Office for Social Environment and Health R

 National Center for Chronic Disease Prevention and Health Promotion • Centers f

Women 

Heart Di

An Atlas of Raci

Disparitie

Se

APED TR M ENT O F HEALTH & HUM AN SERVICES.USAAPED TR M ENT O F HEALTH & HUM AN SERVICES.USA

ROBERT C. BYRD

HEALTH SCIENCES CENTER

As the Nation’s Prevention Agency, the Centers for Disease Control and Prevention (CDC) is committed to reducing the burden ofheart disease – the leading cause of death and a major contributor to disability in the United States. Deaths from heart disease arelargely preventable, and with targeted public health efforts we can alleviate much of the heavy burden of this disease. To meet thischallenge, CDC works to closely monitor geographic and temporal trends in heart disease among racial and ethnic groups,strengthen the delivery of primary and secondary preventive health services to all such groups, and implement policy changesthat support heart-healthy environments for all residents of the United States. CDC’s Associate Director for Women’s Health andAssociate Director for Minority Health serve as the Agency’s focal points for coordinating activities and monitoring programs tomeet these objectives.Among women, mortality rates for heart disease are higher than the rates for all forms of cancer combined. Approximately 373,286women die of heart disease each year, and more than 6.5 million women alive today have suffered a heart attack or angina pectoris(chest pain). In addition, the burden of heart disease among women is not equally distributed among racial and ethnic groupswithin the United States. Women and Heart Disease comprehensively describes the unequal distribution of heart disease amongthese groups.Women and Heart Disease: An Atlas of Racial and Ethnic Disparities in Mortality provides health professionals and concernedcitizens at the local, State, and national levels with information essential to identifying populations of women at greatest risk ofheart disease and in greatest need of prevention efforts. For the first time, county-level maps of heart disease are presented forwomen of the five largest racial and ethnic groups in the United States – American Indians and Alaska Natives, Asians and PacificIslanders, Blacks, Hispanics, and Whites. In addition, Women and Heart Disease includes maps that depict geographic patterns of

local economic and medical care resources, data on the social isolation of women, and population distributions for each racial andethnic group. These maps provide crucial information for tailoring prevention efforts to the communities in need.This publication is the first in a series of atlases related to cardiovascular disease that are in progress through a collaboration between CDC and West Virginia University. The next publication will be Men and Heart Disease: An Atlas of Racial and Ethnic Disparities in Mortality.I am pleased to share this important publication with you. I encourage you to use these data to improve the delivery of preventivehealth services and to create heart-healthy environments for all women.Jeffrey P. Koplan, M.D., M.P.H.Director, Centers for Disease Control and Prevention

A Message from the Direc

for Disease Cont

There is an increasing awareness of the health needs of women and minority populations in the United States. Historically, bothgroups have had limited access to health care resources and have been omitted from many research studies. Government and nongovernment health agencies are beginning to identify the gaps in health care and health outcomes that exist among these groupsand are beginning to develop strategies to reduce these gaps. Since the inception of the Centers for Disease Control andPrevention’s (CDC) Office of Minority Health in 1988 and Office of Women’s Health in 1994, our Offices have been committed to improving the health status of women and of racial and ethnic minority populations throughout the United States.CDC’s Office of Women’s Health is preparing to address the projected demographic trends of the next century and to meet the current and anticipated needs of millions of underserved women in America. By the year 2030, one of every four women will be overthe age of 65, and by the year 2050 women of color will represent one-half of the adult female population. These trends toward theaging and diversification of American women highlight the need to establish health promotion policies and programs that are culturally relevant and address issues surrounding chronic diseases that an aging population will experience – particularly heart disease, the leading cause of death among women in the United States. The data presented in Women and Heart Disease: An Atlas ofRacial and Ethnic Disparities in Mortality, provides for the first time, vital information needed to locate communities of women atgreatest risk of heart disease for each racial and ethnic group. The county-level maps of heart disease and social environmentalconditions provide the basis for taking actions now that could lead to substantially lower rates of heart disease among all U.S.women in the future.A central focus of activities of CDC’s Office of Minority Health is implementation of the President’s Initiative to Eliminate Racialand Ethnic Disparities in Health. Cardiovascular disease is one of the six health status areas targeted for eliminating such disparities by the year 2010. We recognize that achieving this goal requires a major national commitment to identify and address the underlying causes of the racial and ethnic disparities. New insights are needed to understand the determinants of the racial and ethnicdisparities in cardiovascular disease and to apply our knowledge toward eliminating these gaps. In this regard, you will find Womenand Heart Disease: An Atlas of Racial and Ethnic Disparities in Mortality to be a timely publication that provides a new perspective on the racial and ethnic patterns of cardiovascular disease at the community level. The maps will enable health researchers todevelop new hypotheses regarding the determinants of the geographic patterns of heart disease for each racial and ethnic group,and will also enable health professionals in local, State, and national health agencies to design new programs and policies tailoredto the needs of the communities with the highest rates of heart disease mortality.As we continue to identify the health needs of women and minority populations, additional opportunities will arise to expand an

d

modify our public health and medical care strategies for preventing and treating heart disease among all women.Karen K. Steinberg, Ph.D. Walter W. Williams, M.D., M.P.H.Acting Associate Director for Women’s Health Associate Director for Minority Health

