INTRODUCTION Race has been and will continue to be an important factor in our society. It affects the lives of millions on a daily basis. While, most people are familiar with the discrimination that may take place in the job market and education system, few are aware of the more insidious and destructive effects of racism in this country`s health care practices. The current study attempts to shed more light on the health of black people by exploring the ways black women are being affected by heart disease. The aim of this study is to explore the prevalence of deaths due to heart (cardiovascular) disease among black women 35 years or older from 1991-1995 who resided in rural northeastern counties with populations of 50,000 or less at the time of death. The National Center for Health Statistics defines "diseases of the heart" as those including rheumatic heart disease, diseases of pulmonary circulation, hypertensive disease, ischemic heart disease, pericarditis, myocarditis, mitral valve disorders, cardiomyopathy and heart failure (Casper, et al., 1999). Startling statistics show that cardiovascular (heart) diseases are the number one killer of women 40 years or older in the United States (Hanson, 1994). However, this scary reality is even more serious in black communities. In fact, black women in their thirties are increasingly suffering and dying of heart diseases at higher rates than their white counterparts (Wenger as cited in Edwards, Parker, Burks, West & Adams, 1991). The death rate for black women due to heart disease is 553 deaths in a population of 100,000 persons (Casper, et al., 1999). According to the National Center of Health Statistics, the ratio of black/white women deaths due to heart diseases is 1.5 (Duelberg, 1992). It is also noted that although the life expectancy of black women has increased over the last 10 years, they are still likely to die 5 years earlier than white women (Duelberg, 1992). It`s been suggested that the disparity which exist between black and white women in the mortality rates due to heart disease may be a result of differences in education level and income. According to the Report of the Public Health Service Task Force on Women`s Health Issues black women are much more likely to be poor than white women (Edwards, et al., 1991). Education level and income are independently related to increased smoking behaviors as well as a tendency to overeat and not exercise which in turn are risk factors for heart disease (Hanson, 1994; Duelberg, 1992). Researchers are slowly taking interest in the reasons why black women are at such elevated risks for heart disease. They have found that black women are less likely to engage in primary prevention techniques, such as exercise and healthy diet As a result, black women regardless of age group tend to be more obese than white women. Black women in general are also more likely to be smokers than white women, however this differs in rural areas where black women are less likely to smoke than their white counterparts (Duelberg, 1992).Racism, Discrimination and Heart Disease Many of the approaches to treatment for diseases have in the past been based on the erroneous belief that race is a biological concept and therefore illnesses are related to a group`s genetic or biological makeup (Williams, Lavizzo-Mourney & Warren, 1994). This belief has served the larger political power structure because it has allowed research and subsequent treatment measures to ignore the societal and environmental influences or causes of diseases (Williams et al., 1994). Underprivileged minority neighborhoods were exposed to asbestos, lead, toxic chemicals, poor waste removal practices, and limited or inexperienced health care providers could be ignored (Krieger, 1999). This has in essence provided reasonable excuses to explain the secondary ways in which minorities have been treated in this country`s health care system, either in poor quality or limited access to services. Kreiger (1999) explored the ways in which the health of blacks is or can be detrimentally affected by discrimination. She listed residential and occupational segregation as a factor that relates to health risks. Blacks living in poorer neighborhoods which may lack quality supermarkets that supply affordable healthy food choices (Kreiger, 1999). This may lead to diets with high cholesterol and salt content (junk foods) which increases the risk of hypertension. The obvious availability of stores selling alcoholic beverages ("forties") and tobacco in black neighborhoods, along with the high levels of consumption in order to blunt the psychosocial stress often found in high crime and high poverty communities (Kreiger, 1999). These factors put residents at risk of high blood pressure. This is of concern because hypertension (high blood pressure) is an independent risk factor of heart disease. According to Casper and colleagues (1999) black women are more likely to die of heart disease related to hypertension (9%) and ischemic heart disease (54%) than any other form of cardiovascular disease (CVD). According to Anderson, blacks are less likely to receive appropriate medical care such as coronary angiography, bypass surgery, angioplasty, and chemodialysis, than whites (cited in Williams, Lavizzo-Mourney & Warren, 1994). This outcome is also observed when health insurance and clinical status was adjusted. Black women are 40% less likely than white men to be referred for cardiac catheterization