Assessing Neighborhood-Level Effects on Disparities in Cardiovascular Diseases
2014; Lippincott Williams & Wilkins; Volume: 131; Issue: 2 Linguagem: Inglês
10.1161/circulationaha.114.013871
ISSN1524-4539
AutoresAdolfo Correa, Sophia Greer, Mario Sims,
Tópico(s)Cardiovascular Health and Risk Factors
ResumoHomeCirculationVol. 131, No. 2Assessing Neighborhood-Level Effects on Disparities in Cardiovascular Diseases Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBAssessing Neighborhood-Level Effects on Disparities in Cardiovascular Diseases Adolfo Correa, MD, PhD, Sophia Greer, MPH and Mario Sims, PhD Adolfo CorreaAdolfo Correa From the Department of Medicine, University of Mississippi Medical Center, Jackson, MS (A.C., M.S.); and the Division for Cardiovascular Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (S.G.). , Sophia GreerSophia Greer From the Department of Medicine, University of Mississippi Medical Center, Jackson, MS (A.C., M.S.); and the Division for Cardiovascular Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (S.G.). and Mario SimsMario Sims From the Department of Medicine, University of Mississippi Medical Center, Jackson, MS (A.C., M.S.); and the Division for Cardiovascular Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (S.G.). Originally published1 Dec 2014https://doi.org/10.1161/CIRCULATIONAHA.114.013871Circulation. 2015;131:124–127Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 13, 2015: Previous Version 1 Race and Ethnic Disparities in Cardiovascular DiseasesDespite declines in mortality from cardiovascular diseases (CVDs) and many CVD risk factors, CVD remains the leading cause of death in the United States, and racial and ethnic disparities persist. In 2010, rates of CVD mortality per 100 000 were: 192.2 for white women; 260.5 for black women; 278.4 for white men; and 369.2 for black men.1 In 2009 and 2010, metrics of ideal cardiovascular health factors (ie, blood pressure, physical activity, healthy diet, healthy weight, smoking status, and glucose) were noted to be lower for blacks and Mexican Americans than for whites or other racial groups.1 In 2012, the following age-adjusted prevalence estimates among nonwhite adult populations were noted compared with the white population:2 (1) the prevalence of heart disease and coronary heart disease (CHD) was similar in blacks, lower in Hispanics and Asians, and higher in American Indians/Alaska natives, and native Hawaiian or other Pacific Island populations; (2) the prevalence of hypertension was higher in blacks, similar or lower in Hispanics and Asians, and higher in American Indians/Alaska natives, and native Hawaiian or other Pacific island populations; and (3) the prevalence of having had a stroke was higher in blacks, lower in Hispanics, and lower in Asian populations.Article see p 141The persistence of racial and ethnic disparities in CVD is a major public health problem that calls for more understanding of root causes that may inform evidence-based deliberations and policies. Studies have shown that racial and ethnic disparities in CVD: (1) appear to remain after adjusting for known individual-level risk factors such as blood pressure, smoking, body mass index (BMI), and socioeconomic status (SES);3 and (2) tend to vary with age, time, and geography.4,5 These observations suggest that neighborhood-level social or environmental factors not captured by conventional measures of SES (eg, neighborhood segregation, discrimination, perceptions of neighborhood) need to be considered as potential drivers of such disparities and as priority areas for population-based research.Within this context, one factor that has received increasing attention in epidemiological research is racial/ethnic residential segregation, defined as "the degree to which two or more racial/ethnic groups live separately from one another."6 The study by Kershaw et al.7 in this issue of Circulation is important in this regard. Based on data from the Multi-Ethnic Study of Atherosclerosis (MESA), and a novel measure of neighborhood residential segregation, the study shows associations between racial/ethnic residential segregation and an increased CVD risk for blacks, decreased risk for whites, and no effect for Hispanic participants in the study. After accounting for demographics (ie, age, sex, study site, and nativity for Hispanics), neighborhood covariates (ie, neighborhood poverty, neighborhood social environment, and neighborhood physical environment), socioeconomic position (ie, education, income, and health insurance status), and clinical risk factors (ie, systolic blood pressure, total cholesterol, HDL cholesterol, diabetes mellitus, BMI, cigarette smoking, current alcohol use, and physical activity), these associations remained for black but not for white participants. Analyses by subgroup of CVD revealed an association between residential segregation and increased risk for CHD only