who perceive a stronger support network could adapt more quickly and return to a ... Chicago: University of Chicago Press, 1975. 2. Garbarino J, Stocking S: The ...
PUBLIC HEALTH BRIEFS
family, times of great change (e.g., death of spouse, loss of job, illness) could produce a transient decrease in the provision of home stimulation. Perhaps, however, mothers who perceive a stronger support network could adapt more quickly and return to a "baseline" home stimulation level more rapidly than isolated mothers with similar numbers of life changes. The data from this study suggest that the maternal home stimulation provided most rural children cared for by physicians will benefit from a strong maternal social support network. The relevance of these data for urban families is not established, but it seems plausible that the isolated urban mother will also have difficulty providing relatively high levels of home stimulation to her preschool child. The rare, highly stressed mother-rural or urban-may respond favorably to high levels of perceived support and provide more home stimulation than isolated mothers experiencing extreme numbers of life changes. Earlier work has established the importance of didactic sessions and demonstrations of exemplary parent-child interaction in the prevention of parenting problems.'7 This study suggests that providing help with daily task-sharing and maternal emotional support may also facilitate parentchild interaction. Subsequent research in this area should focus on the definition, measurement, and documentation of social supports as well as delineate the mechanism by which maternal social support affects maternal-child interaction. REFERENCES 1. Parke R, Collman C: Child abuse: an interdisciplinary analysis. In: Heatherington EM (ed): Review of Child Development Research, No. 5. Chicago: University of Chicago Press, 1975. 2. Garbarino J, Stocking S: The social context of child maltreatment. In:
Garbarino J, Stocking S (eds): Protecting Children from Abuse/Neglect. San Francisco: Jossey-Bass, 1980. 3. Gottlieb B: The role of individual and social support in preventing child
4.
5.
6. 7.
8.
9. 10. 11.
12. 13. 14.
15. 16. 17.
maltreatment. In: Garbarino J, Stocking S (eds): Protecting Children from Abuse/Neglect. San Francisco: Jossey-Bass, 1980. Garbarino J: The human ecology of child maltreatment. J Marriage and Family 1977; 33:728-736. Cochran M, Brassard J: Child development and personal social networks. Child Development 1979; 50:601-616. Kempe C: A practical approach to protection of the abused child and rehabilitation of the abusing parent. Pediatrics 1973; 51:804-812. Caplan G: Support Systems and Community Mental Health. New York: Behavioral Publications, 1974. Pascoe JM, Loda F, Earp JA: The assocation between mothers' social support and provision of stimulation to their children. Develop Behav Pediatr 1981; 2:15-19. Haggerty RJ: Life stress, illness and social supports. J Develop Med Child Neurol 1980; 22:391-400. Cobb S: Social support as a moderator of life stress. Psychosom Med 1976; 38:5:300-314. Petich J, Holmes TH: Life changes and onset of illness. Med Clin North America 1977; 61:4:835-838. Hunter RS, Kilstrom N, Loda F, et al: Antecedants of child abuse and neglect in premature infants: a prospective study in a newborn intensive care unit. Pediatrics 1978; 61:629-635. Caldwell BM, Elardo R, Bardley R: The relation of infants' home environment to mental test performance from 6 to 36 months: a longitudinal analysis., J Child Develop 1975; 46:71-76. Pascoe JM, Walsh N, Earp JA: Construct validity of the maternal social support index. J Develop Behav Pediatr 1982; 3:122. McCall RB, Hogarty PS, Hurlburt N: Transitions in infant sensory and motor development and the prediction of childhood IQ. Am Psychol 1972; 27:728-748. Kleinbaum D, Kupper L: Applied Regression Analysis and Multivariable Methods. North Scituate, MA: Duxbury Press, 1978. Heber R: The Milwaukee Project: a study of the use of family interventions to prevent cultural familial mental retardation. In: Friedlander BZ (ed): Exceptional Infant: Assessment and Intervention. No. 3. New York: Brunner-Mazel, 1975.
ACKNOWLEDGMENTS
The authors thank Frank Loda, MD, for his help in development of the instruments used in this study. We also thank Ray Helfer, MD, and Chris Ringwald, ACSW, for manuscript review. Dr. Pascoe was a Robert Wood Johnson Clinical Scholar in Chapel Hill, NC, when the data for this paper were collected.
