1. INTRODUCTION
Cardiovascular disease (CVD) is caused by a plethora of lifestyle, genetic, and environmental attributors. From the 2019 Update from the American Heart Association, the main factors that are correlated with CVD are smoking/tobacco use, physical inactivity, nutrition, obesity, high blood cholesterol, high blood pressure, diabetes mellitus, sleep, and genetic factors. Taking a closer look at these said factors reveals an even more interconnected relationship. With physical inactivity and overeating, for example, these factors contribute to a caloric surplus and obesity. Moreover, these key components contributing to CVD seem to be substantially related to the socio-economic status (SES) of a community and individual. Taking each element of CVD piece by piece illuminates on how the income level of a person can affect every level of cardiovascular health.
Firstly, tobacco usage is greater in areas of lower-income households. In families living below the U.S. poverty rate, people are more likely to smoke for twice as many years as those who are not (Siahpush et al., 2009). With a longer history of smoking, this means that lower income people are thus more prone to contracting CVD. They even develop it earlier on average, according to an analysis on national data in 2011 (Ham et al.). Moreover, lower-income communities are targeted by the tobacco industry with a greater density of tobacco retailers. In a 2010 study on the spatial regression of tobacco outlets (e.g. convenience stores, liquor stores), lower-income communities had a far larger number of places to access cigarettes and tobacco products (Yu et al.). This shows how people of a lower SES would be more prone to begin smoking earlier due to the high availability of these products and how long they continue to do so.
Patterns with a positive-feedback loop continue in lower income communities when it comes to obesity and the overweight community in the U.S. In a 2017 study by Chang and Kim, factors limiting physical inactivity in lower income communities included their home environment being unsafe and lower accessibility to parks, gyms, and recreational resources. Furthermore, participation in the Supplemental Nutrition Assistance Program (SNAP) was associated with less healthy household purchases, resulting in a steady increase of calorie consumption among those who used food stamps (Grummon & Taillie, 2017). Lower-income communities are more likely to be living in what are called “food deserts” where fresh produce is not immediately available and “food swamps” where fast-food chain restaurants outnumber the number of supermarkets (Hilmers et al., 2012). As high calorie and nutrient-deficient fast-food is more prevalent in lower-income communities, it may be first welcoming to think that the rapidly growing food industry is feeding more and more people -- but this just is not the case.
While this may be the case for destitute communities, families living under the poverty line in the United States face a different issue -- when the sole distributor of food are fast-food restaurants that provide for calorie-dense food with little to no nutritional content, people are more likely to become obese while still be malnourished (Zenk et al., 2010). The combination between physical inactivity and poor nutrition thus becomes a spiral into obesity. Even more so, healthcare expenses grapple lower income communities as a study estimated the mean annual per capita healthcare expenses associated with obesity were $1160 for males and $1525 for females (An, 2011; American Heart Association 2019). Meaning, as more lower income communities become more obese, more households are struggling to pay for the necessary health care needed to fight against obesity. If there is a lower availability of quality of healthcare, moreover, the problem becomes exacerbated (Patel et al., 2016). As a result, there is a heavier reliance on the cheap food provided by food swamps. And thus, more lower income people are more likely to contract obesity as they stay in these lower-income communities.
With a greater number of people with lower SES developing obesity, these communities become vulnerable to hypertension (high blood pressure), poor sleep, diabetes mellitus, and high blood cholesterol. Findings from a meta-analysis in 2015 were particularly pronounced for education and socioeconomic status, with a 2-fold higher rate of hypertension observed in lower- compared with higher-educated individuals (Leng et al., Kershaw et al., 2011). Less educated individuals are also associated with sleep apnea, a strong correlator with CVD (Beydoun et al., 2017). These evidence all point to the fact that a lower income community is less aware of how to combat these factors of CVD. This becomes clear when a study from 2011 shows how recognition of high LDL-C increased by 13.9% in 1999 to 2004; however, awareness did not increase further through 2009 to 2010 (Muntner et al.). Clearly, this pronounces the key problem: lower income communities are less likely to become aware of the problems that they are most vulnerable to.
While there may still be genetic factors that play into who becomes more susceptible to CVD, environmental, lifestyle, and socio-economic elements become key players in the development of metabolic syndrome in individuals. In this section, we find that there is a disproportionate distribution of cardiovascular disease among communities of lower income. Furthermore, it is important to note: as a direct result of CVD, cardiac arrests are dangerous and sudden cessation of a heart. Living with CVD, individuals are more likely to experience cardiac arrests which can become deadly if they continue for too long. During a prolonged cardiac arrest, the heart no longer delivers oxygen to the brain and ensues deadly consequences. Realizing that lower income communities are more likely to get CVD, it becomes essential to realize that lower income communities are more likely to experience cardiac arrests -- and to die from them (Rainier et al.. 2006). And even more prevalent to today’s current discussion, lower SES hampers CPR training to those who most need it.
