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Higher Community Wellbeing Linked to Reduced CVD Mortality in Study of More than 3000 US Counties


Wellbeing is considered a measurable and modifiable community attribute that study authors show is correlated with CV outcomes.

map ©Tryfonov/stock.adobe.com  Higher Community Wellbeing Linked to Reduced CVD Mortality in Study of More than 3000 US Counties

Higher levels of population wellbeing were associated with lower rates of mortality from cardiovascular disease (CVD) across the US, according to findings of a cross sectional study that included more than a half million individuals living in more than 3000 counties. Financial and community wellbeing were the most important among 5 elements of a wellbeing index related to CV health, the authors report.

The research team, led by Erica S Spatz, MD, MHS, associate professor of cardiovascular medicine at the Yale School of Medicine, found specifically that total CV deaths decreased by 15.5 per 100 000 persons for each 1-point increase in population wellbeing. All but 1 of the 5 components of wellbeing were inversely associated with total CV death, the exception being anticipated life satisfaction.

Spatz and colleagues write that while the concept of social wellbeing is typicallyassociated with economic status, other community factors also are involved, some of which are “modifiable through community engagement and action in combination with public policy.” Previous research, they point out, has identified US counties with high wellbeing that are among those with the country’s highest poverty levels. “During a time of social upheaval and greater awareness of how social determinants of health and structural racism lead to health disparities, population well-being may offer a focus of immediate intervention to improve equity in cardiovascular health outcomes.”

During a time of social upheaval and greater awareness of how social determinants of health and structural racism lead to health disparities, population well-being may offer a focus of immediate intervention to improve equity in cardiovascular health outcomes.

In mounting the current study, Spatz, who is also director of the Preventive Cardiovascular Health Program at Yale/YNHH Heart and Vascular Center, and team hoped to support this type of approach with new data linking wellbeing with CV outcomes. Their findings were published in JAMA Network Open on July 5, 2023.


Their cross-sectional study linked data from the Gallup National Health and Well-Being Index (WBI) survey with rates of CVD mortality by county from the Centers for Disease Control and Prevention Atlas of Heart Disease and Stroke. Gallup conducted the WBI survey among randomly selected US adults aged ≥18 years from 2015 to 2017 (analyzed from August 2022 to May 2023). The WBI is comprised of 5 elements of wellbeing and scored on a scale of 0 to 100, with 0 being the lowest well-being and 100 being the highest. The 5 elements:

  • having a successful life career
  • social relationships
  • financial security
  • relationship to community
  • good physical health

The study's primary outcome was the county-level rate of total CVD mortality; secondary outcomes were mortality rates for stroke, heart failure (HF), coronary heart disease, acute myocardial infarction (MI), and total heart disease.

The team also assessed the association of population wellbeing with CVD mortality and analyzed whether or not that association was modified by structural factors (eg, deprivation, income inequality, urbanicity) and factors related to population health (eg, percentages of adult population with hypertension, diabetes, or obesity; currently smoking; and physically inactive). Finally, using structural equation models, Spatz et al assessed the ability of population WBI to mediate the association between structural factors and CVD.


According to study results, 514 971 individuals living in 3228 counties completed WBI surveys for a final cohort that had an average age of 54.9 years, was 48.9% women, and was 76.0% White.

Overall, the team observed wellbeing scores that were “marginally but statistically lower” among counties where income inequality was greater, and deprivation was more pronounced. Wellbeing scores were similarly lower in counties where rates of hypertension, diabetes, physical inactivity, obesity, and smoking were higher.

Population wellbeing was inversely associated with CVD mortality rate with the overall mortality rate reported as 462 deaths per 100 000 persons.

Primary outcome. Reporting on the primary outcome, Spatz et al found that CVD mortality rates decreased from a mean of 499.7 (range, 174.2-974.7) deaths/100 000 in counties with the lowest quintile of population well-being to 438.6 (range, 110.1-850.4) deaths/100 000 in counties where population wellbeing was in the highest quintile—a difference of 61.1 deaths/100 000 between counties with the highest and lowest WBI values.

The effect size of WBI on CVD mortality before adjustment was −15.5 (1.5; P< .001), ie, a decrease of 15 deaths/100 000 persons for each 1-point increase of population well-being. Deaths from all heart disease were identified as mediating the association and stroke to a lesser degree, according to the findings.

Fully adjusted model. In a model adjusted for the prespecified structural factors and structural plus population health factors, the researchers observed an attenuated but still significant association: for each 1-point increase in wellbeing, total CV death rate decreased by 7.3 deaths/100 000, an effect size of −7.3 (1.6; P<.001). As noted earlier, only anticipated life satisfaction did not show an inverse association with total CV death.

The researchers report in a secondary analysis of all the wellbeing elements, only financial and community wellbeing were independently associated with CVD mortality.

Spatz et al write in the study’s discussion that their findings suggest a role for community interventions that focus on wellbeing to help mitigate CVD mortality. “Results from our path analyses indicating that well-being mediates the association of structural risk factors with CVD mortality (ie, income inequality and the ADI) support this claim,” they said. They also suggest that “while the indirect associations of well-being with CVD mortality are small,” their mitigating effect could be “meaningful” if factored across a range of community risk factors. “Taken together, these findings suggest that targeting interventions to improve well-being in communities with lower socioeconomic measures could be an effective way to mitigate the increased risk of CVD death in those communities.”

Source: Spatz ES, Roy B, Riley C, Witters D, Herrin J. Association of population well-being with carediovascular outcomes. JAMA Netw Open. 2023;6(7):e2321740. Published online July 5, 2023. doi:10.1001/jamanetworkopen.2023.21740

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