TY - JOUR
T1 - Unequal Exposure or Unequal Vulnerability? Contributions of Neighborhood Conditions and Cardiovascular Risk Factors to Socioeconomic Inequality in Incident Cardiovascular Disease in the Multi-Ethnic Study of Atherosclerosis
AU - Hussein, Mustafa
AU - Diez Roux, Ana V.
AU - Mujahid, Mahasin S.
AU - Hastert, Theresa A.
AU - Kershaw, Kiarri N.
AU - Bertoni, Alain G.
AU - Baylin, Ana
N1 - Funding Information:
This work was supported by grant 2R01 HL071759 (Principal Investigator: A.V.D.R.), by contracts N01-HC-95159 through N01-HC-95169 from the National Heart, Lung, and Blood Institute, and by grant 2P60MD002249 (Center for Integrative Approaches to Health Disparities; Principal Investigator: A.V.D.R.) from the National Institute on Minority Health and Health Disparities. We thank Dr. Tyler VanderWeele for thoughtful comments on an earlier version of this article.
Publisher Copyright:
© The Author(s) 2018.
PY - 2018/7/1
Y1 - 2018/7/1
N2 - Risk factors can drive socioeconomic inequalities in cardiovascular disease (CVD) through differential exposure and differential vulnerability. In this paper, we show how econometric decomposition directly enables simultaneous, policy-oriented assessment of these 2 mechanisms. We specifically estimate contributions of neighborhood environment and proximal risk factors to socioeconomic inequality in CVD incidence via these mechanisms. We followed 5,608 participants in the Multi-Ethnic Study of Atherosclerosis (2000-2012) to their first CVD event (median length of follow-up, 12.2 years). We used a summary measure of baseline socioeconomic position (SEP). Covariates included baseline demographics, neighborhood characteristics, and psychosocial, behavioral, and biomedical risk factors. Using Poisson models, we decomposed the difference (inequality) in incidence rates between low- and high-SEP groups into contributions of 1) differences in covariate means (differential exposure) and 2) differences in CVD risk associated with covariates (differential vulnerability). Notwithstanding large uncertainty in neighborhood estimates, our analysis suggested that differential exposure to poorer neighborhood socioeconomic conditions, adverse social environment, diabetes, and hypertension accounted for most of the inequality. Psychosocial and behavioral contributions were negligible. Further, neighborhood SEP, female sex, and white race were more strongly associated with CVD among low-SEP (vs. high-SEP) participants. These differentials in vulnerability also accounted for nontrivial portions of the inequality and could have important implications for intervention.
AB - Risk factors can drive socioeconomic inequalities in cardiovascular disease (CVD) through differential exposure and differential vulnerability. In this paper, we show how econometric decomposition directly enables simultaneous, policy-oriented assessment of these 2 mechanisms. We specifically estimate contributions of neighborhood environment and proximal risk factors to socioeconomic inequality in CVD incidence via these mechanisms. We followed 5,608 participants in the Multi-Ethnic Study of Atherosclerosis (2000-2012) to their first CVD event (median length of follow-up, 12.2 years). We used a summary measure of baseline socioeconomic position (SEP). Covariates included baseline demographics, neighborhood characteristics, and psychosocial, behavioral, and biomedical risk factors. Using Poisson models, we decomposed the difference (inequality) in incidence rates between low- and high-SEP groups into contributions of 1) differences in covariate means (differential exposure) and 2) differences in CVD risk associated with covariates (differential vulnerability). Notwithstanding large uncertainty in neighborhood estimates, our analysis suggested that differential exposure to poorer neighborhood socioeconomic conditions, adverse social environment, diabetes, and hypertension accounted for most of the inequality. Psychosocial and behavioral contributions were negligible. Further, neighborhood SEP, female sex, and white race were more strongly associated with CVD among low-SEP (vs. high-SEP) participants. These differentials in vulnerability also accounted for nontrivial portions of the inequality and could have important implications for intervention.
KW - Multi-Ethnic Study of Atherosclerosis
KW - cardiovascular disease
KW - decomposition
KW - differential vulnerability
KW - neighborhood
KW - residence characteristics
KW - socioeconomic inequality
KW - socioeconomic status
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U2 - 10.1093/aje/kwx363
DO - 10.1093/aje/kwx363
M3 - Article
C2 - 29186311
AN - SCOPUS:85051436985
VL - 187
SP - 1424
EP - 1437
JO - American Journal of Epidemiology
JF - American Journal of Epidemiology
SN - 0002-9262
IS - 7
ER -