The social and cultural environment may act as a precipitant of disease, as with stressful life events; or it may influence predisposition e.g. by the level of social support. There has not been a concerted research programme to determine to what extent social and cultural variations in coronary heart disease (CHD) may be explained by similar variations in 'stress' or predisposition to it. Japanese culture is characterised by a high degree of social support. There is evidence that this may contribute to the low rate of heart disease in Japan, and among Japanese-Americans who retain their traditional culture. Preliminary findings indicate that the higher rate of heart disease in lower income groups in Britain may be associated with less social support, as well as a greater concentration of other coronary risk factors such as smoking and overweight. The link between Type-A behaviour and CHD has been replicated in women as well as men, and in Europe and the U.S.A. But the distribution in the population of Type-A behaviour does not follow the distribution of CHD.
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