Health Equity Indicators for Cardiovascular Disease (CVD) Toolkit
Applying an Equity Approach to Cardiovascular Health
Download this visual two-page summary: Health Equity Indicators for Cardiovascular Disease Toolkit: A Spotlight [PDF – 405 KB].
Download the Executive Summary: Applying an Equity Approach to Cardiovascular Disease [PDF – 307 KB].
Download the full Toolkit: Health Equity Indicators for Cardiovascular Disease Toolkit [PDF – 58 MB].
Cardiovascular disease (CVD) remains the leading cause of death in the United States. Despite advances in clinical care and treatment, stark inequities in cardiovascular risk factors [PDF – 561 KB] and outcomes persist by race and ethnicity, socioeconomic status, geography, and other factors.
Extensive research has shown that social, economic, and environmental factors shape health outcomes even more than what happens inside clinic walls. Therefore, measurement and evaluation approaches need to consider these factors, especially the systems and structures that influence them.
This toolkit presents health equity indicators (HEIs) across eight focus areas, or health equity themes, which influence inequities in cardiovascular disease prevention, care, and management as outlined in the HEI Conceptual Framework for CVD.
HEI Conceptual Framework for CVD
The Framework is based on the Social-Ecological Model and provides a model for understanding health inequities in CVD by graphically representing how HEIs are interconnected and occur through structural and socioenvironmental drivers, across socio-ecological levels, and throughout the lifespan.
Image description: A chart with X and Y axes showing nested circles. The X axis represents life course stages from left to right: in utero, infancy, childhood, and adulthood. The Y axis represents socioecological levels, from bottom to top: individual, interpersonal, organizational, community, and systems. The nested circles contain four layers that represent the health equity focus areas. The outer layer of the circle contains racism; classism; and genderism, sexism, and heterosexism; the next layer is policy; the third layer contains neighborhood characteristics, healthcare access, and socioeconomic factors. The innermost layer of the circle is labeled inequities. An arrow cuts across the nested layers to represent the psychosocial pathways focus area. The arrow points to the right, towards a circle labeled Cardiovascular Health and Well Being, to illustrate how cardiovascular health and well-being are affected by inequities across the 8 focus areas. The health equity focus area layers overlap each other to indicate that these areas are interconnected across socio-ecological levels and throughout the lifespan to influence cardiovascular health.
An indicator profile is available for each focus area (except for classism1) to describe the relevance of the indicators and provide specific measures that health departments or health care organizations may use to support their health equity efforts.
Learn more about the HEI Conceptual Framework for CVD
Inequities are greatly shaped by the consequences of historical and current societal norms, policies, and practices that systematically reduce access to resources for groups that have been marginalized.
The framework recognizes systemic inequities (e.g., racism, genderism/sexism/heterosexism, classism) that have produced policies that created or worsened socioeconomic deprivation, segregation of neighborhoods and schools, and unjust disparities in the quality of and access to health care. The discrimination, inequities, and barriers brought by these factors can create toxic stressors (acute and chronic) that affect psychosocial well-being across the course of an individual’s life.
Each of these factors affects and is affected by interpersonal relationships and social networks; the organizations that provide services or information to individuals; the built environments and communities in which individuals live, work, and play; and the broader systems or enabling environments that govern societal norms and policies. These domains, in and of themselves and in combination with other domains, shape and constrain the ability to engage in healthy behaviors and raise the risks of cardiovascular disease and mortality.
What is the HEI for CVD Toolkit?
The Health Equity Indicators for Cardiovascular Disease (HEI for CVD) toolkit includes a wide range of health equity indicators (HEIs) that can serve as a resource and inspire health care and public health professionals to incorporate health equity–relevant metrics and processes into strategic planning, site selection, and evaluation.
Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health.2 HEIs represent measurable constructs that have been shown to be important for understanding the causes of inequities in cardiovascular disease (CVD) and can be used to measure health inequities.
The toolkit includes the following components:
- Health Equity Indicator Profiles provide definitions and measurement guidance for each HEI. Case Examples and Field Notes are included throughout.
- Glossary of Terms provides definitions for frequently used terms and concepts in the HEI for CVD Toolkit.
- Related Resources are other CDC and external resources that support health equity measurement and evaluation and advance health equity work.
Who is the HEI for CVD Toolkit for?
The toolkit provides local health jurisdictions, city governments, health care organizations, and other agencies with information about equity promoting activities and associated measures to improve cardiovascular health in disproportionately affected communities.
What is the intended use of the HEI for CVD Toolkit?
Indicators profiled in this toolkit can be used to understand inequities at institutional and structural levels and measure efforts to reduce inequities in CVD and mortality rates within specific populations.
