State-level structural sexism and cardiovascular disease outcomes in the United States

Research links structural sexism to health in the US, but its impacts on cardiovascular disease (CVD) remain unknown. We examined: (1) associations between state-level structural sexism and CVD outcomes and (2) whether associations differed across race/ethnicity.

We linked a composite index of state-level structural sexism to participant data from the 2020 Behavioral Risk Factor Surveillance System (n = 349,329). We fit gender-stratified, multilevel linear probability models to calculate probabilities of having four CVD outcomes (diabetes, overweight/obesity, stroke, and heart attack) as a function of structural sexism exposure. Models adjusted for individual- and state-level confounders. Additionally, we investigated whether gender-stratified associations differed across race/ethnic group (Non-Hispanic White, Non-Hispanic Black, Hispanic) through inclusion of interaction terms between race/ethnicity and structural sexism.

Among women, a 1-standard deviation increase in structural sexism was associated with higher likelihood of all four CVD outcomes after adjustment for individual-level covariates. Findings remained significant only for diabetes (0.61 percentage points [pp], 95 % CI: 0.25, 0.98) and stroke (0.28 pp; 95 % CI: 0.12, 0.45) after further adjustment for state-level covariates. Similar patterns were observed for men. Results from interaction models show that associations between structural sexism and CVD outcomes were present only among Non-Hispanic White and Black women and men (all P_interaction < 0.001).

Findings highlight the need to address structural sexism to improve cardiovascular health and underscore the importance of future research to identify the mechanisms through which it operates and to guide interventions.