Independent, stratified, and joint associations of individual-level and area-level socioeconomic status with cardiovascular disease in adults: Systematic review and meta-analysis — The Association Specialists
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  3. Independent, stratified, and joint associations of individual-level and area-level socioeconomic status with cardiovascular disease in adults: Systematic review and meta-analysis

Independent, stratified, and joint associations of individual-level and area-level socioeconomic status with cardiovascular disease in adults: Systematic review and meta-analysis (24201)

Anh Tung Pham 1 , Michalis Stylianou 2 , Stephanie L Duncombe 1 , Ruyi Yu 1 , Gregore Iven Mielke 1
  1. School of Public Health, The University of Queensland, Brisbane, QLD, Australia
  2. School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, QLD, Australia

Background

Although socioeconomic status (SES) is a key predictor of CVD outcomes, available literature syntheses have focused on associations between either individual-level SES (iSES) or neighborhood-level SES (nSES) and CVD outcomes. Therefore, this systematic review and meta-analysis aimed to synthesize the independent, stratified, and joint association between iSES and nSES and CVD incidence and mortality.

Methods

Six databases were searched in August 2025. Articles were included if they represented original research published in English; used population-based cohort data; included adults without CVD at baseline; focused on CVD incidence and mortality; and examined independent (one iSES and one nSES indicator), stratified (by iSES or nSES), and/or joint (iSES and nSES) associations with CVD outcomes. Random-effect models were used with pooled hazard ratios (HR) and 95% confidence intervals (95% CIs) for each type of association with CVD outcomes.

Results

Eighteen studies were included (CVD incidence = 6, CVD mortality = 10, both outcomes = 2). Meta-analytic results from independent associations indicated that low iSES and nSES were associated with higher CVD incidence (HR (95% CIs): 1.42 (1.29-1.57) and 1.16 (1.07-1.26)) and mortality risk (HR: 1.33 (1.20-1.47) and 1.22 (1.10-1.36)) compared with high iSES and nSES. In meta-analyses focusing on stratified associations, participants with lower iSES or who lived in lower nSES had a higher risk of CVD mortality. Overall, those with low iSES and living in low nSES had 57% higher CVD mortality risk compared to those with high iSES and living in high nSES (HR: 1.57 (1.23-2.00)).

Conclusions

This study demonstrates that while low iSES or nSES are associated with increased risk of CVD outcomes, while the largest association is observed among individuals with low iSES and living in low nSES. These findings suggest that CVD prevention strategies must move beyond individual-level interventions to address the structural inequities within neighborhoods.