Elizabeth Barnett

Local Increases in Coronary Heart Disease Mortality Among Blacks and Whites in the United States, 1985-1995

OBJECTIVES This study analyzed coronary heart disease (CHD) mortality trends from 1985 to 1995, by race and sex, among Black and White adults 35 years and older to determine whether adverse trends were evident in any US localities. METHODS Log-linear regression models of annual age-adjusted death rates provided a quantitative measure of local mortality trends. RESULTS Increasing trends in CHD mortality were observed in 11 of 174 labor market areas for Black women, 23 of 175 areas for Black men, 10 of 394 areas for White women, and 4 of 394 areas for White men. Nationwide, adverse trends affected 1.7% of Black women, 8.0% of Black men, 1.1% of White women, and 0.3% of White men. CONCLUSIONS From 1985 to 1995, moderate to strong local increases in CHD mortality were observed, predominantly in the southern United States. Black men evidenced the most unfavorable trends and were 25 times as likely as White men to be part of a local population experiencing increases in coronary heart disease mortality.

Metropolitan and Non-Metropolitan Trends in Coronary Heart Disease Mortality within Appalachia, 1980–1997

OBJECTIVES In this article, we report on metropolitan and non-metropolitan trends in coronary heart disease (CHD) mortality within the Appalachian Region for the period 1980 to 1997. We hypothesized that trends in CHD mortality would be less favorable in non-metropolitan populations with diminished access to social, economic, and medical care resources at the community level. METHODS Our study population consisted of adults aged 35 years and older who resided within the 399 counties of the Appalachian Region between 1980 and 1997. We examined mortality trends for sixteen geo-demographic groups, defined by gender, age, race, and metropolitan status of county of residence. For each geo-demographic group, we calculated annual age-adjusted CHD mortality rates. Line graphs of these temporal trends were created, and log-linear regression models provided estimates of the average annual percent change in CHD mortality from 1980 to 1997. Data on social, economic, and medical care resources for metropolitan vs. non-metropolitan counties were also analyzed. RESULTS Rates of CHD mortality were consistently higher in non-metropolitan areas compared with metropolitan areas for blacks of all ages and for younger whites. CHD mortality declined among almost all geo-demographic groups, but rates of decline were slower among non-metropolitan vs. metropolitan residents, blacks vs. whites, women vs. men, and older vs. younger adults. Non-metropolitan areas had fewer socioeconomic and medical care resources than metropolitan areas in 1990. CONCLUSIONS Appalachia, particularly non-metropolitan Appalachia, needs policies and programs that will enhance both primary and secondary prevention of CHD, and help diminish racial inequalities in CHD mortality trends.

Community Occupational Structure, Medical and Economic Resources, and Coronary Mortality among U.S. Blacks and Whites, 1980–1988

PURPOSE To examine the association between coronary heart disease (CHD) mortality, economic and medical resources, and county occupational structure. METHODS U.S. counties were classified into five occupational structure categories based on the percentage of workers in white-collar occupations. Directly age-adjusted CHD mortality rates (from vital statistics and Census data) and economic and medical care data (from Census and Area Resource File data) were calculated for each occupational structure category. Participants were black and white, men and women, aged 35-64 years, in the U.S. during 1980-88. CHD mortality rates and economic and medical care data were compared across occupational structure categories. RESULTS Among blacks, CDH rates were highest in counties with intermediate levels of occupational structure; rates among whites were inversely associated with occupational structure. Per capita levels of income and numbers of medical-care providers were positively associated with occupational structure. CONCLUSION Strategies to improve the resources of disadvantaged communities and the access of black workers to local occupational opportunities may be important for CHD prevention in high risk populations.

Social Class and Race Disparities in Premature Stroke Mortality among Men in North Carolina

The purpose of this work was to examine the association between social class and premature stroke mortality among blacks and whites. For black men and white men in North Carolina, aged 35-54 years, mortality data from vital statistics files and population data from Census Public Use Microdata Sample files were matched according to social class for the years 1984-1993. Four categories of social class were defined based upon a two-dimensional classification scheme of occupations. For each category of social class, race-specific age-adjusted stroke mortality rates were calculated, and race-specific prevalences of income, wealth, education, unemployment, and disability were estimated. Women were excluded because comparable information on social class was not available from the mortality and population data sources. For both black men and white men, the highest rates of premature stroke mortality were observed among the lowest social classes. The rate ratios (RR) between the lowest and highest social class were 2.8 for black men and 2.3 for white men. Within each social class, black men had substantially higher rates of premature stroke mortality than white men (black-to-white RR ranged from 4.0 to 4.9). Among both black men and white men, the highest social class consistently had the most favorable levels of income, wealth, education, and employment. The inverse association between social class and stroke mortality for both black men and white men supports the need for stroke prevention efforts that address the structural inequalities in economic and social conditions.