A Message from the Associate Director for Women’s Health and the 

for Minority Health of the Centers for Disease Cont

I am pleased to present Women and Heart Disease: An Atlas of Racial and Ethnic Disparities in Mortality. For too long, heart disease has been considered as primarily a “man’s disease”; however, heart disease is also the number one killer of women. In terms oftotal deaths, heart disease claims the lives of more women than men. The gap between women and men is growing as the numberof excess deaths from heart disease among women continues to increase over time.This landmark document supports the President’s Initiative to Eliminate Racial and Ethnic Disparities in Health and addressesthe important need to reduce the risk of heart disease among women of all racial and ethnic groups. The maps in Women and HeartDisease depict heart disease mortality rates among women, county-by-county, for the entire United States, and identify the placeswhere women of each of the five major racial and ethnic groups experience the highest rates of mortality from heart disease. Withthis information, public health professionals at the local, state, and national levels will be able to target prevention resources topopulations of women in greatest need of additional services.Although mortality from heart disease has been declining for several decades, the rate of decline has varied by racial and ethnicgroup, resulting at times in a widening of the gap between such groups for both women and men. Moreover, recent trends indicatea slowing down in the rate of decline of heart disease mortality and underscore the importance of enhancing our efforts to supportinnovative community-based strategies for reducing the risk of heart disease. For women of all racial and ethnic groups (as well asfor men) it is through prevention that we can expect to achieve the greatest cardiovascular health benefits. Women and Heart Disease indicates where those programs are most needed and can have the greatest benefit.It is my hope that Women and Heart Disease: An Atlas of Racial and Ethnic Disparities in Mortality will be used to guide the distribution of funds and resources to those communities of women experiencing excess mortality from heart disease and will promotethe development of culturally sensitive prevention strategies.James S. Marks M.D., M.P.H.Director, National Center for Chronic Disease Prevention andHealth Promotion, Centers for Disease Control and Prevention

A Message from the Director of the Centers for Disease Control and Prevention ..................................................................A Message from the Associate Director for Women’s Health and the Associate Director for Minority Health of theCenters for Disease Control and Prevention ......................................................................................................................Foreword by James S. Marks, M.D., M.P.H. ..................................................................................................................List of Figures................................................................................................................................................................Introduction ................................................................................................................................................................Section 1. Racial and Ethnic Disparities in Heart Disease among Women .................................................................

The Social Construction of Race ..................................................................................................................................Misreporting of Race and Ethnicity on Death Certificates ................................................................................................Specific Categories of Heart Disease Deaths Among Women ..........................................................................................

Age Distribution of Heart Disease Deaths Among Women ..............................................................................................

Heart Disease Death Rate Trends for 1991-1995 ..........................................................................................................

County Variation in Heart Disease Death Rates ..............................................................................................................

Section 2. Reader’s Guide to Understanding and Interpreting the Maps ...................................................................

Calculation of Heart Disease Death Rates .....................................................................................................................National Heart Disease Mortality Map Layouts .............................................................................................................National Map Projections............................................................................................................................................Scale of the National Maps..........................................................................................................................................Guide to National Maps of Local Social Environment .....................................................................................................National Population Distribution Map Layouts ...............................................................................................................Guide to State Maps of Heart Disease Mortality ............................................................................................................State Map Layouts .....................................................................................................................................................
x Women and Heart Disease

Section 2 (continued)

State Map Projections .....................................................................................................................................................

Scale of the State Maps ...................................................................................................................................................

Section 3. Local Social Environment and Women’s Risk for Heart Disease Mortality ...................................................

Population Distributions ....................................................................................................................................................Local Economic Resources ..............................................................................................................................................Social Isolation of Elderly Women .....................................................................................................................................Medical Care Resources ..................................................................................................................................................

Section 4. National Maps of Heart Disease Mortality among Women ............................................................................Section 5. State Maps of Heart Disease Mortality among Women .................................................................................

Alabama .........................................................................................................................................................................

Alaska ............................................................................................................................................................................Arizona ...........................................................................................................................................................................Arkansas ........................................................................................................................................................................California ........................................................................................................................................................................Colorado ........................................................................................................................................................................Connecticut .....................................................................................................................................................................Delaware ........................................................................................................................................................................District of Columbia .........................................................................................................................................................Florida ............................................................................................................................................................................Georgia ..........................................................................................................................................................................Hawaii ............................................................................................................................................................................Idaho .............................................................................................................................................................................
Illinois .......................................................................................................................................................................Indiana .....................................................................................................................................................................Iowa ........................................................................................................................................................................Kansas .....................................................................................................................................................................Kentucky ..................................................................................................................................................................Louisiana ..................................................................................................................................................................Maine .......................................................................................................................................................................Maryland ..................................................................................................................................................................Massachusetts ...........................................................................................................................................................Michigan ...................................................................................................................................................................Minnesota .................................................................................................................................................................Mississippi ................................................................................................................................................................Missouri ...................................................................................................................................................................Montana ...................................................................................................................................................................Nebraska .................................................................................................................................................................Nevada ....................................................................................................................................................................New Hampshire ........................................................................................................................................................New Jersey ...............................................................................................................................................................New Mexico .............................................................................................................................................................New York .................................................................................................................................................................New York City ..........................................................................................................................................................North Carolina ..........................................................................................................................................................North Dakota ............................................................................................................................................................

Section 5 (continued)
xii Women and Heart Disease

Section 5 (continued)

Ohio ...............................................................................................................................................................................

