Research article
Inequities in CHD Incidence and Case Fatality by Neighborhood Deprivation

https://doi.org/10.1016/j.amepre.2006.10.002Get rights and content

Background

Research has not firmly established whether living in a deprived neighborhood predicts the incidence and case fatality of coronary heart disease (CHD), and whether effects vary across sociodemographic groups.

Methods

Prospective follow-up study of all Swedish women and men, aged 35 to 74 (1.9 million women, 1.8 million men). Women and men, without a history of CHD, were assessed on December 31, 1995, and followed from January 1, 1996 through December 31, 2000, for first fatal or nonfatal CHD event (130,024 cases); data were analyzed in 2006. Neighborhood-level deprivation (index of education, income, unemployment, welfare assistance) was categorized as low, moderate, and high deprivation.

Results

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 higher incidence in more deprived neighborhoods was observed across all individual-level sociodemographic groups (age, marital status, family income, education, immigration status, mobility, and urban/rural status). In multilevel logistic regression models, neighborhood deprivation remained significantly associated with both CHD incidence and case fatality for women and men after adjusting for the seven sociodemographic factors (p values <0.01). Effects were slightly stronger for women than men in an ancillary analysis that tested for gender differences.

Conclusions

The clustering of CHD and subsequent mortality among adults in deprived neighborhoods raises important clinical and public health concerns, and calls for a reframing of health problems to include neighborhood social environments, as they may affect health.

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

References (48)

  • G.A. Kaplan

    What is the role of the social environment in understanding inequalities in health?

    Ann N Y Acad Sci

    (1999)
  • K. Sundquist et al.

    Neighbourhood deprivation and incidence of coronary heart disease: a multilevel study of 2.6 million women and men in Sweden

    J Epidemiol Community Health

    (2004)
  • A.V. Diez Roux et al.

    Neighborhood of residence and incidence of coronary heart disease

    N Engl J Med

    (2001)
  • F.B. LeClere et al.

    Neighborhood social context and racial differences in women’s heart disease mortality

    J Health Soc Behav

    (1998)
  • M. Woodward

    Small area statistics as markers for personal social status in the Scottish heart health study

    J Epidemiol Community Health

    (1996)
  • G.D. Smith et al.

    Individual social class, area-based deprivation, cardiovascular disease risk factors, and mortality: the Renfrew and Paisley Study

    J Epidemiol Community Health

    (1998)
  • D.A. Alter et al.

    Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction

    N Engl J Med

    (1999)
  • G. Engström et al.

    Trends in long-term survival after myocardial infarction: less favourable patterns for patients from deprived areas

    J Intern Med

    (2000)
  • S.V. Rao et al.

    Socioeconomic status and outcome following acute myocardial infarction in elderly patients

    Arch Intern Med

    (2004)
  • C. Tonne et al.

    Long-term survival after acute myocardial infarction is lower in more deprived neighborhoods

    Circulation

    (2005)
  • P. Tydén et al.

    Myocardial infarction in an urban population: worse long term prognosis for patients from less affluent residential areas

    J Epidemiol Community Health

    (2002)
  • N.E. Breslow et al.

    Statistical methods in cancer research, Volume I, Analysis of case–control studies

    (1980)
  • K.J. Rothman

    Measures of disease frequency

  • Statistiska Centralbyrån (Statistics Sweden). Eurostat yearbook 2004. Available at:...
  • Cited by (185)

    • Neighbourhood crime and major depression in Sweden: A national cohort study

      2022, Health and Place
      Citation Excerpt :

      Refugees and immigrants are also entitled to social welfare in Sweden (Ludvigsson et al., 2019); c) year of birth; d) education; and (e) neighbourhood deprivation. Neighbourhood deprivation (NDI) is a previously developed summary measure based on the combination of several deprivation variables (Li et al., 2020; Winkleby et al., 2007). The following variables were used for individuals aged 20 to 64; proportion of inhabitants who receive social welfare; low education levels (<10 years of formal education), low income (from all sources, including interest and dividends; that is <50% of the median individual income), and unemployed individuals (excluding full-time students, those completing military service, and early retirees).

    View all citing articles on Scopus

    The full text of this article is available via AJPM Online at www.ajpm-online.net.

    View full text