Research articleInequities in CHD Incidence and Case Fatality by Neighborhood Deprivation
Introduction
A leading cause of death and disability in all industrialized countries is coronary heart disease (CHD).1, 2 Up to 70% of CHD incidence can be explained by individual-level sociodemographic characteristics (age, gender, socioeconomic status [SES]/position); health behaviors (smoking, physical inactivity, poor diet); and risk factors (hypertension, hypercholesterolemia, diabetes).3 Although some of the unexplained causes of CHD may be due to incomplete or inaccurate measurement of these factors, recent work has focused on the environments and social contexts in which these risk factors may develop or be exacerbated.4, 5
One important area of research on the social context of CHD has been on the relationship between neighborhood-level deprivation and individual-level CHD. In general, this research has shown significant neighborhood-level effects after “adjustment” for potential confounding factors including individual-level SES/position.4, 6, 7, 8, 9, 10 This area of research is particularly germane to women, as previous work suggests that residence in a deprived neighborhood may affect the cardiovascular health of women to a greater extent than men.6, 7
Two population-based studies have included both women and men, and examined the associations between neighborhood-level characteristics and CHD incidence.6, 7 Diez-Roux et al.7 reported hazards ratios for CHD among adults in the most disadvantaged versus the most advantaged neighborhoods of 1.6 and 1.8 for white and black women, respectively, and 1.6 and 1.4 for white and black men, respectively, after adjustment for individual-level income, education, occupation, and established CHD risk factors (615 events). Using a neighborhood medical care need index, Sundquist et al.6 reported odds ratios among adults in the most versus the least deprived neighborhoods of 1.9 and 1.4 for women and men, respectively, after adjustment for individual-level age and income (14,259 events). Neither of these studies examined neighborhood-level effects on CHD across a broad array of sociodemographic groups, tested for differences by gender, or examined effects on case fatality, an indicator of severity of disease and quality of care. Separate studies have examined the relationship between area-based measures and case fatality/survival following an acute myocardial infarction,11, 12, 13, 14, 15 and although all found significant associations, only one presented neighborhood results separately by gender,12 and none presented case fatality from overall CHD.
This study had four objectives: First, whether there were additive effects of neighborhood-level deprivation on CHD incidence and case fatality for the total population of Swedish women and men, and across individual-level sociodemographic groups (the latter for incidence only). Second, whether neighborhood-level deprivation remained significantly associated with CHD incidence and case fatality using multilevel models to adjust for individual-level sociodemographic characteristics. Third, whether the risk of CHD in high- versus low-deprivation neighborhoods differed by gender. Fourth, which component of the neighborhood deprivation index was most strongly related to CHD incidence.
Section snippets
Data Sources
The Swedish Statistics Bureau provided individual-level demographic and socioeconomic data for the entire population of women and men, aged 35–74, who resided in Sweden on December 31, 1995, and had lived in Sweden since December 31, 1985 (1.9 million women, 1.8 million men). They were followed from January 1, 1996 through December 31, 2000 for first fatal or nonfatal CHD event (incident cases and 1-year case fatality from CHD). Data were analyzed in 2006.
The home addresses of all Swedish
Results
There were 130,024 CHD events among women and men during the 5 years of follow-up (incident cases) (Table 2). About two thirds of women and men were married and the large majority were born in Sweden. Most people had been “exposed” to their neighborhoods for 5 years or more—almost 80% lived in the same SAMS neighborhood for 5 or more years before the beginning of follow-up.
With each increasing level of neighborhood deprivation, age-standardized incidence increased (Table 2). For the total
Discussion
In this follow-up study of Swedish women and men, neighborhood-level deprivation was a strong predictor of CHD incidence and 1-year case fatality from CHD. Age-standardized CHD incidence was 1.9 times higher for women and 1.5 times higher for men in high versus low deprivation neighborhoods; 1-year case fatality from CHD was 1.6 times higher for women and 1.7 times higher for men in high versus low deprivation neighborhoods. The relationships were remarkably consistent for CHD incidence across
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