%Race, NSES, and CHD ASA 08152010

Is the Relationship between Neighborhood Is the Relationship between Neighborhood Racial/Ethnic Composition and Coronary Heart Racial/Ethnic Composition and Coronary Heart

Disease Risk an Artifact of Neighborhood Disease Risk an Artifact of Neighborhood Socioeconomic Status?Socioeconomic Status?

Shih, Regina A.,Shih, Regina A., Eibner C, Griffin BA, Bird CE, Slaughter M, Lurie N, Eibner C, Griffin BA, Bird CE, Slaughter M, Lurie N, Allison M, Gold R, Manson JE, Masaki K, Michael YL, Rosal M, Allison M, Gold R, Manson JE, Masaki K, Michael YL, Rosal M,

Safford M, Sarto GE, Escarce JJSafford M, Sarto GE, Escarce JJ

American Sociological AssociationAmerican Sociological AssociationAugust 15, 2010August 15, 2010

2

Coronary Heart Disease (CHD) Is Leading Coronary Heart Disease (CHD) Is Leading Cause of Death in WomenCause of Death in Women

• Prognosis is markedly worse for womenPrognosis is markedly worse for women

• There are well-established CHD risk factorsThere are well-established CHD risk factors Low individual-level socioeconomic status (SES)Low individual-level socioeconomic status (SES) Poor health behaviors Poor health behaviors Diabetes, hyperlipidemia, hypertension Diabetes, hyperlipidemia, hypertension Family history of CHDFamily history of CHD

• Recent literature suggests neighborhood Recent literature suggests neighborhood

characteristics could influence CHD riskcharacteristics could influence CHD risk

3

Prior Research Has LimitationsPrior Research Has Limitations

• Neighborhood racial composition has been linked Neighborhood racial composition has been linked with health status and mortalitywith health status and mortality

Hypothesized mechanisms are reduced access to social Hypothesized mechanisms are reduced access to social resources and increased exposure to risk factorsresources and increased exposure to risk factors

Studies have not examined the contribution of Studies have not examined the contribution of neighborhood socioeconomic status (NSES)neighborhood socioeconomic status (NSES)

• Other limitations of prior studiesOther limitations of prior studies Focus on a single cityFocus on a single city

Use of cross-sectional dataUse of cross-sectional data

Examination of broad health measuresExamination of broad health measures

4

Study ObjectivesStudy Objectives

Examine whether neighborhood racial/ethnic Examine whether neighborhood racial/ethnic composition associated with risk of CHD events composition associated with risk of CHD events and mortality in older women and mortality in older women

Examine whether NSES partially explains the Examine whether NSES partially explains the associationassociation

Examine differences by race/ethnicityExamine differences by race/ethnicity

5

Individual-level DataIndividual-level Data

• Geo-coded Women’s Health Initiative Clinical Geo-coded Women’s Health Initiative Clinical Trials (WHI CT)Trials (WHI CT)

N = 68,132 women, ages 50-79 N = 68,132 women, ages 50-79 Enrolled 1993–1998Enrolled 1993–1998 Followed through March 2005 (up to 12 years, mean 7 Followed through March 2005 (up to 12 years, mean 7

years)years) Physician-adjudicated CHD outcomesPhysician-adjudicated CHD outcomes

6

Neighborhood-level DataNeighborhood-level Data

• RAND Center for Population Health and Health RAND Center for Population Health and Health Disparities Data Core Disparities Data Core

-- Racial/ethnic composition at the census tract level Racial/ethnic composition at the census tract level % Black (mean = 9.5; range = 0-100)% Black (mean = 9.5; range = 0-100) % Hispanic (mean = 12.3; range = 0-100)% Hispanic (mean = 12.3; range = 0-100)

- NSES index at the census tract levelNSES index at the census tract level mean = 75.5; range = 25.0-98.0mean = 75.5; range = 25.0-98.0

- Correlation with NSES, by year of enrollmentCorrelation with NSES, by year of enrollment- % Black, -0.48 to -0.62 % Black, -0.48 to -0.62 - % Hispanic, -0.35 to -0.42% Hispanic, -0.35 to -0.42

