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RURAL HEALTH AND WOMEN OF COLOR |
The authors are with the Jackson Heart Study, Jackson, Miss.
Correspondence: Requests for reprints should be sent to Herman A. Taylor, MD, Jackson Heart Study, 350 West Woodrow Wilson Dr, Suite 701, Jackson, MS 39213 (e-mail: herman.a.taylor{at}ccaix.jsums.edu).
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ABSTRACT |
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Many believe that the United States has entered a "Golden Age" of cardiovascular health and medicine. Pharmacological and technological advances have indeed produced an era of declining mortality rates from cardiovascular diseases for the nation as a whole. However, there remain areas of challenge.
Cardiovascular disease (CVD) is still by far the leading cause of death and disability in the United States, and it is the leading killer of US women. Perhaps the single most notable feature of the CVD epidemic in the United States is the substantial difference in morbidity and mortality that exists between White women and women of color, with a disproportionate share of suffering borne by minority women. Unexplained regional variations also cloud the otherwise notable progress of the last 30 years, and many rural areas appear to be uniquely affected by cardiovascular disease.
This commentary reviews the evidence that the CVD epidemic disproportionately burdens women of color who reside in rural areas, itemizes and provides a logical framework for explaining this burden, and suggests approaches to solving this vexing public health problem.
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INTRODUCTION |
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The widening array of preventive and therapeutic tools of modern medicine, along with selective adoption of healthier habits, can be credited as the cause of these substantial declines in CVD mortality.3,4 Most conspicuous among the sweeping behavioral changes is the impressive decline in smoking among American adults, particularly White men, in recent decades. Smoking rates have dropped from 40% in the mid-sixties to approximately 25%, according to recent surveys.5 In the arena of medical therapy, the development of safe and effective therapies for hypertension have led to major gains in prevention of CVD mortality.6 Evidence-based therapies for manifest cardiac and cerebrovascular diseases (such as beta blockers and ACE inhibitors) have contributed to the secondary prevention of disease progression and the reduction in death rates. Established innovations (e.g., coronary care units, cardiac monitoring, coronary artery bypass surgery) and practices (e.g., cardiac rehabilitation) have combined with newer advances to significantly reduce mortality and morbidity from the leading specific cause of cardiovascular death, coronary disease.1,7 Many of these same therapies have been proven effective or are under investigation, in the management of stroke.2,8–13
Despite the clearly positive trends in CVD mortality and morbidity, African American women in rural areas have distinctly elevated mortality rates. Among the counties where estimates are available for Black women, heart disease mortality ranged from 124 to 1275 per 100 000—a 10-fold difference between the lowest and highest county rates. Many of the counties with the highest rates are rural, with low population density, and are located in the Mississippi River Delta. There are other distinct rural areas of high mortality, including southwestern Oklahoma and west central Texas. Low rates of heart disease mortality for rural-dwelling Black women are found in east Texas and northern Florida.
A final set of ethnicity–geography comparisons will lend added perspective to these findings. African American women, taken as a whole, have the highest heart disease mortality among US women. Indeed, rural African American heart disease mortality is among the highest ever recorded anywhere in the world.
Mississippi has both the highest proportion of rural-dwelling African American women and the highest heart disease death rate, 11% higher than that of Nebraska, the next highest rate, and more than twice the rate of the states with the lowest heart disease mortality, such as Minnesota. It is important to note that large numbers of African American women live in rural areas, particularly in the southern United States. This fact, combined with the high death rates, results in a substantial burden of mortality.
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MECHANISMS THAT EXPLAIN GEOGRAPHIC DISPARITIES |
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In contrast to the idealized view of "country life" as active, not stressful, and replete with healthy foods and strong social and community support, the lives of rural Americans are more typically beset with a daunting array of obstacles to health maintenance. Structural barriers to health include high levels of poverty, maldistribution of health care workers, absent or inadequate health infrastructure, remote location, and social isolation, particularly among the elderly and, most often, female rural Americans. Low socioeconomic status has been shown repeatedly to correlate with low levels of knowledge about health maintenance, poor access to preventive care, and reliance on emergency departments or other episodic, discontinuous sources for primary care.14–16 These factors typify health care for the poor, regardless of locale.
In addition to these structural risk factors (and in some cases because of them), rural Americans appear to have higher frequencies of the "classical" risk factors. In a community-based study done by Willems et al. in two rural Virginia counties, the prevalence of diabetes (15.6%), sedentary lifestyle (66.7%), and obesity (64.7%) was highest among rural-dwelling African American women.17 A crosssectional study of urban and rural women's leisure-time physical activity found African American and Native American women in Missouri 35% and 65% more likely, respectively, to be totally inactive than were their White counterparts.17–20 Rural minorities were at greatest risk for sedentary lifestyles. The combination of minority status and rural residence may have a particularly negative impact on coronary heart disease risk factors.