Oklahoma .......................................................................................................................................................................Oregon ...........................................................................................................................................................................Pennsylvania ....................................................................................................................................................................Rhode Island ...................................................................................................................................................................South Carolina ................................................................................................................................................................South Dakota ..................................................................................................................................................................Tennessee .......................................................................................................................................................................Texas .............................................................................................................................................................................Utah ...............................................................................................................................................................................Vermont..........................................................................................................................................................................Virginia ...........................................................................................................................................................................Washington .....................................................................................................................................................................West Virginia ...................................................................................................................................................................Wisconsin .......................................................................................................................................................................Wyoming ........................................................................................................................................................................

Appendix A. State Rankings of Heart Disease Mortality Among Women .....................................................................

Appendix B. Methodological and Technical Notes.........................................................................................................

Appendix C. Resources..................................................................................................................................................Index ..............................................................................................................................................................................About the Authors ............................................................................................................................................................
Figure 1.1Specific categories of heart disease deaths among women 35 years of age and older, by race and ethnicity, 1991-1995 ..................................................Figure 1.2Age distribution of heart disease deaths among women 35 years of age and older, by race and ethnicity, 1991-1995 .......................................................Figure 1.3Trends in heart disease mortality among women 35 years of age and older, by race and ethnicity, 1991-1995 ................................................................Figure 1.4Frequency distribution of smoothed county heart disease death rates for women 35 years of age and older, by race and ethnicity, 1991-1995 ...................

Figure 2.1Example of layout for national heart disease mortality maps ...........................................................................................................................................Figure 2.2Example of layout for national population distribution maps ............................................................................................................................................

Figure 2.3Example of layout for state heart disease mortality maps ...............................................................................................................................................

Figure 3.1Asian Populations in the United States,1990 ................................................................................................................................................................

Figure 3.2Hispanic Populations in the United States,1990 ............................................................................................................................................................Figure 4.1Frequency Distribution of Smoothed Heart Disease Death Rates for Counties, All Women, 1991-1995 .............................................................................Figure 4.2Frequency Distribution of Smoothed Heart Disease Death Rates for Counties, American Indian and Alaska Native Women, 1991-1995 .............................Figure 4.3Frequency Distribution of Smoothed Heart Disease Death Rates for Counties, Asian and Pacific Islander Women, 1991-1995 ...........................................Figure 4.4Frequency Distribution of Smoothed Heart Disease Death Rates for Counties, Black Women, 1991-1995 ........................................................................Figure 4.5Frequency Distribution of Smoothed Heart Disease Death Rates for Counties, Hispanic Women, 1991-1995 ...................................................................Figure 4.6Frequency Distribution of Smoothed Heart Disease Death Rates for Counties, White Women, 1991-1995 ........................................................................

Introduction
16 Women and Heart Disease

Introduction

Maps have historically played a crucial role in the identifi- cation and resolution of public health problems, beginning with John Snow’s maps of the nineteenth century cholera

epidemic in London. During the past 40 years, public health researchers have documented persistent geographic disparitiesin heart disease mortality in the United States. However, mostof these studies have reported findings only for men. Whilethere is growing awareness that heart disease is the leadingcause of death for women, claiming over 372,000 lives in 1995alone, few studies of heart disease in women have examinedgeographic disparities.Why is it critical to understand local geographic disparities inthe burden of heart disease among women? We contend thathealth disparities among places reflect underlying inequalitiesin local social environments that make some communities morehealth-promoting than others. The social environment provides the context within which individuals are exposed to

structural risk factors (e.g. lack of erty, and social isolation) that contradvantageous behaviors (e.g. cigaretivity, poor diet). Ameliorating the communities will require structuraimprovements in community social inequalities within those communthat bear the greatest burden of hnecessary first step to targeting approving the local social environmethose communities.In Women and Heart Disease: An Disparities in Mortality, we have pof national and state maps that predisease death rates for all women, ANative women, Asian and Pacifwomen, Hispanic women, and wh
1991-1995. These maps highlight both substantial racial andethnic disparities in heart disease and the marked geographicdisparities in the burden of heart disease that exist within eachrace and ethnicity group. In addition, we have included national maps of local indicators of the social environment. Theseindicators include the geographic distribution of population byrace and ethnicity, availability of local economic resources, social isolation of elderly women, and the availability of medicalcare resources.An important strength of Women and Heart Disease is our examination of geographic disparities in heart disease mortalityfor American Indian and Alaska Native women, Asian and Pacific Islander women, and Hispanic women. Previous reportshave focused predominantly on reporting data for blacks andwhites. While there are important data quality limitations for raceand ethnic groups other than whites and blacks, we chose topresent results for women of all race and ethnicity groups. We hope

that these results will both highlight the need for improved deathcertificate and population data quality, and provide useful information to public health agencies and advocacy groups who areworking to improve health outcomes in diverse populations.Two perspectives on geographic disparities in heart diseaseamong women are presented in Women and Heart Disease: a

national perspective and a state perspective. The national perspective allows the comparison of heart disease death rates forall localities in the United States, visible on national maps thatpresent county death rates separately for each race andethnicity group. In contrast, the state perspective allows thecomparison of heart disease death rates for all localities withina single state. Women and Heart Disease includes over 200state maps, with at least two maps (for all women and whitewomen) and up to six maps presented for each state. The national and state perspectives provide complementary information useful for targeting resources to high risk communities.

