Research Article: Links between discrimination and cardiovascular health among socially stigmatized groups: A systematic review

Date Published: June 10, 2019

Publisher: Public Library of Science

Author(s): Gregory A. Panza, Rebecca M. Puhl, Beth A. Taylor, Amanda L. Zaleski, Jill Livingston, Linda S. Pescatello, Karen L. Tang.


There is a high prevalence of cardiovascular disease across diverse groups in the U.S. population, and increasing research has identified stigma as a potential barrier to cardiovascular disease prevention and treatment. This systematic review examines evidence linking discrimination and cardiovascular health among socially stigmatized groups.

Six databases were systematically reviewed from inception through February 2018 for studies with adult subjects, focusing on cardiovascular health indicators among social groups stigmatized because of their gender, race/ethnicity, age, body weight/obesity, or sexual orientation. The Newcastle-Ottawa Scale was used to evaluate the methodological quality and risk of bias for nonrandomized studies, and the Cochrane Collaboration 7-item domain for randomized controlled and experimental trials.

The search identified 84 eligible studies published between 1984 and 2017. Studies retrieved were categorized according to demonstrated links between stigma and cardiovascular disease risk factors including blood pressure (n = 45), heart rate variability (n = 6), blood/saliva cardiovascular biomarkers (n = 18), as well as other indicators of cardiovascular health (n = 15). Based on the findings from included studies, 86% concluded that there was a significant relationship among stigma or discrimination and cardiovascular health indicators among socially stigmatized groups. However, there were varying degrees of evidence supporting these relationships, depending on the type of discrimination and cardiovascular health indicator. The current evidence implies an association between perceived discrimination and cardiovascular health. However, a majority of these studies are cross-sectional (73%) and focus on racial discrimination (79%), while using a wide variety of measurements to assess social discrimination and cardiovascular health.

Future research should include longitudinal and randomized controlled trial designs, with larger and more diverse samples of individuals with stigmatized identities, using consistent measurement approaches to assess social discrimination and its relationship with cardiovascular health.

Partial Text

Many American adults face social stigmatization, the experience of being discredited and/or rejected because of a particular characteristic or attribute that is deemed socially undesirable [1]. Societal stigma can lead to prejudice, stereotyping, unfair treatment, discrimination, and remains common among a number of groups in Western society. According to the National Survey of Midlife Development in the United States, gender was the most commonly reported type of discrimination in America from 1995/6 through 2005/6, particularly among women (27%) [2]. Other reported types of discrimination included race (17% men, 9% women), age (10% men, 11% women), weight [5% men, 10% women; 40% for adults with a body mass index (BMI) ≥35kg/m2] [3], other aspects of physical appearance (8% men, 4% women), and ethnicity/nationality (6% men, 3% women) [2]. Recent surveys continue to show a high prevalence of discrimination amongst these socially stigmatized groups [4].

Fig 1 describes the search and selection process which resulted in 1,272 identified records, yielding 84 eligible studies, published between 1984 and 2017. All included studies examined the relationship between social discrimination and one or more cardiovascular health indicators among at least one socially stigmatized group. A summary of study characteristics for the 84 included studies are described in Table 2. A more detailed table of study characteristics (study design, population, measures used to assess discrimination and cardiovascular health indices, and study findings) is presented in S2 Table. Cross-sectional and longitudinal cohort studies included in the systematic review scored an average of 7.5 out of 9 on the NOS (Table 3). Randomized controlled and experimental studies included in the systematic review had an overall average of 35.3% low risk, 37.0% high risk, and 27.7% unclear risk across all 7 domains (Fig 2), with the highest risk shown for “blinding of outcome assessment” (detection bias) and “other bias” (e.g., no power analysis indicated; S1 Table). Summarized below are research findings pertaining to each of the four cardiovascular health indicator categories: 1) BP, 2) HR/HRV, 3) blood/saliva cardiovascular biomarkers, and 4) ‘other’ various disease states as indices of cardiovascular health.

This review aimed to provide an overview of the scientific evidence linking discrimination and cardiovascular health indicators among socially stigmatized groups. Overall, there was support for the CDC [5] and the WHO’s [6] recognition of stigma as a public health priority because of its potential to accelerate disease processes, with 86% of studies in the current review concluding that there is a significant relationship between discrimination reported by stigmatized groups and indicators of adverse cardiovascular health. However, there are varying strengths of evidence supporting this relationship based on study design and types of discrimination and cardiovascular health indicator (Table 4). The majority of included studies were cross-sectional (61 of 84); thus, a causal relationship between social discrimination and cardiovascular health outcome cannot be determined in many cases. Longitudinal, RCT designs should be implemented to better establish sequences of events which can lead to different relationships between social discrimination and cardiovascular health over time. Examining this relationship both acutely and chronically will provide a better understanding of the role that social discrimination plays in the disease pathology and progression of CVD.