Available data suggest that women in general may receive suboptimal care for acute CVD. Data on the diagnosis and management of coronary heart disease illustrate the disparity in treatment.21–23 When women arrive at a hospital, treatments and procedures are often delayed or not made available. Women are less likely to receive an electrocardiogram and electrocardiogram monitoring, less likely to be admitted to a coronary care unit, and less likely to receive a cardiology consultation. African American women are much less likely than men or White women to have access to lifesaving therapies for heart attack. Most of the 1 million US patients who have heart attacks each year are candidates for reperfusion therapy (reopening of blocked arteries), either thrombolytic drugs or primary angioplasty. African American women, however, are least likely to receive reperfusion therapy (44%), followed by African American men (50%), White women (56%), and White men (59%).24 A study by Schulman et al. also found a substantial reduction in odds of referral for cardiac catheterization for African American women.25
These findings suggest that there are salient explanations for the mosaic pattern of CVD death in the United States and that changing this pattern presents enormous challenges that will not be easily met. Ensuring equitable access to health care is an important public policy goal, however, and a significant body of research and policy analysis has been focused on documenting barriers to access for vulnerable populations and suggesting policy options to eliminate such barriers.26
Rural populations have often been viewed as especially vulnerable with respect to health care access. Poorly developed and fragile health infrastructures, socioeconomic hardships, and physical barriers such as distance and unavailability of transportation all contribute to limiting access in rural areas. Problems in access to care for CVD are parallel for urban and rural women. But the magnitude of the problems is greater for rural women because of isolation, lower socioeconomic status, and lack of resources. Rural residents are more likely to suffer from chronic disease such as CVD; at the same time, the low proportion of CVD specialists in rural areas is of particular concern with regard to access to care. For example, over 80% of the counties in Mississippi have no physicians who specialize in CVD. Lack of medical care resources such as coronary care unit beds and cardiac rehabilitation units also limit opportunities for CVD intervention and treatment. An analysis of services to Medicare beneficiaries found that the volume of cardiology services for the rural Medicare enrollees was 40% lower than for urban beneficiaries as a result of the lower volume of physician services per beneficiary (15%) in rural areas, especially for technology-intensive procedures.27
For those not covered by Medicare, lack of affordable access is a major barrier to adequate and timely health care. Different patterns of insurance coverage and employment patterns are seen in rural residents.28 They are more likely to be self employed and unable to afford private insurance. When rural residents are employed by a firm, the firm is usually small, does not pay for medical leave, and generally either is unable to provide comprehensive health insurance or offers no insurance coverage at all. The inhabitants of rural areas tend to have lower rates of private insurance coverage and higher rates of public insurance coverage than do residents of more populated areas.
Adequate health literacy is very important to motivate any behavioral modification necessary for good cardiovascular health.29 Individual beliefs about the effectiveness of health care, and feelings of trust toward medical professionals, may affect use of health care services among rural populations. The absence of adequate prevention resources, such as safe and affordable physical activity programs, access to healthy and affordable food sources, and health insurance reimbursement for preventive services, is also an impediment to CVD prevention.
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IMPROVING CARDIOVASCULAR HEALTH IN RURAL AMERICA |
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Broad-Based Prevention
To identify and treat secondary (metabolic) causes of CVD including hypertension, diabetes, and dyslipidemia, it is necessary to address issues affecting access to high-quality health care. Insurance coverage; sufficient numbers of local health care providers, including CVD specialists; transportation; and continued education among providers and in the community must be offered in a gender specific and culturally appropriate manner. Intervention regarding primary causes of CVD, such as overnutrition (related to overweight and obesity) and cigarette smoking, is also essential. Information must be disseminated in various forms and by various means with respect to diversity of gender, age (young versus old), and ethnicity. Education and dissemination of information among health care providers, patients, communities, and policymakers (legislators, public health officials, health policymakers, and health insurance agencies) are critical.
Policy Adjustments
Lack of insurance coverage is a major barrier to access, and creating policy to remove this barrier and improve access is crucial for the well-being of the rural populace. Given the variable employment patterns and less employer-based insurance in rural communities, state high-risk insurance plans to provide coverage to the rural residents would be an asset. Since 1997, active insurance pools have operated in 26 states, and 7 states have provided an alternative to private insurance through BlueCross BlueShield associations; however, the conversion of these associations to for-profit entities will decrease the number of states that provide open enrollment with affordable premiums. Unfortunately, data on the numbers of rural residents who have enrolled in these programs are not available.
Outreach Initiatives
The Jackson Heart Study is an observational epidemiological study investigating environmental and genetic factors that influence the progression of CVD in African Americans. The study's target sample consists of 6500 participants in 3 counties, including both metropolitan and nonmetropolitan geographic areas. The study will provide premier information regarding cardiovascular disease among African Americans in addition to providing models for community outreach and education.
Future Research
The model of a causal sequence from lifestyle to CVD shows a linear relationship between behavioral risk factors, metabolic risk factors (dyslipidemia, type II diabetes, and hypertension), and cardiovascular events (coronary heart disease, cerebrovascular accident, congestive heart failure, and end-stage renal disease). Modifications of this model must include the environmental and social causation factors related to racism, sexism, discrimination, as well as specific cultural dynamics such as spirituality, place of birth, migration patterns, and acculturation.
Consideration must be given to designing long-term strategies that take into account the influence of socioeconomic status and cultural beliefs on individual perceptions of health and willingness to adopt lifelong behavioral modifications. More important, policymaking must progress beyond discussion of "thinking out of the box" to a paradigmatic shift in the axiology, methodology, implementation, and evaluation of efforts focused on rural minority women. This shift should come from community input and from experienced researchers with an understanding of key issues and challenges for rural women.
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SUMMARY |
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The root causes of such huge disparities are clearly many. Resolution of these inequities will require comprehensive action strategically appropriate to the affected groups. Mere extrapolation of research findings and efficacious practices relevant to one group will not suffice and may be naïve at best, counterproductive at worst. Efforts to resolve health inequities must be informed by thoughtful, focused, and comprehensive research conducted among the target populations.
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Footnotes |
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Accepted for publication January 2, 2002.
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References |
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