Racial and Eth

Disparities inHeart Diseaseamong Women

1
20 Women and Heart Disease

In February 1998, at the direction of the President, the Department of Health and Human Services launched the Initiative toEliminate Racial and Ethnic Disparities in Health. One of thegoals of this initiative is to eliminate disparities in cardiovascular disease by the year 2010. Efforts to meet this goal must include the analysis and presentation of accurate and timely dataon the current burden of cardiovascular disease among racialand ethnic minorities in the United States. This publication ispart of that effort. We examined geographic disparities in heartdisease mortality for American Indian and Alaska Nativewomen, Asian and Pacific Islander women, black women, Hispanic women, and white women. These race and ethnicity categories have been officially adopted by the federal Office ofManagement and Budget (see Appendix B). Under the federaldata reporting scheme, Hispanic is considered a designation ofethnicity, not race. Therefore, data for Hispanic women were included within each of the four racial categories, and also analyzed separately. We use the terms “black” and “African American” interchangeably throughout this publication; similarly,“Latina” and “Hispanic” were used interchangeably as well.

The Social Construction Following several experts in huma

race and ethnicity as valid scient

valid biological or genetic categorclude both biological and social science perspective race and ethnicity ity of socially distinct groups in groups typically share certain culcharacteristics, and are often multiravisions are the result of historical evhostile encounters (e.g. wars anpopulation groups that were formeDifferences in physical appearance that were politically in conflict acqcance, compared with differenceamong individuals of the same grouThe idea that geographically-defisuch as “Africans” or “Japanese,” and genetically distinct human “racpopular credence in the nineteenth ries.3 Most of the scientific evidentimes to support theories of biologhas since been discredited and dtists.3-5 These scientists have dem

cance attributed to these physical ccial and historical in origin, and doegenetically important differences there is still popular belief in the ideences in physical appearance amoand ethnic groups must be linked to cant genetic differences in behaviorbility to disease.Empirical evidence from population the theory of genetically distinct racman beings share the same genes. species. Each person has two copbecause our chromosomes come in our mother, and one inherited from 

Figure 1.1Specific categories ofheart disease deathsamong women 35 yearsof age and older, by raceand ethnicity, 1991-1995

Racial and Ethnic Disparities in Heart Disease among Women

White Women

Hispanic Women

Black Women

Asian and Pacific

Islander Women

American Indian and

Alaska Native Women

Percent of all Heart Disease Deaths

0 10 20 30 40 50 60 70 80 90 100

Ischemic

heart disease Hypertensive heart disease Diseases of pulmonary circulation Other forms of heart disease Rheumatic heart disease

62 6 1 29 2

66 3 2 28 1

67 5 2 25 1

54 9 3 33 1

59 3 2 34 2
Racial and Ethnic Disparities in Hea

White Women

Hispanic Women

Black Women

Asian and Pacific

Islander Women

American Indian and

Alaska Native Women

35-44 years 45-54 years 55-64 years 65-74 years 

Percent of all Heart Disease D

0 10 20 30 40 50 60 

44 33 

33 30 

26 30 

25 27 

31 31 

in the form, and sometimes the function, of individual genesdo exist in human populations. These gene variations arecalled alleles. However, 75% of all human genes are monomorphic, meaning that only one allele exists in all people.1 Only avery small fraction of all human alleles impact severely on genefunction in a way that leads to disease. Most importantly,there are no particular alleles (whether detrimental, beneficial,or neutral) that can be found to exist only in one racial or ethnic population and not in others. For example, the allele of thehemoglobin gene that leads to sickle cell disease, typicallythought to be solely found in Africans, is also found in someAsian populations.In summary, the five racial and ethnic groups described inWomen and Heart Disease are socially, but not biologically,distinct groups. Moreover, we recognize that each of thesebroad racial and ethnic groups includes people of tremendousdiversity with regard to culture, socioeconomic status, heritage, and area of residence. If we accept the idea that differentracial and ethnic groups do not vary systematically in their inherent genetic susceptibility to disease, then to what can weattribute racial and ethnic disparities in heart disease mortality?Current research suggests a number of possibilities, includingdifferences in social class, culture, behavioral risk factors, psychosocial risk factors, and the direct effects of racism, segregation, and discrimination.6Misreporting of Race and Ethnicity onDeath CertificatesAn important concern for examining racial and ethnic disparities in heart disease mortality is the accuracy of race andethnicity information reported on the death certificate. Separate entries are available for race (American Indian or AlaskaNative, Asian or Pacific Islander, black, and white) and Hispanic origin (yes or no). Unfortunately there is evidence fromseveral studies that race and ethnicity are not always reportedaccurately on death certificates. There are instances whenAmerican Indians and Alaska Natives along with Asian andPacific Islanders are mistakenly identified as white, and Hispanics are mistakenly reported as non-Hispanics. This misreporting results in artificially lower mortality rates for those racial and ethnic groups. It is uncommon for race to be misreported for blacks. Misreporting of race and ethnicity on death certificates does not significantly increase mortality rates for whites, because the number of decedents who are misidentified as white on their death certificates is small rela- tive to the very large white population. One study7 compared race and ethnicity information from the Current Population Survey with similar data on death certifi- cates for 43,000 individuals who died during 1979 to 1985. The study found that race was coded incorrectly on the death cer- tificate for 0.8% of whites, 1.8% of blacks, 17.6% of Asian and Pacific Islanders, and 26.6% of American Indians. Hispanic ethnicity was miscoded on the death certificate for 10.3% of in- dividuals who self-identified as Hispanic on the survey, with the greatest errors for persons who identified themselves as Cuban or “other Hispanic.” A similar study found high rates of Fig