7

We Examined Survival Models With and We Examined Survival Models With and Without Adjustment for NSES Without Adjustment for NSES

Cox proportional hazard models examined time to: Cox proportional hazard models examined time to: All-cause mortalityAll-cause mortality CHD eventCHD event Myocardial infarction or CHD death (MI/CHD death)Myocardial infarction or CHD death (MI/CHD death) CHD deathCHD death

Key explanatory variablesKey explanatory variables % Black % Black % Hispanic% Hispanic

CovariatesCovariates Individual-level sociodemographic characteristics Individual-level sociodemographic characteristics without without

NSESNSES ((Race/ethnicity, education, income, marital status, and clinical Race/ethnicity, education, income, marital status, and clinical

trial study arm)trial study arm) With NSESWith NSES

8

We Modeled Overall and Race/Ethnicity-We Modeled Overall and Race/Ethnicity-Stratified HazardsStratified Hazards

Models accounted for geographic clusteringModels accounted for geographic clustering

Overall sample and stratified by race/ethnicity Overall sample and stratified by race/ethnicity (non-blacks vs. blacks; Hispanics vs. non-(non-blacks vs. blacks; Hispanics vs. non-Hispanics)Hispanics)

9

Analytic Sample Characteristics (N = 57,113)Analytic Sample Characteristics (N = 57,113)

• Outcomes Outcomes All cause mortality All cause mortality 5.4% (n = 3,070)5.4% (n = 3,070)

CHD eventCHD event 6.8% (n = 3,896)6.8% (n = 3,896)

MI/CHD deathMI/CHD death 3.2 % (n = 1,829)3.2 % (n = 1,829)

CHD deathCHD death 0.9% (n = 513)0.9% (n = 513)

• Covariates Covariates Non-Hispanic white (82%), Non-Hispanic black (10%), Non-Hispanic white (82%), Non-Hispanic black (10%),

Hispanic (4%), Other (4%)Hispanic (4%), Other (4%)

61% Married61% Married

94% ≥ High school94% ≥ High school

Household income: ≤ $34,999 (42%), $35,000 - $74,999 Household income: ≤ $34,999 (42%), $35,000 - $74,999 (41%), ≥ $75,000 ((41%), ≥ $75,000 (17%)17%)

10

Living in Neighborhood with Higher Black Living in Neighborhood with Higher Black Composition Is Associated with Increased Risk for Composition Is Associated with Increased Risk for

All-cause Death and MI/CHD DeathAll-cause Death and MI/CHD Death

0.92

0.94

0.96

0.98

1.00

1.02

1.04

1.06

1.08

All-cause mortality CHD event MI/CHD death CHD death

Hazard ratios

*

(1.449)

(0.762)

*

Without NSES

Hazard ratios per 10%-point increase in % Black

*Statistically significant p<0.05

11

Increased Risk Associated with Higher Black Increased Risk Associated with Higher Black Composition Is Explained by NSESComposition Is Explained by NSES

0.92

0.94

0.96

0.98

1.00

1.02

1.04

1.06

1.08


Hazard ratios

*

(1.449)

(0.762)

(1.234)

(0.818)

*

Without NSES With NSES

Hazard ratios per 10%-point increase in % Black


12

Higher Hispanic Composition Is Associated with Higher Hispanic Composition Is Associated with Increased Risk for All-cause Mortality andIncreased Risk for All-cause Mortality and

CHD EventsCHD Events

0.92

0.94

0.96

0.98

1.00

1.02

1.04

1.06

1.08(1.536)

(0.738)

* *

Hazard ratios



Without NSES

Hazard ratios per 10%-point increase in % Hispanic

13

Increased Risk Associated with Higher Hispanic Increased Risk Associated with Higher Hispanic Composition Is Explained by NSESComposition Is Explained by NSES

0.92

0.94

0.96

0.98

1.00

1.02

1.04

1.06

1.08(1.536)

(0.738)

(1.310)

(0.799)

* *

Hazard ratios





14

Higher Hispanic Composition Is Associated with Higher Hispanic Composition Is Associated with Higher Risk Among Non-HispanicsHigher Risk Among Non-Hispanics

