ There are a couple of different approaches to scoring. The first approach scores the survey as a total of 0 to 12 points with three groupings: limited social network (SNI 0–3), medium social network (SNI 4–5), diverse social network (SNI ≥6).⁶⁴ The second approach scores the survey as a total of 0 to 4 points with four groupings: socially isolated (SNI 0–1), moderately isolated (SNI 2), moderately integrated (SNI 3), and socially integrated (SNI 4).^52,58,61 The full scale is available through Carnegie Mellon University’s Common Cold Project website.

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Stigma

Why is this indicator relevant?

Social stigmatization is the experience of being discredited or rejected due to a characteristic or attribute that is considered undesirable and can lead to prejudice, stereotyping, and/or discrimination.⁶⁵ Stigma-consciousness refers to the extent to which a person anticipates discrimination or prejudice.⁶⁶ Chronic exposure to stigma and chronic self-consciousness of stigmatized status may affect CVD risk by negatively affecting physiological response to stress and increasing the risk of physiological dysregulation.^65,67

The experience of stigma and the anticipatory vigilance of stigma-consciousness are social stressors that may result in heightened acute or chronic stress. Acute stress can cause increased heart rate, blood pressure, and secretion of stress hormones.⁶⁸ Chronic stress can cause constantly elevated heart rate and blood pressure and vasoconstriction, which may lead to higher likelihood of developing myocardial ischemia, atherosclerosis, and thrombosis.⁶⁹ Several attributes of stigma, including race, weight, gender, and sexual orientation, are associated with negative cardiovascular risk factors and health outcomes.⁷⁰ One study found that weight-related stigma and perceived discrimination was associated with a two-fold risk of high allostatic load.⁷¹ Another study found that racial discrimination and stigma-consciousness was associated with higher blood pressure and hypertension in Black/African American and Hispanic/Latino men.⁷²

Measure 1: City and County Minimum Wage
Definition	A person’s stereotyped status and the life experiences it pervades.
Data Availability	Individual
Data Source(s)	Stigma-Consciousness Questionnaire (SCQ): Stigma-consciousness has been studied in more than 200 previous projects, primarily using and adapting a self-reported measure Pinel developed in 1999, the SCQ.⁶⁶ In the original work to develop and validate the SCQ, Pinel began with a version designed to measure stigma-consciousness among women and adapted it to assess stigma-consciousness related to homosexuality⁷³ and race.^74,75 The measure includes 10 items that ask respondents to indicate their level of agreement with statements about how much they expect to be stereotyped. The total score is calculated by summing the scores across each item. Higher scores indicate greater stigma-consciousness. Seven of the 10 items are reverse-scored, as detailed in the Pinel article.^{^⁶⁶} The full questionnaire and scoring are available at the Evidence-based Measures of Empowerment for Research on Gender Equality (EMERGE) website from the University of California, San Diego. Users of the survey will need to adapt questions for stigma related to race and stigma related to sexual orientation. The statements can be adapted by changing key phrases. For example, Pinel adapted an item that originally read, “When interacting with men, I feel like they interpret all my behaviors in terms of the fact that I am a woman,” to, “When interacting with heterosexuals who know of my sexual preference, I feel like they interpret all my behaviors in terms of the fact that I am a homosexual.”⁷³

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Stress

Why is this indicator relevant?

Stress is the physiological or psychological response to internal or external stressors.⁷⁶ Perceived stress, or how an individual experiences stress, may include stressors experienced throughout the life course, including during childhood, adolescence, and adulthood.^77,78,79 Although experiencing stress can be normal and some stress can be a motivating factor, chronic stress, or stress that remains constant and persists over an extended period, can be debilitating and overwhelming, affecting an individual’s physical and psychological well-being. Chronic stress can cause a variety of problems, including anxiety, insomnia, muscle pain, high blood pressure, and a weakened immune system.⁸⁰ Furthermore, research shows stress contributes to “the development of major illnesses, such as heart disease, depression, and obesity.”⁸¹ Many of the indicators covered elsewhere in these profiles, such as racial/ethnic discrimination, sexism, genderism, heterosexism, unemployment, and poverty, are contributing factors to both acute and chronic stress, which have well-established connections to CVD.^{82,83,84,85,86}