Agdis35 rac
22 Women and Heart Disease

1991 1992 1993 1994 1995

200250300350400450500550600

All WomenAmerican Indian and Alaska Native WomenAsian and Pacific Islander Women

Black Women

Hispanic WomenWhite Women

Age-adjusted rate (deaths/100,000)

Specific Categories of HDeaths Among WomenThe definition of heart disease useegory “diseases of the heart” as deter for Health Statistics (see Appendnition encompasses a variety of foring rheumatic heart disease (a constococcal infection that can cause heart valves over time), diseases of pertensive disease, ischemic heart coronary arteries which decreases heart), and other forms of heart disease carditis, mitral valve disorders, cardioFor women of all racial and ethnic ease was the primary specific categof the heart (Figure 1.1). Among alolder, 64% of heart disease deaths heart disease. The contribution varrace and ethnicity, with the largest pamong Latina women and the smacurring among African American heart disease deaths from hypertentably according to race and ethnicityof heart disease deaths were a coheart disease, compared with only for white women and Asian and PacAge Distribution of HearAmong WomenHeart disease mortality increases delderly women (85 years and oldeHeart disease deaths that occur befally considered premature, preventfore of particular public health signithe proportion of heart disease deturely among women varied consid(Figure 1.2). The least favorable agease deaths were experienced by A

disagreement between AIDS case reports and death certificates for American Indians (46%), Asians and Pacific Islanders(12%), and Hispanics (14%).8 A study of infant mortality inCalifornia found significant underestimation of rates for American Indians and Asians.9 Correct reporting of American Indianorigin on death certificates was found to be associated withtribal affiliation and percentage of American Indian ancestry ina study that linked IHS records and death certificates in Washington State.10A recent report from the national Center for Health Statisticsestimates that death rates (for all causes of death combined)corrected for both misreporting of race and ethnicity on thedeath certificates, and population undercounts in census files,would be 21% higher than currently reported for American Indians and Alaska Natives, 11% higher for Asians and PacificIslanders, and 2% higher for Hispanics.11 No studies to date

have evaluated the extent of geographic variation in the accuracy of reporting race and ethnicity on the death certificate andin the degree of population undercounts.

Figure 1.3Trends in heart diseasemortality among women 35years of age and older, by raceand ethnicity, 1991-1995
Racial and Ethnic Disparities in Hea

0

102030405060

0 100 200 300 400 500 600 700 800 

Percent of Counties

Smoothed Heart Disease Death Rates (deaths pe

AAABHW

Native women (23.4% of deaths were premature) and blackwomen (21.7% of deaths were premature). In contrast, only7.7% of heart disease deaths among white women occurredprematurely. White women also experienced the highest proportion of heart disease deaths after age 75 years (76.7%).Heart Disease Death Rate Trends for1991-1995Disparities in the level of heart disease mortality among the fiverace and ethnicity groups of women were observed for theyears 1991-1995 (Figure 1.3). The highest rates occurred amongAfrican American women, followed by white women, AmericanIndian and Alaska Native women, and Asian and Pacific Islander women. The heart disease death rates for Hispanicwomen of all races were similar to the rates for American Indianand Alaska Native women. Throughout the time period, therewas a more than twofold difference between the lowest rates(Asian and Pacific Islander women) and the highest rates (blackwomen). The low heart disease death rates nationwide forAsian and Pacific Islander women are predominantly a reflection of the mortality experience of Asian women. A study ofheart disease mortality in Hawaii found that rates for Hawaiianand other Pacific Islander women were two to six times higherthan the death rates for Chinese, Philipino, and Japanesewomen.12In 1995, the heart disease death rates among black women were2.6 times higher than the rates for Asian and Pacific Islanderwomen, 2.1 times higher than the rates for Latina women as wellas American Indian and Alaska Native women, and 1.4 timeshigher than the rates for white women. However, as discussedabove, misreporting of race and ethnicity on the death certificate may have led to spuriously lower heart disease death ratesfor American Indians and Alaska Natives and Asians and Pacific Islanders, compared with African Americans and whites.Although the 1970s and 1980s were times of substantial declines in heart disease death rates among women, the rate ofdecline slowed substantially in the 1990s. The trend data presented here indicate that among women of each race and ethnicity group there was very little decline in heart disease death rates in the 1990s. On average, heart disease death rates dropped 1.25% per year for women of all racial and ethnic groups combined. (The average annual percent change in death rate was calculated by subtracting the 1991 rate from the 1995 rate, dividing by the 1991 rate, and then dividing by 4). Hispanic women and Asian and Pacific Islander women experi- enced slightly faster declines (1.53% and 1.46% per year, re- spectively) than black women (1.25% per year) and white women (1.24% per year). American Indian and Alaska Native women experienced negligible declines in heart disease mortal- ity from 1991 to 1995 (0.54% per year). County Variation in Heart Disease Death Rates Considerable variation in heart disease death rates for women across counties was evident for 1991-1995 (Figure 1.4). The 
24 Women and Heart Disease

8 Kelly JJ, Chu SY, Diaz T, Leary LS

misclassification of persons reported with Agroups and the supplement to HIV/AIDS suand Health 1996; 1(1):87-94.