2. THE PROBLEM WITH CPR
Comparing studies from the Cardiac Arrest Registry to Enhance Survival (CARES), findings showed that the number of out-of-hospital cardiac arrest, or OHCA, events have not decreased since 2005 to 2018 in the age range of 50 to 64. This means that there has either not been increased intervention against cardiac arrests in this age group, or the interventions given are not enough to stymie this complication. One of these said interventions is cardiopulmonary resuscitation (CPR). Bystander, layperson CPR has shown to be associated with a higher rate of survival from a cardiac arrest. In comparison to waiting to go to a hospital, layperson-initiated CPR increases the rate of survival from 12.4% to up to 43.6% (American Heart Association, 2019). While 43.6% is still not a desirable survival rate, it is ranked the highest in survival rates among lay AED, EMS treatment, and others (Resuscitation Outcomes Consortium, 2014). Meaning, CPR training should be looked for as a priority when trying to deal with the disparity among lower income communities. We find, however, people of a lower socio-economic status are less likely to be trained in CPR.
Figure 1. Cardiac Arrest Survival Rates
Figure 1. When a bystander witnesses a cardiac arrest and administers CPR, the rate of survival is higher. Source: Cardiac Arrest Registry to Enhance Survival 2018 Annual Report.
According to Selby, traditional CPR certification courses were already poorly targeted to communities with a smaller chance of cardiac arrests since 1982. Since then, only about three percent of the population gets trained in CPR annually (Graham et al., 2015). In 2017, a logistical regression model showed that among lower-income and less-educated communities, the likelihood of being trained was the lowest. Even more alarming, among the 9,022 participants, 24% of those under the USA poverty line of $11,770 per capita were never trained in CPR. Of the participants, 82% who had not been trained in CPR were below the San Francisco Bay Area 2017 poverty line ($82,200 per capita). We find this disproportion again when we find how likely people are willing to perform CPR in lower income communities. In 2014, a study found that laypeople are less likely to perform CPR in low-income black or Hispanic communities than in high-income white communities (Moon et al.). While low-income communities are more prone to more cardiac arrests, this is problematic when thinking of the efficiency of where CPR training is given. To solve this disparity, then, between communities of low SES and high SES, we must take a closer look at the factors contributing to where people are getting cardiac arrests, what they need, and how they need them.
In the Committee on the Treatment of Cardiac Arrest, they identify the four main barriers that a bystander faces during a out-of hospital cardiac arrest (OHCA):
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An inability to recognize an OHCA followed by a delayed activation of EMS,
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A lack of adequate CPR training,
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Concerns about possible liability, and
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Psychological factors, rescuer confusion, and health concerns.
Proper CPR training is able to alleviate these issues if it addresses how to recognize a cardiac arrest, how to respond, and how to deal with the consequences. If there are health concerns in doing mouth-to-mouth resuscitation, a study shows that continuous chest compressions (CCC) are effective enough to help a person receive enough oxygen until further emergency medical services are reached (Ewy, 2018). Meaning, spreading awareness of proper CPR and CCC procedures can increase the chances of bystanders for helping a OHCA situation. This is shown in a study from 2013 where being introduced to the idea of CPR resulted in sustained confidence to help others (Knight et al.). Thus, it becomes favorable to train people in CPR, but it also brings to question who to train. As the American Heart Association attests, “Given that four out of five cardiac arrests occur in at home, the people most likely to be on hand to provide immediate response to CPR are family members (AHA, 2015b; Swor et al., 2003; Waalewijn et al., 2001).”
Moreover, noticing that the majority of people who experience cardiac arrests in their life start from the ages 50 and up, it becomes necessary for younger family members, such as their children, to learn CPR. This proposal becomes even more clear the necessary quality that CPR needs to achieve before reaching efficiency. Chest compression depth, chest compression rate, and the duration of interruptions to compressions are key factors that play into the success of CPR (Cheskes et al., 2014; Idris et al., 2015; Kramer-Johansen et al., 2006; Stiell et al., 2014). Being able to provide suitable continuous chest compression requires for a person to be at least 13 years old (Aelen et al., 2013; Tomlinson et al., 2007). As a result, this points to the clear conclusion: it becomes favorable for lower income communities to teach middle and high school students how to perform CPR. That way, these students will be better prepared skill-wise and psychologically to handle situations if their family members were ever to experience cardiac arrest.
Figure 2. Percentage of Cardiac Arrest by Age
Figure 2. In comparison, the number of cardiac arrests that have occurred have not significantly decreased in the last years where the majority of cardiac arrests occur beginning the age 50. Source: Cardiac Arrest Registry to Enhance Survival (CARES) 2005-2010 and 2018 Annual Report
Potential benefits of training middle and high school students of low SES become countless. For one, training students of disadvantageous backgrounds gives them an equal chance of being able to apply for jobs that require prior knowledge. If these students were ever needed in an emergency situation, they would be just as capable as their higher-income counterparts. Moreover, equipping these students provides awareness for our next generation against CVD. Educating lower income communities about lifestyle changes and better decision making can become essential in the future when students age. Looking at how disadvantaged communities in the United States are to CVD, it should not be disappointing; rather, it should be seen as an opportunity to empower the current generation.
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