Coronary Heart Disease Mortality Trends in Minnesota, 1960-80: The Minnesota Heart Survey RICHARD F. GILLUM, MD, PETER J. HANNAN, MSTAT, RONALD J. PRINEAS, MB, BS, PHD, DAVID R. JACOBS, JR., PHD, ORLANDO GOMEZ-MARIN, PHD, RUSSELL V. LUEPKER, MD, JUDITH BAXTER, PHD, THOMAS E. KOTTKE, MD, AND HENRY BLACKBURN, MD Abstract: Age-adjusted mortality rates and trends from coronary heart disease (CHD) in Minnesota for the years 1960 to 1980 differed among eight health service areas. Regression of ten socioeconomic and demographic factors and intensive care and coronary care unit beds on area CHD mortality levels and slopes revealed a significant positive association only for levels of welfare incomemaintenance assistance with CHD mortality levels; there were no associations with trends. Further studies are needed to explain variation within states of CHD mortality rate levels and trends. (Am J Public Health 1984; 74:360-362.)
From the Division of Epidemiology, School of Public Health, University of Minnesota. Address reprint requests to Dr. Richard Gillum, Associate Professor, Laboratory of Physiological Hygiene, School of Public Health, University of Minnesota, 611 Beacon Street, SE, Stadium Gate 27, Minneapolis, MN 55455. This paper, submitted to the Journal August 23, 1982, was revised and accepted for publication June 6, 1983.
© 1984 American Journal of Public Health 0090-0036/84 $1.50
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Introduction Coronary heart disease (CHD) mortality rates have decreased for nearly every age, sex, and race group in the United States.' Considerable geographic variation exists among states in CHD mortality rates and in the steepness of trends since 1968.2 Even within states there is substantial variation in CHD mortality rates among counties.34 Variation within states of CHD mortality trends has not been examined.5 The Minnesota Heart Survey examined mortality trends within Minnesota for the years 1960 to 1980. The following null hypotheses were posed: Significant variation in CHD mortality levels and trends does not exist among the eight Minnesota health service areas; area rank on seven socioeconomic-demographic and three welfare/income maintenance factors measured in the 1970s does not correlate with the levels or trends in CHD mortality rates between 1968 and 1980; area number of intensive/coronary care unit beds per population aged 30-74 years in 1977-1980 does not correlate with levels or trends in CHD mortality rates between 1968 and 1980. AJPH April 1984, Vol. 74, No. 4
PUBLIC HEALTH BRIEFS TABLE 1-Coronary Heart Disease Mortality in Minnesota for All Races Ages 30-74 Years 1960 to 1980: Rate per Million Standardized to 1970 US Total Population
Health
Service Area
1970 Population
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
32922 75466 37321 72565 67142 44629 78098 355684 763827
4901 5413 4512 4746 4308 4145 4758 5723 5115
4641 6072 4153 4457 4320 4664 4715 5742 5172
4900 6093 4731 4954 4513 4650 4439 5529 5172
4958 6300 4331 5065
5587 6204 5161 5121 4798 5097 4590 5953
4833 5901
5468 5853
4891 6210
5984 5949
4916 5196
5227 5818 4990 5313 4684 6043
5247 4784 4521 4874 5824
5475 6340 4930 4949 4552 4625 4317 5461
5511
5414
4618 5314 4372 4902 5066 5788 5378
5280
4464 4530 4566 5881 5325
5369 6426 5007 5265 4542 4801 4924 5810 5451
5617
5448
5185
32182 78747 38015 73125 68553 46848 82436 388338 808244
1663 2519 1498 1926 1497 1838 1552 1941 1875
1616 1602 1666 1740 1526 1411 1689 1807 1698
1695 1869 1174 1610 1746 1556 1601 1804 1713
1536 2140 1408 2015 1647 1389 1507 1851 1773
1728 2220 1571 1858 1595 1799 1481 1771 1765
1902 2047 1526 2050 1679 1605 1463 1795 1776
1994 1977 1791 1731 1439 1635 1406 1727 1702
1639 2208 1885 1793 1451 1716 1390 1781 1746
1661 2446 1753 2079 1386 1453 1573 1764 1785
1365 1942 1701 1931 1360 1544 1599 1807 1729
1365 2155 1753 1765 1264 1766 1246 1799 1698
MALES NW NE
w C SW SC SE
MT MN FEMALES NW NE
W C SW SC SE MT MN
4800 5643 4806 5764
Key to Health Service Areas: NW, northwest; NE, northeast (includes Duluth); W, west; C, central; SW, southwest; SC, southcentral; SE, southeast; MT, metropolitan (7-county St. PaulMinneapolis metropolitan area); MN, entire state of Minnesota.