among black participants. No associations were evident for residential segregation and increased or decreased risk for CHD in other race/ethnicity groups or for incident stroke or stroke death for any of the race/ethnicity groups examined. The differences in the association by race/ethnicity could reflect both the harmful effects of segregation through social and economic isolation and the beneficial effects of segregation through social support. This study highlights 4 important points: (1) knowledge and knowledge gaps related to residential segregation and CVD disparities; (2) value of new developments in measuring neighborhood residential segregation; (3) opportunities for future research in residential segregation and CVD outcomes; and (4) implications for research and policies regarding residential segregation as a contributor to CVD disparities by race/ethnicity.Knowledge Gaps Related to Racial Residential Segregation and CVDHistorically, residential segregation in the United States resulted from discriminatory housing practices, laws, and economic and educational institutions that limited choices and created neighborhoods that were racially separate. Although the Civil Rights Act of 1968 made housing discrimination illegal, the effects of these practices coupled with institutional discrimination led to the lack of social and economic investment in the predominantly minority neighborhoods, and to persistent lack of access to educational, economic, social, and health opportunities.8 Currently, black and Hispanic populations are more likely to live in neighborhoods that are poor and lack social and economic opportunities compared with their white counterparts.9,10 These neighborhoods are characterized by a high prevalence of poverty, lack of access to physical activity resources and healthy foods, unsafe conditions, and fewer educational resources.8,11 These are contributing factors to CVD disparities.Several knowledge gaps are identified by Kershaw et al with regard to the role of racial/ethnic segregation in CVD risk. First, segregation is often examined in relation to mortality but has not been examined in relation to incident CVD. Second, the pathways by which segregation operates to increase risk of CVD have not been identified. Third, segregation has not often been modeled as a time-varying predictor to account for differential exposure across the life course. Fourth, the occurrence of segregation may be a result of individual and family choices (eg, being close to a group with similar culture, religious practices, language, physical activity, diet, and social cohesion), which could have a beneficial effect on health, but these beneficial effects of segregation have not been fully explored.Evaluating the impact of residential segregation on CVD risk requires conceptual models that trace the pathways from residential segregation to CVD risk. Kershaw et al modeled residential segregation as a main predictor of CVD incidence and biological, behavioral, and select neighborhood characteristics as potential confounders, mediators, or pathways. Although these additional covariates/characteristics modeled in the Kershaw et al paper were found to confound or mediate the association of segregation and CVD risk for white participants but not for black participants, several additional neighborhood characteristics that could impact CVD risk, such as access to health care and quality of health care,12 were not included and should be explored in future studies.Value of New Developments in Measures of Residential SegregationIn their assessment of residential segregation and CVD risk, Kershaw et al used the Getis-Ord Gi* statistic, which measures the extent to which the number or proportion of the racial/ethnic population that resides in the census tract (as well as neighboring census tracts) varies from the mean racial/ethnic composition of the larger areal unit (in this case, a set of counties) represented in each metropolitan area site in the MESA cohort. Higher positive Gi* scores indicate higher segregation (or clusters of relatively high proportions of a racial/ethnic group), whereas lower scores near 0 represent lower segregation (or neighborhoods with relatively similar concentrations of a racial/ethnic group compared with larger geographic area). Lower negative scores indicate underrepresentation (or clusters of relatively lower concentrations of the racial/ethnic group compared with the larger geographic area). The authors highlighted that this measure is an improvement on the census tract-level racial composition measure, which has served as a proxy for residential segregation in much of the previous neighborhood segregation literature. Using a similar technique, the Figure shows a national view of the census-tract level Getis Gi* segregation measure for blacks, whites, and Hispanics for the contiguous United States. These data are from the 2000 