Hazard ratios

0.70

0.75

0.80

0.85

0.90

0.95

1.00

1.05

1.10

1.15

1.20





(1.714)

(0.690)

(1.423)

** *

15

Higher Hispanic Composition Is Associated with Higher Hispanic Composition Is Associated with Lower Risk Among HispanicsLower Risk Among Hispanics

Hazard ratios

0.70

0.75

0.80

0.85

0.90

0.95

1.00

1.05

1.10

1.15

1.20





*

**

16

Summary of Results Summary of Results

• In the overall sample, observed associations between In the overall sample, observed associations between

higher black or Hispanic composition and increased higher black or Hispanic composition and increased

CHD risk appear to be explained in large part, by NSESCHD risk appear to be explained in large part, by NSES

• Among Hispanic women, higher Hispanic composition Among Hispanic women, higher Hispanic composition

was associated with lower risk of CHD death, was associated with lower risk of CHD death,

suggesting a protective effect of Hispanic enclavessuggesting a protective effect of Hispanic enclaves

• Protective effect of higher Hispanic composition did Protective effect of higher Hispanic composition did

not extend to non-Hispanic womennot extend to non-Hispanic women

17

Our Results Have Limitations and Our Results Have Limitations and StrengthsStrengths

• LimitationsLimitations

- Limited generalizability of the WHI CT sampleLimited generalizability of the WHI CT sample

- Did not have data on country of origin or recency of immigration Did not have data on country of origin or recency of immigration

- Individuals may self-select into neighborhoodsIndividuals may self-select into neighborhoods

• StrengthsStrengths

- Large, national sample with substantial geographic, racial/ethnic, and Large, national sample with substantial geographic, racial/ethnic, and socioeconomic heterogeneitysocioeconomic heterogeneity

- Examination of both neighborhood % Hispanic and % blackExamination of both neighborhood % Hispanic and % black

- Physician-adjudicated CHD outcomes in women Physician-adjudicated CHD outcomes in women

18

ImplicationsImplications

• Women living in lower NSES neighborhoods might Women living in lower NSES neighborhoods might

benefit from a greater level of CHD screening and benefit from a greater level of CHD screening and

prevention efforts than the general female populationprevention efforts than the general female population

• Social policies targeting neighborhood Social policies targeting neighborhood

characteristics may improve both individual and characteristics may improve both individual and

population healthpopulation health

19

CollaboratorsCollaborators

Chloe Bird, PIChloe Bird, PI

Christine Eibner, co-PIChristine Eibner, co-PI

Beth Ann Griffin Beth Ann Griffin

Mary E. SlaughterMary E. Slaughter

Nicole LurieNicole Lurie

Tamara DubowitzTamara Dubowitz

Matthew AllisonMatthew Allison

Rachel GoldRachel Gold

This study was funded by NHLBI R01HL084425

The authors have no conflict of interest to declare

JoAnn MansonJoAnn Manson

Kamal MasakiKamal Masaki

Yvonne MichaelYvonne Michael

Milagros RosalMilagros Rosal

Monika SaffordMonika Safford

Gloria SartoGloria Sarto

José J. EscarceJosé J. Escarce

20

Extra SlidesExtra Slides

21

Conclusions Conclusions Observed associations between higher black or Observed associations between higher black or

Hispanic composition and increased CHD risk are Hispanic composition and increased CHD risk are largely explained by NSESlargely explained by NSES

Social, cultural, and behavioral factors in higher % Social, cultural, and behavioral factors in higher % Hispanic neighborhoods may buffer against CHD death Hispanic neighborhoods may buffer against CHD death in Hispanic womenin Hispanic women

Women from lower NSES neighborhoods may benefit Women from lower NSES neighborhoods may benefit from greater level of CHD screening and prevention from greater level of CHD screening and prevention than the general female populationthan the general female population

Social policies targeting neighborhood characteristics Social policies targeting neighborhood characteristics may improve both individual and population healthmay improve both individual and population health

22

Components of NSES IndexComponents of NSES Index

• Median household income Median household income

• Adults ≤ high school education (%)Adults ≤ high school education (%)

• Male unemployment (%)Male unemployment (%)