9 Farley DO, Richards T, Bell RM. Einfant mortality rate estimates for racial of Health Care for the Poor and Under10 Frost F, Tollestrup K, Ross A, Sabottracial coding of American Indians and Aton state death certificate. American J1994; 10(5):290-294.11 Rosenberg HM, Maurer JD, Sorlie EDdeath rates by race and Hispanic origin: Vital and Health Statistics Reports. RocHealth Satistics (in press).12 Braun KL, Yang H, Onaka AT, Horiuchmortality, differences in Hawaii. Social 

county distributions highlight the disparities in the burden ofheart disease among women of different races and ethnicities.By focusing on the tails of the distributions it is evident thatthere was very little overlap in the county rates for Asian andPacific Islander women and the rates for African American

women. In other words, the highest county heart disease deathrates for Asian and Pacific Islander women were lower than almost all of the county rates for black women. For white women,the high end of the tail of the distribution was about midpointin the distribution of county rates for African American women.The peaks in the distribution graphs for each racial and ethnicgroup indicate the most common county heart disease death

rates for that group. The peak occurblacks than for any other group. A

lander women, the most common counties is lower than for any of thbution of county heart disease deatand Alaska Native women is mugroups of women, with a primary p100,000 women and a secondary p100,000 women. The bimodal distrease rates highlights the geographiheart disease across the populatioNations that were combined into poses of data analysis.

1 Lewontin R. Human Diversity. New York: Scientific American Books, 1995.2 Gould SJ. The Mismeasure of Man. New York: W.W. Norton and Company,

1981.

3 Smedley A. Race in North America: Origin and Evolution of a Worldview.Boulder, CO: Westview Press, 1993.4 Freeman HP. The meaning of race in science – considerations forcancer research. Cancer 1998; 82(1):219-225.5 Cooper R. A note on the biologic concept of race and its application inepidemiologic research. American Heart Journal 1984; 108:715-723.6 Williams DR, Collins C. U.S. socioeconomic and racial differences inhealth: patterns and explanations. Annual Review of Sociology 1995;21:349-386.7 Sorlie PD, Rogot E, Johnson NJ. Validity of demographic characteristics on the death certificate. Epidemiology 1992; 3(2):181-184.


Reader’s Guid

Understandingand Interpretinthe Maps

2
28 Women and Heart Disease

Reader’s Guide to Understanding and Interpreting the Maps

Calculation of Heart DisOur study population consisted of older who resided in the United County maps of heart disease mogroups of women: all women, Ametive women, Asian and Pacific IslaHispanic women, and white womeease death rates at the county leveusing death certificate data from tSystem and population data colleCensus. We defined a heart disea

which the underlying cause of decertificate fell into the category “dfined by the National Center for egory included deaths coded 390-3Ninth Revision of the Internationa(see Appendix B for details).Important methodological issues hacould map geographic patterns of women. Analyses at the county levspatial specificity but are also subjeases. Specifically, for counties wsmall numbers of heart disease drates were likely to have large varimany counties having estimated rously high or low. The issue of smlarly relevant for examining patternby race and ethnicity, since racial ato be concentrated in certain geogrother regions. For all races and more sparse in rural than urban couGiven the assumption that, in generato some random variation,1 countie

more likely to exhibit rates that fluctrue, unknown rates. This fluctuatiotations of the true geographic patte

proaches to reduce the statistical vatality rates for heart disease: 1) temp

Maps have the potential to convey large amounts of com- plex information in an efficient and visually appealing

format. Several important elements are necessary for creating awell-designed and accurate map, including the subject matter

or content of the map (in this case, heart disease death rates),the layout of the map (i.e., the location and meaning of different items on the page), the projection of the map (i.e., themethod by which the earth’s curved surface is translated ontoa flat page), and the scale of the map (i.e., the size of featureson the map relative to their actual size on the earth). This section describes each element, and provides additional information useful for interpreting and using the maps.We have designed the maps in Women and Heart Disease toprovide the reader with easy access to important informationon the geographic distribution of heart disease mortalityamong women of diverse races and ethnicities. One of the attractions of maps is that they enable communication of hugeamounts of information. Precisely because so much information is being presented, however, it is important to be aware ofthe strengths and limitations of map display.Women and Heart Disease includes heart disease death ratemaps for the nation as a whole and for each individual state.Our rationale for including both national and state maps wasstraightforward. The national maps illustrate the broadscalegeographic patterns of heart disease mortality for each raceand ethnicity group, and enable the reader to compare any region, state, or county with other parts of the country. The statemaps allow the reader to identify the high-rate and low-rateareas within each state for all of the race and ethnicity groups.For each state, the categories for high- and low-rate areas arebased only on the county rates for that state. Consequently, thespatial pattern of heart disease death rates for a particular stateon the national map will look different than the spatial patternshown on the state map. With care, it is possible to contrastmortality patterns and rates among states and among the different race and ethnicity groups.
Reader’s Guide to Understandin

for the five year period 1991-1995, and 2) application of a statistical procedure known as spatial smoothing.Spatial smoothing involves calculating spatial moving averages for all counties.2 Heart disease deaths (numerators) andpopulation counts (person-year denominators) for each countywere summed together with the deaths and populations of theimmediate neighboring counties (i.e. contiguous counties) andthen divided to produce an average rate. Stated another way,the rate shown on the map for a single county represents anaverage of the heart disease mortality experience of that countyand all its contiguous neighbors (see Appendix B for completedetails).All rates were age-adjusted using the 1970 United States population as the standard, and are presented as deaths per 100,000population. On each map, counties were grouped into five categories of approximately equal number (quintiles) based on the