TABLE 1-Coronary Heart Disease Mortality In Minnesota for All Races Ages 30-74 Years 1960 to 1980: Rate per Million Standardized to 1970 US Total Population (continued)
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
Absolute Change 1968-78
5762 6156 4082 5277 4651 4646 4524 5311 5159
4744 5925 5280 5494 4357 5304 4437 5270 5155
4953 5435 4907 4880 4625 4857 4514 5207 5017
4520 5526 4340 4734 4388 4303 4299 4510 4591
5259 5391 4845 4795 4232 4222 3830 4476 4570
4220 4788 4351 4658 3997 4419 3926 4395 4375
5257 4703 4008 4414 3678 4320 3763 4292 4247
4424
3780 4361 3479 4076 4094
3877 4384 3284 3822 3913 3428 2959 3862 3761
4253 4278 3728 3558 3312 3774 2933 3688 3652
467 1541 1521 1404 1210 952 1205 1967 1523
9.6 24.8 29.1 24.1 24.3 17.9 25.7 32.6 27.1
1597
1765 2035 1961 1882 1391 1329 1407 1686 1679
1870 1801 1377 1713 1314 1276 1252 1493 1500
1714 1728 1253 1447 1301 1229 1160 1491 1437
1427 1789 1366 1447 1118 1341 1093 1429 1392
1370 1704 1108 1229 1000 1223 1060 1269 1255
1815 1428 1289 1554 1067 1245 1062 1344 1329
1364 1698 797 1422 1125 1321 1128 1217 1259
866 1389 966 1226 1066 1121 988 1171 1144
1386 1577 1014 1354 1091 1184 861 1130 1176
297 748 956 657 261 132 445 547 526
17.9 30.6 54.5 31.6 18.8 9.1 28.3 31.0 29.5
1988 1392 1779 1396 1320 1497 1713 1650
Materials and Methods A general description of the Minnesota Heart Survey has been published.6 This report is based on all death certificates of Minnesota residents for the years 1960 to 1980 coded by the Minnesota Department of Health to the underlying cause of coronary heart disease: International Classification of Diseases Adapted (ICDA), Seventh Revision (1960-1967), Codes 420, 422; Eighth Revision (1968-1978), Codes 410-413, 428; Ninth Revision (1979-1980), Codes 410-414. Decedents were grouped according to residence in the eight health service areas of the state. Population estimates for the state and the eight areas were generated from 1960, 1970, and 1980 US Census data, using standard methAJPH April 1984, Vol. 74, No. 4
4669 3706
4414
Relative Change 1968-78 as % of 1968
ods for estimation of intercensal populations.6 Age-adjusted mortality rates were calculated by the direct method, using the 1970 US total population as standard. Data summarizing socioeconomic-demographic data and statistics on welfare income maintenance in the mid-1970s7 were obtained from the Minnesota Department of Planning, Energy and Development.* Each county was assigned a score between 1 and 5, corresponding to its quintile on each of the ten factors. Each health service area was then assigned a score for each factor derived from the average scores of its counties. The *This summary of 92 variables was done by factor analysis resulting in socioeconomic-demographic and three welfare-income maintenance
seven
factors.
361
PUBLIC HEALTH BRIEFS
scores for the ten factors were then entered into a stepwise linear regression as independent variables after forcibly entering sex. The average number of total intensive care unit and coronary care unit beds per population aged 30-74 years in each area in 1977-1980 was obtained from the Minnesota Department of Health. Earlier data were not available. This variable was also entered into a regression as an independent variable. The dependent variable in both regressions was mean level of CHD mortality rate over the years 1968 to 1980, or the slope of mortality rates over those years. The results of the regression were examined to see if the addition of any or all of the ten factors or the bed variable significantly reduced the error sum squares using the F-test for additional variables. Results Table 1 shows sex-specific, age-adjusted CHD mortality rates for all races 30-74 years from 1960-1980 by area, and the absolute and per cent changes for each area between 1968 and 1978, the period of use of ICDA Eighth Revision. CHD mortality rates were highest in the northeast region throughout the period in both men and women, lowest in the southern and western health service areas, with intermediate rates in the metropolitan and central areas. Among men, the absolute and relative declines in CHD mortality rate were greatest in the metropolitan area. Among women, this pattern was not apparent, several regions experiencing declines of similar magnitude. The mean level of CHD mortality rates between 1968 and 1980 was significantly related to only one of the welfareincome maintenance factors (p = 0.01), the factor representing general levels of income maintenance assistance.** In the factor analysis obtained from the Department of Energy, Planning and Development several variables had high loadings on this factor including: the proportion of recipients of Aid for Dependent Children, the relative frequency of cases funded under general assistance, emergency assistance, supplementary aid to the disabled, and general assistance Medicare; per capita Title XX funds expended; the average number of food stamp recipients per 1,000 population; and the average Minnesota supplemental aid payment. Areas with high CHD mortality rates also had high levels of welfare income maintenance. None of the ten socioeconomic-demographic or welfare income maintenance factors was significantly related to the slope of CHD mortality rate between 1968 and 1980. The number of intensive care-coronary care unit beds per population aged 30-74 years in each area in 1977-1980 was significantly related to neither level nor slope of CHD mortality rates between 1968 and 1980. The number of beds per 100,000 was highest in the Minneapolis-St. Paul area, and ranged from 19.9 to 11.8 among areas.