These indicators can serve as a resource for health care and public health professionals who seek to incorporate equity-relevant metrics, measurement considerations, and inclusive community engagement processes into their work. However, they are not a comprehensive set of all measures that matter for cardiovascular equity.
Public health and health care professionals can use this toolkit to
- Identify gaps between what is currently measured and what can be measured.
- Consider new data collection methods for identifying root causes and key drivers of inequities.
- Consider upstream and structural factors that influence lifestyles and behaviors, environments and communities, and access to early detection and treatment of CVD.
- Identify possible indicators and measures that can bolster current evaluation efforts.
- Use resources and case examples to guide health equity measurement and evaluation.
How can I navigate the HEI for CVD Toolkit?
Visit specific focus areas that correlate with poor cardiovascular health (e.g., Policy) under each Health Equity Indicator Profile. Each focus area provides a definition of the focus area and lists indicators and measures for the focus area.
Case Examples and Field Notes are included throughout the Health Equity Indicator Profiles. The Case Examples and Field Notes include short summaries that describe an organization’s experience with gathering data for specific indicators and lessons learned.
Selecting an indicator (e.g., Spending Per Capita) from the focus areas shows users the definition of each indicator, presents evidence on the importance of the indicator related to health and CVD, lists measures for operationalizing the indicator, and lists case examples related to the indicator if applicable.3 To learn how to assess indicators, users can view the measures (e.g., Per Capita Spending on Health Care). Measure (e.g., Per Capita Spending on Health Care) provide users with data sources, measurement guidance, and relevant case examples (if applicable).
For additional resources on how to support health equity work, visit the Related Resources page. Users should refer to the Glossary of Terms page to find definitions for commonly used terms in the HEI for CVD Toolkit.
How was the HEI for CVD Toolkit developed?
An initial literature scan was conducted in 2017 to identify the primary topics and themes most relevant for addressing equity within the context of prevention and management of CVD. The literature review was updated in 2021 and identified eight focus areas that are correlated with poor CVD health outcomes for groups that have been historically marginalized.
Findings from the literature review informed the development of the initial conceptual framework, which then provided the structure for the development of the HEIs. For each focus area, CDC developed indicators as a way to operationalize the health equity themes and measure health inequities.
CDC conducted a pilot test of a subset of HEIs to assess the feasibility of gathering and analyzing data on these indicators within health care settings. Seven health care organizations participated in the HEI Pilot Study from January to April 2022. Findings from the pilot were used to update and clarify the guidance provided within the HEI Profiles and develop case examples that illustrate the real-world application (data collection, analysis, and use) of HEIs to inform health equity efforts within health care organizations.
CDC also conducted a yearlong pilot at the Grady Health Camp Creek Comprehensive Care Center. The purpose of the Patient Informed HEI Pilot Study was to understand patient lived experiences with CVD through the collection of equity-focused indicators derived from quantitative and qualitative data. CDC collaborated with Melvin Echols, MD, and Sameia Udoji to recruit and interview patients. A unique component of this pilot was that the purpose was to capture the patient’s perspective. Findings from this pilot will assist in identifying common causes and key drivers of inequities, gain a deep understanding of patients living with CVD in an outpatient setting, and inform and strengthen ongoing quality improvement at outpatient centers. It also examines the process of collecting data on these selected indicators, including the barriers and facilitators to help inform their use.
CDC engaged with various external subject matter experts (SMEs) to inform the development of the HEI Conceptual Framework and Toolkit. SMEs included researchers and practitioners.
The researcher SMEs were academic experts in health equity and CVD who provided input on the conceptual framework, conceptualized the indicators, identified existing measures and data sources for operationalizing the HEIs, and outlined measurement considerations for the indicator profiles. They also actively informed the development, implementation, and analysis of the pilot study. The practitioner SMEs were experts in applying evidence in their clinical and public health work, who provided practical considerations for measurement guidance in the indicator profiles and shared lessons learned via case examples and field notes.
The HEI for CVD Toolkit is a collaborative effort among the Centers for Disease Control and Prevention (CDC) Division for Heart Disease and Stroke Prevention (DHDSP) Evaluation and Program Effectiveness Team (EPET), Prevention Institute, and Deloitte Consulting. The project began with a literature review conducted by EPET in 2017. From 2020 to 2021, EPET collaborated with Prevention Institute and a panel of SMEs to conceptualize the health equity indicators, draft a conceptual framework, and draft indicator profiles for the HEIs based on EPET’s literature scan. The HEIs, indicator profiles, and conceptual framework were further refined and expanded by Deloitte Consulting and two independent SMEs contracted by Deloitte Consulting from 2021 to 2022.