Evidence of increasing coronary heart disease mortality among black men of lower social class.

PURPOSE Few data are available to examine coronary heart disease (CHD) mortality trends by social class in the United States, in contrast to ample data and well-documented social class disparities in CHD in Europe. In addition, previous analyses of U.S. national data indicated that the rate of decline in CHD mortality slowed substantially for blacks in the 1980s. Using a recently published method for calculating mortality rates by social class, we examined trends in CHD mortality for black men and white men aged 35-54 in North Carolina from 1984 to 1993. METHODS Men were assigned to one of four social classes: primary white collar (I), secondary white collar (II), primary blue collar (III), or secondary blue collar (IV), based on usual occupation as recorded on the death certificate. Population denominators for each social class were constructed using data from census Public Use Microdata Sample files. Average annual percent change in mortality rates for each race-social class group was derived from linear regression of the log-transformed age-adjusted rates. RESULTS For black men, CHD mortality increased by 18% in social class II, by 2% in social class III, and by 6% in social class IV over the 10-year study period. In contrast, CHD mortality decreased by 33% for black men in social class I (the highest class). CHD mortality declined for all white men, with the greatest decline in social class I and the least decline in social class IV. CONCLUSIONS These results suggest that CHD prevention efforts have not benefited black men of lower social class, and that public health programs need to be targeted to these men.

Social class and premature mortality among men: a method for state-based surveillance.

OBJECTIVES This study examined trends in mortality by social class for Black and White men aged 35 through 54 years in North Carolina, for 1984 through 1993, using an inexpensive, newly developed state-based surveillance method. METHODS Data from death certificates and census files permitted examination of four social classes, defined on the basis of occupation. RESULTS Premature mortality was inversely associated with social class for both Blacks and Whites. Blacks were at least twice as likely to die as Whites within each social class. CONCLUSIONS Adoption of state-specific surveillance of social class and premature mortality would provide data crucial for developing and evaluating public health programs to reduce social inequalities in health.

Urbanisation and coronary heart disease mortality among African Americans in the US South.

STUDY OBJECTIVE: Despite significant declines since the late 1960s, coronary mortality remains the leading cause of death for African Americans. African Americans in the US South suffer higher rates of cardiovascular disease than African Americans in other regions; yet the mortality experiences of rural-dwelling African Americans, most of whom live in the South, have not been described in detail. This study examined urban-rural differentials in coronary mortality trends among African Americans for the period 1968-86. SETTING: The United States South, comprising 16 states and the District of Columbia. STUDY POPULATION: African American men and women aged 35-74 years. DESIGN: Analysis of urban-rural differentials in temporal trends in coronary mortality for a 19 year study period. All counties in the US South were grouped into five categories: greater metropolitan, lesser metropolitan, adjacent to metropolitan, semirural, and isolated rural. Annual age adjusted mortality rates were calculated for each urban status group. In 1968, observed excesses in coronary mortality were 29% for men and 45% for women, compared with isolated rural areas. Metropolitan areas experienced greater declines in mortality than rural areas, so by 1986 the urban-rural differentials in coronary mortality were 3% for men and 11% for women. CONCLUSIONS: Harsh living conditions in rural areas of the South precluded important coronary risk factors and contributed to lower mortality rates compared with urban areas during the 1960s. The dramatic transformation from an agriculturally based economy to manufacturing and services employment over the course of the study period contributed to improved living conditions which promoted coronary mortality declines in all areas of the South; however, the most favourable economic and mortality trends occurred in metropolitan areas.

Joint effects of social class and community occupational structure on coronary mortality among black men and white men, upstate New York, 1988–92

Study objective: Occupational structure represents the unequal geographical distribution of more desirable jobs among communities (for example, white collar jobs). This study examines joint effects of social class, race, and county occupational structure on coronary mortality rates for men, ages 35–64 years, 1988–92, in upstate New York. Design: Upstate New York’s 57 counties were classified into three occupational structure categories; counties with the lowest percentages of the labour force in managerial, professional, and technical occupations were classified in category I, counties with the highest percentages were in category III. Age adjusted coronary heart disease (CHD) mortality rates, 35–64 years, (from vital statistics and census data) were calculated for each occupational structure category. Main results: An inverse association between CHD mortality and occupational structure was observed among blue collar and white collar workers, among black men and white men, with the lowest CHD mortality observed among white collar, white men in category III (135/100 000). About two times higher mortality was observed among blue collar than white collar workers. Among blue collar workers, mortality was 1.3–1.8 times higher among black compared with white workers, and the highest rates were observed among black, blue collar workers (689/100 000). Also, high residential race segregation was shown in all areas. Conclusions: Results suggest the importance of community conditions in coronary health of local populations; however, differential impact on subpopulations was shown. Blue collar and black workers may especially lack economic and other resources to use available community services and/or may experience worse working and living conditions compared with white collar and white workers in the same communities.