county distribution of smoothed heart disease death rates. Counties were first ranked from lowest to highest based on heart disease death rates. The lowest 20% of counties were assigned tothe first quintile; counties with death rates within the range from20% to 39% were assigned to the second quintile; from 40% to59% to the third quintile; from 60% to 79% to the fourthquintile, and the top 20% of counties were assigned to thehighest quintile. The use of quintiles for mapping is appropriatefor smoothed death rates and helps the reader to avoidover-interpreting the data.Because the severity of heart disease mortality varied by raceand ethnicity, the quintile cutpoints are different for each of thenational maps, and the range of values represented by a givenquintile varies from map to map. Therefore, comparisons of thespatial patterns of heart disease mortality across the mapsshould be limited to comparing relative differences among different groups of women. To determine whether the mortalityrates were absolutely higher or lower for one race and ethnicitygroup than for another, the reader must study the relevant legends and compare the cutpoints. It is well worth making a mental note of the range of county heart disease death rates foreach group when comparing geographic patterns across maps.

National Heart Disease MortalityMap LayoutsEach national heart disease mortality map follows a standardlayout (Figure 2.1). The title in the upper left hand corner identifies the subject. The upper right hand title identifies the raceor ethnicity of the women represented in the map. Most of thepage is devoted to a map of the continental United States. Wefollowed the common convention of displaying Alaska and

Hawaii as insets in the lower left hand corner of the layout.Two cities with very large populations, New York City and theDistrict of Columbia, are very small in area and hence difficultto see on the continental map. Therefore, these two areas arealso displayed as insets. County boundaries are displayedwith a thin black line, and state boundaries are displayed witha thick black line.The legend, located beneath the map, indicates the range ofcounty heart disease death rates in each quintile, and the number of counties in each quintile. For example, among blackwomen (see Figure 2.1) the cutpoint for the lowest quintile is484, indicating that black women in 20% of counties experienced heart disease death rates less than or equal to 484 deathsper 100,000 population. Counties in each quintile are displayedin a different color on the map. Counties in the highest ratequintile are the darkest color, while counties in the lowest ratequintile are the lightest color. Counties for which there was insufficient data to calculate a heart disease death rate are shadedgray.

National Map ProjectionsAlthough no flat map can be a perfect representation of thecurved surface of the earth, use of a suitable map projectionpreserves essential characteristics such as relative size, shape,and orientation. For the national heart disease mortality maps,the three map projections we used maximize the visibility ofspatial information. For the contiguous 48 states, we choseAlbers Equal Area, a map projection that preserves the accurate presentation of relative area and thus enhances comparison of one county with another. Alaska was projected on
30 Women and Heart Disease

Miller’s Cylindrical projection to provide a suitable orientationon the layout. Hawaii was presented using geographic coordinates (latitude and longitude), for reasons of shape and orientation. New York City and the District of Columbia were alsopresented using geographic coordinates.Scale of the National MapsScale is the number of distance units on the earth representedby one distance unit on a map. Scale is a dimensionless ratioand can therefore be expressed in any set of distance units(e.g. miles, kilometers, inches, centimeters). Every national mapof heart disease mortality actually contains five separate maps,each displayed at a different scale. To display the entire UnitedStates on one page, we had to compromise by displaying

Alaska and Hawaii as insets. Alasscale than the map of the contigularge in land area. Hawaii, New YColumbia are displayed at larger scstates because these areas are relaSince these maps are thematic in nafor displaying or measuring distanprovide the exact linear scale for eac

Guide to National Maps EnvironmentAn emerging body of research haimportance of the social environmtion patterns of heart disease mortments provide the context within work, and can create both barriers tenance of healthy homes, work works, and individual lifestyles.3,4

that represent four dimensions of evant to geographic patterns in heaThe first dimension was population five maps, the residential location oolder during 1991-1995 was portraand ethnicity group. The second nomic resources. Using data on mpational structure, and unemploymdex of local economic resources wthird dimension of the social envirocial isolation of elderly women. Wwomen’s social isolation for womeprevalence of living alone and self-care limitations. Finally, the focare resources. Maps of county dlar specialty physicians, coronary rehabilitation units were produced. Dsources and indicator definitions ca

Figure 2.1Example of layout for nationalheart disease mortality maps

National Maps of Heart Disease Mortality among Women 79

Smoothed County Heart Disease Death Rates1991-1995

Black Women

Ages 35 Years and Older
Reader’s Guide to Understandin

Evaluation of the maps of the social environment in conjunction with the heart disease mortality maps may suggest hypotheses about the determinants of geographic disparities inheart disease death rates among women. These maps also provide important information useful for developing programs andpolicies to reduce the burden of heart disease among women.National Population DistributionMap LayoutsOne set of maps in this section, the population distributionmaps, display two indicators on the same map and use a legend that may be unfamiliar to many readers. In the exampleshown in Figure 2.2, the first indicator is the percent of allwomen in each county who were black, and the second indicator is the number of black women in each county. Values ofeach indicator were divided into three categories. Thecutpoints for the categories were chosen to best display therange of variation in population distribution across counties.Consequently, an unequal number of counties fell into each ofthe three categories for each variable. The categories for thepercent of all women who were black were 1) less than 10%, 2)10%-34%, and 3) greater than or equal to 35%. The categoriesfor the number of black women were 1) fewer than 5000, 2)5000-49,999, and 3) greater than or equal to 50,000. The samecutpoints were used for the maps of all the race and ethnicitygroups.Combining the two indicators resulted in a total of nine categories for mapping which are displayed in a grid format in the legend. There are two color axes on this grid which correspond tothe two indicators. Shades of yellow-gray are used for thepopulation number indicator, and shades of yellow-orange areused for the population percent indicator. Categories at the topand left of the grid show low values of the indicators, while categories at the bottom and right of the grid show high values ofthe indicators. Numbers of counties in each category are alsoshown in the legend.