CDC engaged various SMEs and health care organizations through small workgroups and one-on-one sessions to inform toolkit development. SMEs provided technical insight, methodological considerations, and measurement guidance.
Additionally, seven health care organizations participated in a pilot test of a subset of indicators from January 2022 to March 2022. CDC also conducted a patient informed pilot test with Grady Health Camp Creek Comprehensive Care Center from August 2021 to August 2022. Lessons learned from the pilots are captured in the case examples, which document organization’s experience with HEI data collection.
CDC thanks all partners, SMEs, and pilot sites for their contributions to the development of this toolkit.
Subject Matter Experts
Amani Allen, PhD, MPH
Executive Associate Dean
Community Health Sciences and Epidemiology
UC Berkeley School of Public Health
Sharrelle Barber, ScD, MPH
Epidemiology and Biostatistics
Dornsife School of Public Health at Drexel University
Jonathan Z. Butler, PhD, MDiv
Assistant Professional Researcher
Department of Family Community Medicine
CeNter for the StUdy of AdveRsiTy CardiovascUlaR DiseasE (NURTURE Center)
Division of Cardiology, Department of Medicine
University of California, San Francisco
David Chae, ScD, MA
Associate Dean for Research
Director, Society, Health and Racial Equity (SHARE) Lab
Global Community Health and Behavioral Sciences
Tulane University School of Public Health and Tropical Medicine
Yvonne Commodore-Mensah, PhD, MHS, RN, FAHA, FPCNA, FAAN
Johns Hopkins School of Nursing
Chandra Ford, PhD, MPH, MLIS
Department of Community Health Sciences
Center for the Study of Racism, Social Justice & Health
Fielding School of Public Health at the University of California at Los Angeles
Allana Forde, PhD, MPH
Epidemiology and Genetics Research
National Institutes of Health Intramural Research Program
Tracy Hilliard, PhD, MPH
Center for Culturally Responsive Engagement
Health Equity & Community Health
Michigan Public Health Institute
Tené Lewis, PhD, MA
Rollins School of Public Health at Emory University
Mahasin Mujahid, PhD, MS, FAHA
Lillian E.I. and Dudley J. Aldous Chair in Public Health
University of California, Berkeley School of Public Health
Anekwe Onwuanyi, MD, FACC
Morehouse School of Medicine
Jasmine Opusunju, DrPH, MSEd, MCHES, CPH
Clinical Assistant Professor
Social and Behavioral Health Sciences
Somava Saha, MD, MPH
Well Being in the Nation (WIN) Network
Institute for Healthcare Improvement
100 Million Healthier Lives Initiative
Community Health/Healthy Equity and Well-Being
Well Being Trust
Sharon Austin, PhD
Owner and Director
Water’s Edge Consulting
Samantha De Leon, PhD
Program Evaluation, Research, and Analysis
New York City Department of Health
Tony Kuo, MD, MSHS
Division of Chronic Disease and Injury Prevention
LA County Department of Public Health
Melvin Echols, MD, FACC
Chief Diversity Officer
American College of Cardiology
Cardiovascular Disease Fellowship
Grady Cardiovascular Line Research Committee
Department of Medicine
Morehouse School of Medicine
Cardiovascular Medical Director
Grady Health Camp Creek Comprehensive Care Center
Chief Administrator Officer
Williamson County Cities Health District
Victoria M. Nielsen, MPH
Office of Statistics & Evaluation
Massachusetts Department of Public Health
James Peacock, MPH, PhD
Epidemiologist Supervisor Senior
Health Promotion and Chronic Disease Division
Minnesota Department of Health
Myduc Ta, PhD
DPH Assessment, Policy Development and Evaluation Unit
Public Health—Seattle & King County
Sameia Udoji, NP
Grady Health Camp Creek Comprehensive Care Center
Elizabeth Yoder, MPH
Former Program Manager
Clay County Public Health Center
Dignity Health, St. Joseph’s Hospital and Medical Center
Los Angeles County Department of Public Health
ProMedica Toledo Hospital
Ventura County Community Health Improvement Collaborative
Grady Health Camp Creek Comprehensive Care Center
References and Footnotes
- Although classism is an important determinant of CVD inequities, indicators of classism are similar to those specified for other focus areas (e.g., racism, socioeconomic factors, neighborhood characteristics, policy). Therefore, there is not a separate indicator profile for classism.
- Centers for Disease Control and Prevention. Advancing Health Equity in Chronic Disease Prevention and Management. Updated December 8, 2022. Accessed June 3, 2022.
- Not all indicators and measures have a relevant case example.