US Census. As shown in the Figure, there is significant geographic variation of highly segregated neighborhoods among whites, blacks, and Hispanics.Download figureDownload PowerPointFigure. Maps show clusters of high and low concentrations of whites, blacks, and Hispanics in US census tracts. Dark red areas represent hot spots or highly segregated areas in which the racial/ethnic group is clustered. Dark blue spots represent cold spots or areas in which the particular race group is underrepresented. The areas in between represent areas where the proportion of the race/ethnic group does not differ significantly than expected. Data Source: US Census, 2000; Analysis performed in ArcMap10.1 (ESRI, Redlands, CA). Std. Dev. indicates standard deviation.Use of the Gi* statistic is also important in that it adds an additional neighborhood-level approach to the residential segregation literature, which has been most commonly conceptualized and examined at the metropolitan level.13 This is an important distinguishing feature of the work by Kershaw et al. The process of segregation can operate at many geographic levels. Use of metropolitan-level measures of segregation may help to identify macrolevel interventions that may be considered for mitigating the effects of structural inequality on CVD phenotypes. On the other hand, neighborhood-level segregation measures describe more proximal processes that affect how social and economic resources are distributed within neighborhoods and may help to identify potential interventions at the microlevel.Although spatial measures of segregation improve the measurement of segregation on the neighborhood scale, challenges still remain. There is no standard measure of neighborhood segregation that limits the ability to compare one study with another. Also, the spatial scale at which segregation is measured influences the value of the segregation metric as well as the interpretability. Reliance on census tracts and other administrative boundaries may not reflect the level at which segregation is operating. Consequently, it has been suggested that the interpretation of segregation may vary by the measure used and the geographic scale.14Opportunities for Future ResearchFuture work examining the relationship between racial residential segregation in different populations and CVD should examine multiple dimensions of segregation with CVD risk in order to delineate the extent to which segregation operates at the neighborhood scale, metropolitan scale, or other geographic scale. Such analyses will help public health practitioners and policymakers determine at what geographic scale programs aimed at ameliorating the effects of segregation will be most effective. Using different measures of segregation (eg, clustering and dissimilarity index) by race/ethnicity and SES could help define the processes by which segregation may operate. Given that segregation operates through a variety of different pathways outside of limiting education and economic opportunities, future work should expand to examine how factors such as housing, transportation, and labor markets help explain the association between segregation and cardiovascular health.To gain further insight into the findings by Kershaw et al, additional analyses could be conducted to identify pathways by which segregation influences cardiovascular health. For instance, Jargowsky used the neighborhood typology proposed in his seminal work15 and found that the distribution of neighborhoods by poverty status (high, low, and none) was directly associated with less favorable social and economic life chances (ie, education, job, family formation, etc.) in US metropolitan areas. Using such an approach or other similar methodologies in racial residential segregation research could possibly show how segregation differentially exposes different population groups to conditions that predispose them to CVD or to other chronic disorders.Future work should utilize Geographic Information Systems (GIS) tools such as mapping and spatial statistics, including the segregation measure used in the Kershaw et al paper, to examine spatial relationships between segregation and CVD risk. The presentation of GIS tools, such as maps, could provide a clear visualization and better appreciation of the findings from the statistical models of segregation and CVD. Another possibility for future research is the use of path analysis methods that may enable separation of the direct, indirect, and mediating effects between racial residential segregation and CVD risk. This method can estimate the potential for bidirectionality in the association between racial residential segregation and CVD risk through nonrecursive modeling. Because individual-level and neighborhood-level factors do not occur in isolation, the simultaneity of estimation used in path analysis16 may enable the researcher to portray a more realistic effect