Cardiovascular Health in Black Americans

See Article by Kim et al

The field of positive psychology—which includes much of the early research on resilience—was founded after experiments showed that some individuals remained optimistic despite adversity. Accordingly, resilience came to be understood as the dynamic ability to maintain normal levels of function or return to psychological health after setbacks. Resilient people can replace grief with eventual gratitude, vulnerability with strength.² Resilience has been associated with positive health outcomes such as improved quality of life and decreased depression.³ When evaluating disease risk, resilient individuals are further defined as those who evade disease despite risk factors.⁴ Additionally, the concept of resilience can be extended to communities that recover well from adversity.⁵

In assessing individual risk, data indicate that Black Americans have higher odds of developing cardiovascular disease (CVD) compared with other racial groups. A multitude of well-conducted analyses have demonstrated the persistent association of Black race with poorer CVD outcomes. Yet, fewer studies have examined the mechanisms that mitigate or prevent CVD among Black individuals. In the study by Kim et al, “Individual Psychosocial Resilience, Neighborhood Context, and Cardiovascular Health in Black Adults: A Multilevel Investigation from the Morehouse-Emory Cardiovascular Center for Health Equity Study,” the authors strive to identify mechanisms for race-based disparities in CVD.⁶ The authors keenly note that some Black people develop heart disease, whereas others do not, and use the concept of resilience to operationalize this heterogeneity among Black individuals. Furthermore, the authors hypothesize that Black people living in resilient neighborhoods would have better cardiovascular health. The study examines the association between individual- and neighborhood-level resilience and cardiovascular health as measured by the American Heart Association Life’s Simple 7 (LS7) targets.

This study fits well in the context of an evolving understanding of race in America. The year 2020 has been marked with dramatic social movements in response to race and racism. Institutional policies are being met with overdue scrutiny to determine how to implement improvements for equity. Clinicians increasingly recognize that race-based disparities do not stem inherently from race; instead, these disparities stem from the underlying social determinants of health (living conditions, access to food, access to equal pay, etc)⁷ and the structural racism that enables and perpetuates them. It is, therefore, critical that research of racial disparities examines psychosocial factors that often confound race-based outcomes to suggest strategies for interventions.

The study by Kim et al identified positive associations between resilience and LS7 scores. The study used a composite of 5 measures (environmental mastery, purpose in life, optimism, resilient coping, and lack of depressive symptoms) to derive a continuous indicator of psychosocial resilience. Neighborhood resilience was defined as lower-than-expected rates of CVD based on neighborhood socioeconomic profiles as characterized by census data. Participants with either higher psychosocial resilience or neighborhood resilience measures were found to have higher LS7 scores. When measuring the interaction between psychosocial and neighborhood resilience on LS7, the findings were not statistically significant. The largest difference in LS7 scores was between individuals with high (versus low) psychosocial resilience living in low-resilience neighborhoods. We expect that the absence of synergism between high individual and high neighborhood resilience stems from the definition of the latter used here. In this study, neighborhood resilience is all too imprecise, not accounting for multiple factors that promote health: green spaces, transportation, neighborhood cohesion, crime, and other components of social welfare.

In addition to the challenges with the definition of neighborhood resilience, the study has other limitations that we consider noteworthy. First, Kim et al used a convenience sample of 389 healthy Black residents living in a Southern metropolitan city, therefore, limiting the applicability to other Black Americans. The study did not assess the effect of nativity status or cultural heterogeneity among Black individuals. Second, the authors did not clearly delineate the cohort’s exposure to risk beyond self-reported health status. Third, determination of individual resilience was ascertained from a composite of 5 measures—an approach not previously validated. Fourth, the study did not account for healthcare access, which is fundamental for CVD prevention. Fifth, the authors did not include individual psychosocial factors and neighborhood-level characteristics known to be associated with CVD (eg, social cohesion, safety, and discrimination). Lastly, it could be argued that the small differences in LS7 scores observed here may have limited clinical significance.

Despite these noted limitations, this study complements the existing data describing LS7 among Black individuals by adding the association of resilience with health outcomes. Few studies of resilience have focused on Black individuals. Findings from the Jackson Heart Study—the largest longitudinal cohort of Black Americans—have previously shown the association between psychosocial distress (eg, discrimination) and CVD risk among Black individuals.⁸ Alternatively, Kim et al have called attention to the importance of positive determinants of health, such as resilience, within the Black community.

Based on these findings, the implications of this study would underscore the importance of psychosocial support and empowerment for Black patients at risk for developing CVD. However the factors that moderate the relation between resilience and cardiovascular health have yet to be defined. The authors advocate for the promotion of psychosocial resilience among Black people living in communities with poor cardiovascular health. Although resilience techniques can be taught, to do so requires intentional acknowledgement of the conditions and experiences from which the adversity originated.² Thus, the superficial application of positive psychology strategies is likely insufficient to bring parity in cardiovascular health outcomes. Moreover, the community context in which resilience thrives not only includes psychosocial well-being; economic well-being and healthcare accessibility are needed as well.⁵

Sociology literature has proposed that resilience is essentially a survival response in hierarchical systems of oppression. The oppressed group does not have the required power or agency to overcome adversity. Thus, racial inequalities drive minorities’ need for resilience.⁹ Thus, promoting resilience in Black people insinuates that injustice must be overcome without fully acknowledging any associated trauma. Instead, the goal should be to work with communities that have been historically marginalized or made vulnerable to restore agency for positive outcomes.¹⁰ Eliminating disparities in cardiovascular health will require community-engaged partnerships based on common goals to provide care and to rebuild healthcare systems. We advocate for promoting health equity and social justice first, thereby rendering interventions to bolster resilience unnecessary.

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