when they arrive at emergency rooms with chest pain (Schulman, et al., 1999). Physicians are also less likely to detect acute cardiac ischemia, acute infarction, or unstable angina pectoris in minority patients (Pope, et al., 1999). Blacks also have less access to health care due to insufficient health insurance coverage (Williams, Lavizzo-Mourney & Warren, 1994). According to the Health Insurance Status of Workers and Their Families (1996, cited by Agency for Health Care Quality and Research), 22% of working black women lack health insurance coverage.Rural America and Heart Disease There are many differing definitions of rural. However, most statistical estimates suggest that ¼ of the U.S. population reside in rural areas (Pearson & Lewis, 1998; Weiner, 1995). According to the U.S. Census Bureau, defines rural areas as those with populations of 2,500 or less, while the Office of Management and Budget defines rural/non-metropolitan areas in relation to metropolitan statistical areas (MSA) (Weiner, 1995). A metropolitan statistical area includes an urban area along with the adjacent communities, while a rural or non-metropolitan area includes all areas outside of this delineation (Pearson & Lewis, 1998). In the present study rural areas are defined as counties with populations of 50,000 or less. Rural areas have consistently had higher rates of poverty than urban areas. In fact, 29% of poor Americans live in rural areas (Pearson & Lewis, 1998). Poverty is often associated with low educational status and health care practices (Edwards, et al., 1991). According to Edwards and colleagues (1991) since 1979, statistics indicate that rural Americans are dying at higher rates from cardiovascular diseases than those living in urban areas. Researchers have discovered the heart disease risk factors that rural black women face. Women living in rural agriculturally based societies usually have diets rich in fat and cholesterol. They are also more likely to be diabetic. These factors are very powerful predictors of cardiovascular diseases (Edwards, et al., 1991). Due to the isolated environment, rural black women are often unable to access cardiologists, either because of limited numbers of such health care professionals, and long distances to the few rural clinics and hospitals (Casper, et al., 1999). Seventy percent (70%) of the counties in the U.S. had no CVD specialty physicians in 1991, therefore it is not uncommon that the few cardiologists in surrounding areas often have heavy patient loads (Casper, et al., 1999). The available health care professionals may also be unaware of updated medical education (newest and better treatments) resulting in slow medical attention and late identification of symptoms (Casper, et al., 1999). According to Casper and colleagues (1999) rural hospitals often have insufficient funding, outdated medical equipment, uninsured patients, and inadequate transport. Unfortunately, rural areas also often lack emergency telephone systems (e.g. 911) and available mediums (television, radio, Internet, and billboards) to distribute information about heart diseases (Casper, et al., 1999). The latter factor results in a lack of public awareness (via effective health promotional messages) and education about the symptoms of heart disease (Pearson & Lewis, 1998).
METHOD In the current study, a secondary analysis was done on the heart disease mortality rates of black women 35 years or older residing in rural counties from 1991-1995 at the time of death. Twenty-five counties with populations of at most 50,000 persons in several Northeastern states (Rhode Island, Massachusetts, New York, Pennsylvania, and Maryland) were investigated in this study. There was no data available for mortality of black women in Vermont, New Hampshire or Maine. These states lacked sufficient data inclusion in the original study on which this secondary analysis was based. Delaware, New Jersey, and Connecticut were excluded because they lacked counties of 50,000 or less. The data were obtained from the first major study that investigated racial disparities in heart disease among U.S. women, which was developed by West Virginia University and published online by Centers for Disease Control and Prevention (Casper, et al., 1999). The population was made up of women aged 35 years or older who died of heart disease in the U.S. from 1991-1995. The death rates based on heart disease were obtained from the National Vital Statistics System and the population data were collected from the Bureau of the Census. Deaths due to heart disease was defined by the National Center for Health Statistics and coded 390-398, 402, 404-429 by the Ninth Revision of the International Classification of Disease (ICD-9) (Casper et al., 1999). Some states had either no or little racial or ethnic minorities and therefore statistically reliable heart disease death rates were not calculated for those states. For each county the "smooth death rate for heart disease" was calculated as a spatial moving average. This means the heart disease deaths in each county are divided by the population for ten-year age groups then summed over the five-year period from 1991-1995. The numbers of heart disease deaths and population were then summed with all other neighboring counties, then divided the numbers of neighbors plus one to get an average rate. This smoothed age specific rate was then age-adjusted to the 1970 United States population (Casper, et al., 1999).