of segregation on CVD.The work by Kershaw et al suggests a number of additional research questions for consideration for future research. Examples of such questions include: the extent to which CVD risk from residential segregation might vary with degree, duration, and age of exposure to residential segregation; the extent to which CVD risk from residential segregation might be amenable to amelioration by implementation of focused interventions; the relative impacts of independent and joint effects of SES and racial/ethnic segregation on CVD risk and how these might vary by race/ethnicity group; and possible factors that could account for the beneficial health effects resulting from neighborhood segregation of majority racial/ethnic groups. Such evaluations may suggest beneficial factors (eg, availability of healthier diet choices, access to health services, safe environment, and greater opportunities for physical activity) that could become part of pilot or prototype interventions for possible replication and evaluation in neighborhoods characterized by poorer health outcomes.Implications for Intervention DeliberationsThe work by Kershaw et al has implications for deliberations on addressing racial/ethnic inequities in CVD. Public health interventions designed to reduce disparities in CVD should consider the barriers and consequences that result from residing in racially segregated neighborhoods. Some of the broader social factors that could be associated with residential segregation and should be considered are concentrated poverty, lack of access to quality health care, lack of access to healthy foods, and lack of physical activity resources.8,11,17 These contextual factors are likely to be barriers to medication adherence, adoption of healthy dietary practices, and efforts to increase physical activity levels and will need to be taken into account in the development of intervention efforts targeted to the needs of different groups in a given community, particularly the most vulnerable groups. At the neighborhood level, formulation of interventions will need to consider efforts on various fronts, ranging from improving social and economic conditions to more structural changes such as improving access to healthy foods and physical activity resources. These tasks are daunting, with no simple or readily available solutions, but such tasks need to be given appropriate attention and priority to ensure that future interventions have a strong likelihood of success in reducing racial/ethnic disparities in CVD in a substantive manner. From a public health policy perspective, it will be important to identify neighborhood-level interventions that address these underlying social and economic conditions and are effective in reducing CVD disparities resulting from racial residential segregation. Securing and sustaining interventions aimed at modifying social and economic conditions will be a critical challenge and an opportunity for policymakers. Such changes will be necessary to ensure that the concentration of segregated and under-resourced neighborhoods and related adverse health effects in the residents of such neighborhoods will be minimized and, eventually, eliminated.DisclosuresThe findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Drs Correa and Sims were supported by contracts HHSN268201300046C, HHSN268201300047C, and HHSN268201300049C from the National Heart, Lung, and Blood Institute and the National Institute on Minority Health and Health Disparities, and by a subaward from P60MD002249-01 (Diez-Roux) from the National Institute on Minority Health and Health Disparities. The authors have indicated no financial conflicts of interest.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Adolfo Correa, MD, PhD, Department of Medicine, University of Mississippi Medical Center, 2500 North State St, Jackson, MS 39216. E-mail [email protected]References1. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, Dai S, Ford ES, Fox CS, Franco S, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Huffman MD, Judd SE, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Mackey RH, Magid DJ, Marcus GM, Marelli A, Matchar DB, McGuire DK, Mohler ER, Moy CS, Mussolino ME, Neumar RW, Nichol G, Pandey DK, Paynter NP, Reeves MJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Wong ND, Woo D, Turner MB; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2014 update: a report from the American Heart Association.Circulation. 2014; 129:e28–e292. doi: 10.1161/01.cir.0000441139.02102.80.LinkGoogle Scholar2. Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for US adults: national health interview survey, 2012.Vital Health Stat 10. 2014:1–161.MedlineGoogle Scholar3. Diez-Roux AV, Nieto FJ, Muntaner C, Tyroler HA, Comstock GW, Shahar E, Cooper LS, Watson RL, Szklo M. Neighborhood environments and coronary heart disease: a multilevel analysis.Am J Epidemiol. 