• Households with income below poverty (%)Households with income below poverty (%)

• Households receiving public assistance (%)Households receiving public assistance (%)

• Households headed by a single female (%)Households headed by a single female (%)

23

Living in a neighborhood with higher minority Living in a neighborhood with higher minority composition is associated with increased risk for all-composition is associated with increased risk for all-

cause mortality and CHD outcomescause mortality and CHD outcomes Percent Black- Overall

All-cause Death

CHD Event MI or CHD Death

CHD Death

Model A

1.028 (1.005,1.051)

1.017 (0.997,1.039)

1.032 (1.002,1.063)

1.051 (0.762,1.449)

Model B

1.004 (0.979, 1.030)

0.987 (0.963,1.011)

1.002 (0.969,1.037)

1.005 (0.818,1.234)

Percent Hispanic – Overall

All-cause

Death CHD Event MI or

CHD Death CHD Death

Model A

1.049 (1.020,1.079)

1.046 (1.017,1.075)

1.008 (0.969,1.048)

1.064 (0.738,1.536)

Model B

1.028 (0.997,1.060)

1.020 (0.991,1.051)

0.975 (0.935,1.016)

1.023 (0.799,1.310)

24

Association between higher minority Association between higher minority composition and risk for all-cause death and composition and risk for all-cause death and

CHD, appears to be attributable to NSESCHD, appears to be attributable to NSES

All-cause Death


CHD Death

Blacks (n = 5,670) Without NSES

1.019 (0.985,1.055)

1.024 (0.991,1.058)

1.067 (1.013,1.124)

1.100 (0.661,1.831)

With NSES

0.988 (0.947,1.030)

1.017 (0.976,1.059)

1.048 (0.984,1.116)

1.081 (0.705,1.657)

Non-Blacks (n = 51,443) Without NSES

1.033 (1.002,1.064)

1.014 (0.99,1.04)

1.01 (0.97,1.05)

1.02 (0.80,1.31)

With NSES

1.009 (0.976,1.043)

0.974 (0.944,1.005)

0.970 (0.929,1.013)

0.961 (0.843,1.095)

25

Higher Hispanic composition is associated Higher Hispanic composition is associated with increased risk for all-cause mortality with increased risk for all-cause mortality

and CHD events and CHD events

Percent Black- Overall All-cause


CHD Death CHD Death

Model A

1.028 (1.005,1.051)

1.017 (0.997,1.039)

1.032 (1.002,1.063)

1.051 (0.762,1.449)

Model B

1.004 (0.979, 1.030)

0.987 (0.963,1.011)

1.002 (0.969,1.037)

1.005 (0.818,1.234)

Percent Hispanic – Overall

All-cause


CHD Death CHD Death

Model A

1.049 (1.020,1.079)

1.046 (1.017,1.075)

1.008 (0.969,1.048)

1.064 (0.738,1.536)

Model B

1.028 (0.997,1.060)

1.020 (0.991,1.051)

0.975 (0.935,1.016)

1.023 (0.799,1.310)

26

Among Hispanics, higher percent Hispanic Among Hispanics, higher percent Hispanic is associated with lower risk of CHD death, is associated with lower risk of CHD death,

even after NSES adjustmenteven after NSES adjustment

All-cause Death


CHD Death

Hispanics (n = 2,565) Without NSES

1.055 (0.970,1.149)

1.073 (1.004,1.146)

1.042 (0.930,1.167)

0.838 (0.810,0.866)

With NSES

1.015 (0.912, 1.129)

1.058 (0.973,1.149)

1.002 (0.869,1.156)

0.763 (0.753,0.774)

Non-Hispanics (n = 54,548) Without NSES

1.057 (1.026,1.089)

1.047 (1.016,1.080)

1.007 (0.965,1.050)

1.088 (0.690,1.714)

With NSES

1.037 (1.004,1.070)

1.021 (0.989,1.055)

0.974 (0.932,1.018)

1.046 (0.769,1.423)

27

Limitation: Selection Limitation: Selection of Women into Neighborhoodsof Women into Neighborhoods

• Individuals may self-select into neighborhoods Individuals may self-select into neighborhoods spurious correlation between neighborhood SES spurious correlation between neighborhood SES and health outcomesand health outcomes