Stress management, and accompanying coping resources, offer a range of strategies to help individuals better handle stress and adversity. Coping, which is defined as cognitive and behavioral efforts made in order to manage internal or external stimuli, include task-oriented (problem solving and taking direct action to address a stressor), emotion-oriented (regulating distressing emotions), and avoidance-oriented (engaging in other activities and distancing oneself from stressor) strategies.⁸⁷ By managing stress and utilizing coping resources, individuals can lead a more balanced and healthier life.⁸⁸ External stress management and coping resources include general wellness programs, psychiatrists, counselors, therapists, and social workers. Community resources include connections to local businesses, community organizations, and various social networks, as well as neighborhood greenspaces and opportunities for physical activity.^89,90,91

Stress is a strong predictor of CVD risk: Epidemiologic data show that chronic stress predicts coronary heart disease (CHD) occurrence.⁹² Positive and adaptive coping can be used as a behavioral intervention across the prevention, treatment, and rehabilitation stages of CVD. Studies show that coping strategies can reduce CVD risk, as well as manage stress and improve outcomes among CVD patients.^93,94

Stress is the physiological or psychological response to internal or external stressors. Perceived stress, or how an individual experiences stress, may include stressors experienced throughout the life course, including during childhood, adolescence, and adulthood. This indicator can be assessed by the following measures. Click on each measure to learn more:

Measure 1: City and County Minimum Wage
Definition	A measure of an individual’s appraisal of situations in their life as stressful.
Data Availability	Individual
Data Source(s)	Perceived Stress Scale (PSS): The PSS is a widely used self-report instrument for measuring how often situations are appraised as stressful.^95,96The PPS assesses the degree to which life in the past month was unpredictable, uncontrollable, and overloaded. Several PSS versions exist. The original version included 14 items; it was later shortened to 10 questions (PSS-10) and to 4 questions (PSS-4). Scores are obtained by summing across all survey items, where the higher the aggregate score, the more perceived stress. For the PSS-10, items 4, 5, 7, and 8 are reverse coded. For the PSS-4, items 2 and 3 require reverse coding. The PSS-10 and PSS-4 are available at the University of Wisconsin–Madison’s Addition Research Center website.

Measure 1: City and County Minimum Wage
Definition	Using strategies to reduce unpleasant emotions associated with stressors.
Data Availability	Individual
Data Source(s)	Brief COPE Inventory The Brief COPE is a 28-item multidimensional measure of strategies used for coping or regulating cognitions in response to stressors. This abbreviated inventory (based on the complete 60-item COPE Inventory) comprises items that assess how frequently a person uses different coping strategies (e.g., “I’ve been turning to work or other activities to take my mind off things,” “I’ve been making fun of the situation,” “I’ve been criticizing myself”) rated on a scale from 1(“I haven’t been doing this at all”) to 4 (“I’ve been doing this a lot”) There are 14 two-item subscales within the Brief COPE; each is analyzed separately: 1) self-distraction; 2) active coping; 3) denial; 4) substance use; 5) use of emotional support; 6) use of instrumental support; 7) behavioral disengagement; 8) venting; 9) positive reframing; 10) planning; 11) humor; 12) acceptance; 13) religion; and 14) self-blame. The measures and scoring guidelines are available through the Science of Behavior Change website at Columbia University’s Medical Center Link: https://scienceofbehaviorchange.org/measures/brief-cope/#:~:text=The%20Brief%20COPE%20is%20a%2028-item%20multidimensional%20measure,coping%20or%20regulating%20cognitions%20in%20response%20to%20stressors.
Additional Measurement Considerations	For additional measures related to coping, refer to the Access to Mental Health Care and Social Support indicators within this profile, as well as the Social Cohesion in the Neighborhood Characteristics Indicator Profile.

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Case Example

This case example was developed from the Health Equity Indicators (HEI) Pilot Study. Seven health care organizations participated in the HEI Pilot Study from January 2022 to April 2022 to pilot-test a subset of HEIs in order to assess the feasibility of gathering and analyzing data on these indicators within health care settings. The pilot case examples document participating sites’ experiences with data collection and lessons learned from piloting the HEIs.