Discussion Between 1960 and 1980, there was considerable variation among the eight health service areas in Minnesota, both in mean CHD mortality rate level and in the change over the **Details of analyses available on request to author.
362
period. Possible explanations for these variations include differences in population risk factor distributions, which may be associated with socioeconomic status. Persons of lower socioeconomic status are more likely to smoke cigarettes and have hypertension.8 The positive association of high levels of CHD mortality with welfare assistance is consistent with such an explanation. Another possible explanation is differing access to sophisticated emergency medical services and to coronary care. This hypothesis is not supported by the results reported above for intensive care-coronary care unit beds. Both analyses were weakened by the lack of published data for 1968-1976 for the areas, which precluded relating trends in socioeconomic and bed data to CHD mortality trends. The results of these analyses and the difficulty in interpreting the results stress the need to monitor simultaneously socioeconomic and demographic variables within populations, as well as risk factor levels and CHD morbidity, mortality, and medical care.5 Minnesota mortality data for 1979 and 1980 indicate continued downward trends in CHD mortality. Therefore, effective monitoring of CHD mortality trends and their possible causes will continue to be important throughout the 1980s. The Minnesota Heart Survey is measuring simultaneous trends in acute myocardial infarction, mortality, hospitalization, and case fatality rates as well as CHD risk factors and health behavior within the Minneapolis-St. Paul metropolitan area.5 6 This and similar studies in other areas of the United States and in other industrialized nations should help to establish the causes of changing CHD mortality. REFERENCES 1. Blackburn H, Gillum RF: Prevention of chronic disease and disability: heart disease. In: Last JM (ed): Preventive Medicine and Public Health, I Ith Ed. New York: Appleton-Century Croft, 1980. 2. Leaverton PE, Thom TH, Kleinman JC, Gittelsohn A: Coronary heart disease mortality by states. In: Gillum RF (ed): Coronary Heart Disease in Black Populations. Am Heart J. Suppl, 1983. 3. Keil JE, Hudson MB, Stille WT, Sandifer SH: Coronary heart disease and stroke death in South Carolina: geographical differences. J S Car Med Assoc 1978; 74:173-178. 4. Fabsitz R, Feinleib M: Geographic patterns in county mortality rates from cardiovascular diseases. Am J Epidemiol 1980; 11 1:315-328. 5. Gillum R, Blackburn H, Feinleib M: Current strategies for explaining the decline in ischemic heart disease mortality. J Chron Dis 1982; 35:476-474. 6. Gillum RF, Prineas RJ, Luepker RV, Taylor HL, Jacobs DR, Kottke TE, Blackburn H: The decline in coronary heart disease mortality: The Minnesota Mortality and Morbidity Surveillance Program. Minnesota Med 1982; 65:235-238. 7. US Bureau of the Census: A profile analysis of Minnesota counties. Washington DC: US Bureau of the Census, 1979. 8. Khoury PR, Morrison JA, Laskarerski P, Kelly K, Mellies MJ, King P, Larsen R, Glueck CJ: Relationships of education and occupation to coronary heart disease risk factors in school children and adults: the Princeton School District Study. Am J Epidemiol 1981; 113:378-345.
ACKNOWLEDGMENTS This research was supported by National Heart, Lung, and Blood Institute Grant 5R01 HL23727 and Research Career Development Awards 5K04 HL00329 (Dr. Gillum), and IK04HLO-0287 (Dr. Jacobs), National Research Service Award 5T32HL0736 (Dr. Kottke). This paper was presented in part at the American Heart Association Epidemiology Council Scientific Sessions, San Antonio, March 5, 1982.
AJPH April 1984, Vol. 74, No. 4