• Control for a comprehensive set of individual Control for a comprehensive set of individual characteristicscharacteristics

• Propensity score analysisPropensity score analysis Weighted women with different levels of NSES to be well Weighted women with different levels of NSES to be well

balanced on the covariatesbalanced on the covariates

• Analysis of moversAnalysis of movers Assume that CHD takes several years to developAssume that CHD takes several years to develop If a recent move appears to influence CHD mortality, then If a recent move appears to influence CHD mortality, then

this is likely to be a selection effectthis is likely to be a selection effect

28

MethodsMethods

• Cox Proportional Hazard model analyze time Cox Proportional Hazard model analyze time until adverse CHD eventsuntil adverse CHD events

• Shared frailty models account for geographic Shared frailty models account for geographic clustering of women at the census tract and clustering of women at the census tract and Metropolitan statistical area levelsMetropolitan statistical area levels

• Neighborhood variables (Neighborhood variables (xx) measured at the ) measured at the census tract level, from RAND’s CPHHD Data Corecensus tract level, from RAND’s CPHHD Data Core

)exp()()( ijkkjoijk xthth

29

Many Gaps in Existing LiteratureMany Gaps in Existing Literature

• Traditionally, CHD has been understudied in women relative Traditionally, CHD has been understudied in women relative

to mento men

• The neighborhood context may have a bigger effect on The neighborhood context may have a bigger effect on

women than menwomen than men

• Prior studies on neighborhoods and healthPrior studies on neighborhoods and health

Had limited geographic and racial heterogeneityHad limited geographic and racial heterogeneity

Neglected the relative importance of residential instabilityNeglected the relative importance of residential instability

Were cross-sectional in natureWere cross-sectional in nature

Lacked physician-adjudicated CHD outcomes Lacked physician-adjudicated CHD outcomes

Lacked a robust NSES index beyond education income six Lacked a robust NSES index beyond education income six neighborhood factorsneighborhood factors

30

Neighborhoods Influence CHD Directly, and Neighborhoods Influence CHD Directly, and Indirectly Through MediatorsIndirectly Through Mediators

Incident CHD Outcomes

BaselineHealth Status

Demographics

NeighborhoodSocial Environments

NeighborhoodBuilt Environments Social Support

Health Habits

Follow-Up Health Status

Psychological Well-Being

Individual Characteristics

Community Characteristics

Mediating Factors

CHD Outcomes

Per Capita County Medical Care Resources

31

WHI DataWHI Data

Data CategoryData Category ExamplesExamples

Individual DemographicsIndividual Demographics Age, race, education, incomeAge, race, education, income

Social SupportSocial Support Social activities, emotional and Social activities, emotional and instrumental supportinstrumental support

Quality of LifeQuality of Life Depression, personal outlook, Depression, personal outlook, life satisfactionlife satisfaction

Behavioral Risk FactorsBehavioral Risk Factors Smoking, alcohol intake, Smoking, alcohol intake, physical activity, dietphysical activity, diet

Health StatusHealth Status Family health history, Family health history, biomarkers, chronic illnessbiomarkers, chronic illness

Medical CareMedical Care Medications, use of medical careMedications, use of medical care

CHD & Mortality OutcomesCHD & Mortality Outcomes MI, angina, revascularizationMI, angina, revascularization

33

Lower NSES Is Independently Associated with Lower NSES Is Independently Associated with Increased Hazard of CHD Event or DeathIncreased Hazard of CHD Event or Death

1.00

1.01

1.02

1.03

MI/CHD death CHD death

1.02

1.01

CHD event

1.01

Ha

zard

Ra

tio

s

34

Results In a Real World ContextResults In a Real World Context

Northwest DC

Southeast DC

35

CHD Hazard Ratios: CHD Hazard Ratios: Southeast vs. Northwest DCSoutheast vs. Northwest DC

1.00

1.20

1.40

1.60

1.80

2.00

MI/CHD death CHD death

1.50

1.27

Ha

zard

Ra

tio

s

CHD event

1.23

0.80

Documents

%Race, NSES, and CHD ASA 08152010