Site: Dignity Health St. Joseph’s Hospital and Medical Center
Focus Area: Psychosocial Pathways
Measure: Mental Health Care Provider Ratio

This content presents an example of how one health care site, Dignity Health St. Joseph’s Hospital and Medical Center in Phoenix, Arizona, used data on the health equity indicator access to mental health care. Access to mental health care is the extent to which mental health care is available in a geographic area. Low mental health care service availability at the county level is linked to higher county-level suicide rates, and individuals with serious mental illnesses living in areas with poor access to mental health care services are more likely to be admitted to the hospital.^97,98 Mental health disorders play a role in multiple aspects of the pathogenesis of cardiovascular disease (CVD) and other chronic diseases and may affect the success of prevention, detection, evaluation, and treatment of CVD.⁹⁹ Dignity Health St. Joseph’s Hospital and Medical Center used the mental health care provider ratio to measure mental health care access. The mental health care provider ratio is defined as the population size compared with the number of mental health providers.¹⁰⁰ For more information on the mental health care provider ratio measure, please see the access to mental health care indicator in the Psychosocial Pathways Indicator Profile.

The description of Dignity Health St. Joseph’s Hospital and Medical Center’s data analysis methods, data sources, challenges, and facilitators summarized below reflects insights gathered during the Health Equity Indicators for CVD Pilot Study conducted between January and April of 2022.

Health Equity in Action: Dignity Health St. Joseph’s Hospital and Medical Center

Serving the approximately 4.3 million residents of Maricopa County, Dignity Health St. Joseph’s Hospital and Medical Center is part of CommonSpirit Health^®, which is one of the nation’s largest nonprofit health care systems, with more than 1,000 care sites and 140 hospitals in 21 states. Dignity Health St. Joseph’s Hospital and Medical Center’s Heart and Vascular Institute and Community Benefit and Health Equity Department participated in the CDC pilot reviewing select health equity indicators, including the access to mental health care indicator. The pilot supported Dignity Health’s core mission of advancing social justice and improving health for all, especially for the most vulnerable. Some of the hospital’s current health equity efforts also include improving interoperability and analytic capabilities for data systems that contain health equity measures, the standardization of health equity data collection processes, health equity data visualization, and ultimately using data to inform decisions that address health inequities.

Overview of Dignity Health St. Joseph’s data collection methods

Indicator: Access to Mental Health Care

Measure: Mental Health Care Provider Ratio

Data Collection Method: Secondary data collection

Data Source: County Health Rankings & Roadmaps (CHR)

Data Availability: County- and state-level

Application/Use: Comparative analysis of mental health care provider ratio at county and state levels.

Data Collection and Analysis Methods. As part of the pilot reviewing select health equity indicators, Dignity Health St. Joseph’s Hospital and Medical Center piloted the access to mental health care indicator using the mental health care provider ratio measure from the County Health Rankings & Roadmaps (CHR&R) website. The CHR&R is based on a conceptual population health model that includes both health outcomes (length and quality of life) and variables for different determinants of health across four areas: health behaviors, clinical care, social and economic factors, and physical environment. Dignity Health St. Joseph’s Hospital and Medical Center worked with the Maricopa County Department of Public Health on collecting and analyzing data from the CHR&R. Specifically, the team looked at the mental health care provider ratio data element in this data set and conducted a comparative analysis of provider ratios at the county and state levels. One finding from the analysis was that Maricopa County has a mental health care provider ratio (700:1) similar to that of the state overall (710:1). Although the team did not link their comparative analysis of the mental health care provider ratio at county and state levels to their patient population at Dignity Health St. Joseph’s Hospital and Medical Center, they noted that hospital staff regularly connect patients with mental health disorders to the necessary available county resources. Additionally, the team from Dignity Health St. Joseph’s Hospital and Medical Center mentioned that they plan to share these findings with their hospital’s executive leadership team to inform data-driven decisions that support health equity and monitor and track results. Given the link between CVD and mental health disorders,¹⁰¹ this analysis has the potential for broader application in assessing the relationships between access to mental health care and CVD outcomes.

Facilitators. Strong support from Dignity Health St. Joseph’s Hospital and Medical Center patient care and executive leadership teams at the local, division, and national levels greatly facilitated the pilot’s data collection and analysis.

Challenges and Limitations. The team did not encounter any challenges in using the CHR&R website to obtain data regarding access to mental health care but noted that since Dignity Health is a large organization, it can be difficult to change data collection practices at the local facility level.

Future Plans. In partnership with the Maricopa County Department of Public Health’s Office of Informatics & Epidemiology, Dignity Health St. Joseph’s Hospital and Medical Center is developing an implementation strategy to address the community health equity needs identified in the Community Health Needs Assessment (CHNA). This process includes using available data sources and findings from this pilot to support the development of targeted programs and services that address identified health and social inequities, standardizing data collection processes across local facilities, and building a data infrastructure that promotes health equity and measurement of sustainable program and service impact.

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