1. Coke, Lola A. PhD, ACNS-BC, FAHA, FPCNA, FNAP, FAAN
  2. Hayman, Laura L. PhD, MSN, FAAN, FAHA, FPCNA

Article Content

Inequity in the social determinants of health is a key issue in the United States as the financial resources, home and neighborhood environments, and access to basic needs for food and water are severely inadequate in underrepresented minority populations. With the COVID pandemic, as people become more disadvantaged with job loss and housing issues, stress magnifies daily. In addition, the visual reality of the violence that many underserved in the United States face, disproportionately more prevalent in people of color, arose as we watched the deaths of George Floyd and Breonna Taylor unfold. These violent acts must open the dialogue among healthcare professionals to strategize how to minimize this constant stress state and mitigate its root causes in these disparate populations. Besides social determinants of health, structural racism has been identified as an important cause of stress, violence, and health disparities. Structural racism is defined as "the normalization and legitimization of an array of dynamics-historical, cultural, institutional and interpersonal-that routinely advantage White people while producing cumulative and chronic adverse outcomes for people of color."1 The implications of structural racism are important for healthcare providers to understand because it impacts the cardiovascular health of disparate populations across the lifespan.


Lukachko et al2 conducted a study to determine the impact of structural racism on myocardial infarction especially in Blacks compared with Whites. They identified 4 state-level indicator domains of structural racism that included (1) political participation (voter registration), (2) employment and job status (rate of employment and where employed), (3) educational attainment (level of education through bachelor's degree and higher), and (4) judicial treatment (ratio of incarceration).2 The results of their study showed that, in the first 3 domains, Black representation was proportionately lower than Whites. For example, the percentage of Blacks who were registered to vote by state was 85% lower on average than the percentage of registered Whites. In the judicial treatment domain, Blacks were significantly higher in the proportion of incarceration rates compared with Whites, with a range of 1.9-fold increase to a 19.0-fold increase depending on the state of residency. When comparing the domains with presence of myocardial infarction, Blacks had higher odds ratios than Whites in all domains except education, with greater prevalence of myocardial infarction in states that demonstrated higher levels of structural racism (range of odds ratios, 1.32-1.74; 95% confidence interval, 1.08-2.04). This study clearly demonstrates the relationship between aspects of structural racism and cardiovascular health.


Racism results in chronic discrimination, stress, and depression that adversely impact persons from historically marginalized populations. Adverse childhood through adult experiences accelerates toxic stress. This toxic stress results in constant release of stress hormones that can cause maladaptive changes in gene expression, and structural and functional remodeling of brain and other organs in the body.3 Other researchers have demonstrated deleterious effects of chronic stress caused from structural racism that manifests as unhealthy coping behaviors such as smoking, unhealthy eating, and substance abuse, all contributing factors to cardiovascular health.4 In addition, there is research that demonstrates that limiting access to critical resources and power, such as education, employment, safe housing and living environments, quality healthcare, and political representation, causes harmful health effects.5


Although there have been strides to reduce deaths due to cardiovascular disease, there continues to be disparity in racial and ethnic groups, with Blacks experiencing 30% to 45% higher mortality than other groups.6 In late 2020, the American Heart Association published a call to action to address structural racism as a cause of health disparities in the United States.1 This call to action discusses the historical context and the current state of structural racism. It describes potential solutions to address structural racism to combat cardiovascular disease in underrepresented minorities who live with the effects of structural racism. Clearly, as part of the call, it is the responsibility of all healthcare providers to do what they can to mitigate the effects of structural racism on all racial and ethnic groups, but especially Blacks. In addressing the future, there are 5 action items that were identified for all individuals. First, policies and interventions must be implemented at the individual, community, and population levels that allow disenfranchised racial and ethnic groups equitable access to the resources needed to promote optimal health. Second, there needs to be advocacy for policies that improve living environments including housing and neighborhoods to improve not only physical health but also mental health. Third, there is a need for strategies to improve access to quality healthcare for all. Fourth, there is a need for allyship-the opportunity to understand and accept racial differences and attitudes resulting in empathy for these differences. Finally, for those who conduct research, developing studies in which authors investigate all types of racism (structural, interpersonal, cultural, and anti-Black) and their impact on health outcomes and health disparities is merited.


As a national organization, the American Heart Association is committing its energies and resources toward efforts to actively combat all forms of racism in the United States and globally. They identify the following strategies as a call to action that impacts all of us in cardiovascular care:


1. Embrace antiracism and work with other organizations to partner to share these values.


2. Overcome structural racism through education, quality improvement, and advocacy.


3. Develop and support national awareness of structural racism and promote national reconciliation around race.


4. Build an antiracism research agenda, with input from key stakeholders.


5. Intentionally address racism and structural inequities as fundamental causes of disparities.


6. Enhance programs in quality improvement to include health disparities that provide improvement in data collection on race, ethnicity, and social determinants of health.



We all share the responsibility to work with our communities to share allyship and optimize healthcare for all. It is our role to embrace these strategies and use them whenever possible. Nurses are in a key stakeholder role to address these issues at all levels of healthcare.




1. Churchwell K, Elkind MSV, Benjamin RM, et al. American Heart Association. Call to action: structural racism as a fundamental driver of health disparities: a presidential advisory from the American Heart Association. Circulation. 2020;142:e454-e468. [Context Link]


2. Lukachko A, Hatzenbuehler ML, Keys KM. Structural racism and myocardial infarction in the United States. Soc Sci Med. 2014;103:42-50. [Context Link]


3. Albert MA, Slopen N, Williams D. Cumulative psychological stress and cardiovascular disease risk: a focused review with consideration of black-white disparities. Curr Cardiovasc Risk Rep. 2013;7:318-325. [Context Link]


4. Keyes KM, Barnes DM, Bates LM. Stress, coping and depression: testing a new hypothesis in a prospectively studied general population sample of U.S.-born Whites and Blacks. Soc Sci Med. 2011;72(5):650-659. [Context Link]


5. Kreiger N. Methods for the scientific study of discrimination and health: An ecosocial approach. Am J Public Health. 2012;102(5):936-944. [Context Link]


6. Centers for Disease Control and Prevention. About underlying cause of death, 1999-2018. Accessed January 25, 2021. [Context Link]