1997; 146:48–63.CrossrefMedlineGoogle Scholar4. Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the United States.Circulation. 2005; 111:1233–1241. doi: 10.1161/01.CIR.0000158136.76824.04.LinkGoogle Scholar5. Diez Roux AV, Mair C. Neighborhoods and health.Ann N Y Acad Sci. 2010; 1186:125–145. doi: 10.1111/j.1749-6632.2009.05333.x.CrossrefMedlineGoogle Scholar6. Massey DS, Denton NA. The dimensions of residential segregation.Social Forces. 1988; 67:281–315.CrossrefGoogle Scholar7. Kershaw KN, Osypuk TL, Do DP, De Chavez PJ, Diez-Roux AV. Neighborhood-level racial/ethnic residential segregation and incident cardiovascular disease: the multi-ethnic study of atherosclerosis.Circulation. 2015; 131:141–148.LinkGoogle Scholar8. Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health.Public Health Rep. 2001; 116:404–416.CrossrefMedlineGoogle Scholar9. Logan JR. The Persistence of Segregation in the 21(st) Century Metropolis.City Community. 2013; 12:. doi: 10.1111/cico.12021.CrossrefMedlineGoogle Scholar10. Osypuk TL, Galea S, McArdle N, Acevedo-Garcia D. Quantifying separate and unequal: racial-ethnic distributions of neighborhood poverty in metropolitan America.Urban Aff Rev Thousand Oaks Calif. 2009; 45:25–65. doi: 10.1177/1078087408331119.CrossrefMedlineGoogle Scholar11. Kramer MR, Hogue CR. Is segregation bad for your health?Epidemiol Rev. 2009; 31:178–194. doi: 10.1093/epirev/mxp001.CrossrefMedlineGoogle Scholar12. Sarrazin MV, Campbell M, Rosenthal GE. Racial differences in hospital use after acute myocardial infarction: does residential segregation play a role?Health Aff (Millwood). 2009; 28:w368–w378. doi: 10.1377/hlthaff.28.2.w368.CrossrefMedlineGoogle Scholar13. Massey DS, Denton NAAmerican Apartheid: Segregation and the Making of the Underclass. Boston, MA: Harvard University Press; 1993.Google Scholar14. Kramer MR, Cooper HL, Drews-Botsch CD, Waller LA, Hogue CR. Do measures matter? Comparing surface-density-derived and census-tract-derived measures of racial residential segregation.Int J Health Geogr. 2010; 9:29. doi: 10.1186/1476-072X-9-29.CrossrefMedlineGoogle Scholar15. Jargowsky PAPoverty and Place: Ghettos, Barrios and the American City. New York, NY: Russell Sage Foundation; 1997.Google Scholar16. Maruyama GBasics of Structural Equation Modeling. Thousand Oaks, CA: SAGE Publications; 1998.CrossrefGoogle Scholar17. Williams DR, Jackson PB. Social sources of racial disparities in health.Health Aff (Millwood). 2005; 24:325–334. doi: 10.1377/hlthaff.24.2.325.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Iyanda A and Lu Y (2021) 'Gentrification is not improving my health': a mixed-method investigation of chronic health conditions in rapidly changing urban neighborhoods in Austin, Texas, Journal of Housing and the Built Environment, 10.1007/s10901-021-09847-8, 37:1, (77-100), Online publication date: 1-Mar-2022. Leak-Johnson T, Yan F and Daniels P (2021) What the Jackson Heart Study Has Taught Us About Diabetes and Cardiovascular Disease in the African American Community: a 20-year Appreciation, Current Diabetes Reports, 10.1007/s11892-021-01413-4, 21:10, Online publication date: 1-Oct-2021. Erickson S, Bravo M and Tootoo J (2020) Geosocial Factors Associated With Adherence to Statin Medications, Annals of Pharmacotherapy, 10.1177/1060028020934879, 54:12, (1194-1202), Online publication date: 1-Dec-2020. Rodriguez F, Hu J, Kershaw K, Hastings K, López L, Cullen M, Harrington R and Palaniappan L (2018) County‐Level Hispanic Ethnic Density and Cardiovascular Disease Mortality, Journal of the American Heart Association, 7:19, Online publication date: 2-Oct-2018.Min Y, Anugu P, Butler K, Hartley T, Mwasongwe S, Norwood A, Sims M, Wang W, Winters K and Correa A (2017) Cardiovascular Disease Burden and Socioeconomic Correlates: Findings From the Jackson Heart Study, Journal of the American Heart Association, 6:8, Online publication date: 2-Aug-2017. Shin J, Choi Y, Kim S, Lee S and Park E (2017) Cross-level interaction between individual socioeconomic status and regional deprivation on overall survival after onset of ischemic stroke: National health insurance cohort sample data from 2002 to 2013, Journal of Epidemiology, 10.1016/j.je.2016.08.020, 27:8, (381-388), Online publication date: 1-Aug-2017. Davis A, Taitel M, Jiang J, Qato D, Peek M, Chou C and Huang E (2016) A National Assessment of Medication Adherence to Statins by the Racial Composition of Neighborhoods, Journal of Racial and Ethnic Health Disparities, 10.1007/s40615-016-0247-7, 4:3, (462-471), Online publication date: 1-Jun-2017. January 13, 2015Vol 131, Issue 2 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.114.013871PMID: 25447043 Originally publishedDecember 1, 2014 Keywordscardiovascular diseasesinequalitiesdisparities, healthcareepidemiologyEditorialsPDF download Advertisement SubjectsEpidemiologyEthics and Policy
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