RESULTS The results demonstrate that the average heart disease mortality rate for black women at time of death who resided in northeastern counties with populations of 50,000 or less was 540 per 100,000 persons. The death rates by county ranged from a minimum of 350 to a maximum of 854. In the general population black women`s the mortality rates for U.S. counties extend from 124 to 1,276 per 100,000 with a mean of 553/ 100,000 moralities (Casper, et al., 1999). There were only 25 counties with populations of 50,000 or less in the Northeast region where data of deaths of black women were available. Of these 25 counties only 4 had populations of 2,500 or less. In the general population, the heart disease mortality rate of all black women and all women, age 35 or older residing in the U.S. from 1991-1995 respectively, was 553 per 100,000 and 401 per 100,000 persons. In the data set of rural counties, 12 counties were considered to be urban adjacent to metropolitan areas, 5 metropolitan areas, 4 urban not adjacent to metropolitan areas and 4 were rural areas of 2,500 or less. Black women who resided in urban communities not adjacent to metropolitan areas had the highest rates of heart disease mortality (602 per 100,000).
LIMITATIONS OF THE STUDY Only 25 counties with populations of less than 50,000 or less, defined as rural in this study, had data available on cardiovascular mortality for black women in Northeast U.S. Therefore the results may not generalize to entire U.S. population. It`s possible that heart disease mortality rates may differ due to geographical location. In some areas, due to the small populations of black women, their mortality rates were not included in original data set for confidentiality purposes. States in the northeast that were excluded were Vermont, New Hampshire and Maine which lacked sufficient data on the mortality rates of black women. Delaware, New Jersey, Connecticut were excluded because they lacked rural counties. A secondary analysis of original data set was done and the original data was spatially smoothed which may have altered the mortality rates.
CONCLUSION In the U.S., black women live predominantly in large metropolitan areas and rural southern counties (Casper, et al., 1999). This study primarily focused on counties in the northeastern U.S. because the low populations of black women in these areas are easily overlooked. In order for substantial improvements to be made in women`s health, research cannot neglect the women living in isolated rural areas. This study explored the relationship between black women and mortality from heart disease. The results showed that rural black women residing in rural northeastern counties with 50,000 or less population are dying due to heart diseases at rates (540 per 100,000 persons) similar to the general population of black women (553 per 100,000). Rural black women in this study also had significantly higher mortality rates than the general population of women in the U.S. (401 per 100,000 persons). Rural areas are in need of more community interventions geared to preventing high-risk behaviors related to heart diseases. It is important that health professionals promote healthier diets with low cholesterol, low fat, low salt and high fiber content. However, health professionals should be aware that certain foods might be strongly related to cultural traditions in minority communities. It is also a concern that black women often do not practice primary prevention techniques so physical activity, such as walking, and cardio-respiratory exercises. Transportation to health care providers who can adequately diagnose and treat cardiovascular disease is a priority need for black women living in rural counties which often are isolated because of geographic location, poor roads, and low economic status. Increasing health insurance coverage and regular physical exams especially in minority communities should also be a major priority. Medical training of physicians should emphasize that personal, subtle ethnic or racial stereotypes may play a detrimental role in their treatment referrals and symptom detection practices. Biases can become fatal barriers as seen in the study by Schulman and colleagues (1999), which indicated that physicians are less likely to refer black women for cardiac catheterization than white men. Physicians should also be aware of the potential mistrust of health care professionals in minority communities. It is essential that research on health behaviors and treatment related to heart diseases in minority communities include and investigate the political, racial, and cultural factors that may exist. There is a fertile opportunity for future research investigating minority groups and heart disease risk factors, along with possible preventative measures.
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