Guide to State Maps of Heart DiseaseMortalityTo create the state heart disease mortality maps, we used thesame heart disease death rates that were generated for the national heart disease mortality maps. A description of the methods used to calculate the rates can be found on pages 28-29. Itis important to remember that each county rate is based on aspatial moving average of that county and its neighbors.Therefore, for a county in a given state, neighboring countiesthat are part of adjacent states contributed to the smoothedrate for that county, even though those neighboring countiesare not displayed on the state map.There is one important difference between the national mapsand the state maps. The five categories (quintiles) into whichall counties are grouped on the national maps were derived

Geographic Distribu

<= 4,999 5,000 - 49,999 >= 50,000

< 10.00 %

10.00 - 34.99 %

>= 35.00 %

POPULATION

PROPORTION A1B1

C1

A2 A3B2 B3C2 C3

Low Population, Low PropMiddle Population, Low PrHigh Population, Low PropLow Population, Middle PrMiddle Population, Middle High Population, Middle PLow Population, High PropMiddle Population, High PHigh Population, High ProNo Population

A1A2A3B1B2B3C1C2C3

Geographic Distribution of Population 1995

Ages 
32 Women and Heart Disease

from the range of heart disease death rates experienced bywomen in counties across the nation. Consequently, all thecounties in a particular state could fall into the same quintileand be the same color on a national map. At the state level, wederived quintiles based only on the smoothed heart diseasedeath rates for counties in each state. Therefore, each state hascounties that fall into five different quintile categories.In addition, separate quintile cutpoints were generated for eachrace and ethnicity group within each state. Our rationale forhaving separate cutpoints by race and ethnicity was the sameas for the national heart disease mortality maps, namely, wewanted to display the full range of geographic variability foreach racial or ethnic group of women. Therefore, comparisonsof the spatial patterns of heart disease mortality across themaps should be limited to comparisons of the relative differences among different groups of women. In order to determinewhether the mortality rates were absolutely higher or lower forone race or ethnicity group compared to another, the readermust study the relevant legends and compare the cutpoints. Itis well worth making a mental note of the range of county heartdisease death rates for each group when comparing geographicpatterns across maps.State Map LayoutsAs with the national maps, for ease of use we have standardized the map layouts at the state level. The page layout for thestate maps is presented in Figure 2.3, and uses Arizona as anexample. The number of maps produced for each state varies,depending on the number of race and ethnicity groups that hadsufficient population sizes to permit mapping of heart diseasedeath rates. The number of maps per state ranges from a minimum of two (maps for all women and maps for white women aredisplayed for all states) to a maximum of six. States for whichthere are two or three maps have a single-page layout, andstates for which there are four to six maps have a double-pagelayout.For single-page layouts, the map title, the first point of referencefor the reader, appears at the top right with the state name at top

left. On double-page layouts, the teven numbered pages and top left ostate name can also be used as a qurace and ethnicity appears at top rigappears at either the bottom right or Counties in the highest rate quintile counties in the lowest rate quintile ties for which there was insufficient ease death rate are shaded gray.For each state, a table is displayeside of the first page of the layoumary data for the state as a whole. 1995 are provided for each of the Since all Hispanic women were also race categories, the population couthe sum of the four race groups onlfor women of each race and ethntable. For some states, a particulamay not have a county map displayheart disease death rate presented error but simply reflects the fact thties with sufficient data to generate sary for a map) but that there were as a whole to calculate a rate for thaState Map ProjectionsAll states were projected using the state has a separate, official State Ption based on the shape and orieState Plane system has a standard jections based on the Transverse Mformal projection. In the case of Plane zones, we used the central zominimum distortion to the state as ing the State Plane projection is thation for each state is likely to be avtion, which makes comparison with ex
Reader’s Guide to Understandin

Scale of the State MapsFor each state, the scale is consistent across the maps for different racial and ethnic groups. However, each state is mappedat a different scale compared with other states because weused the largest scale that would fit the layout, in order to maximize the size of the state image. Therefore, states with a smallland area were mapped at a larger scale than states with a larger

land area. Comparisons among states should be performed recognizing that, for different states, a unit length on the page willnot represent the same distance on the ground. It is useful touse the national map as a point of reference when comparingindividual state maps. Because these maps are thematic andwere not designed for displaying or measuring distances, wehave not provided the exact linear scale for each map.

1 Chiang CL. Standard error of the age-adjusted death rate. Vital Statistics- Selected Reports. Washington DC: U.S. Government Printing Office1961: 47(9).2 Cressie N. Statistics for spatial data. New York: Wiley, 1991.3 Armstrong D, Barnett E, Casper M, Wing S. Community occupational structure,medical and economic resources, and coronary mortality among U.S. blacks andwhites, 1980-1988. Annals of Epidemiology 1998; 8(3):184-191.

4 Robert SA. Community-level socioeconomic status effects on adulthealth. Journal of Health and Social Behavior 1998; 39:18-37.5 Wing S, Casper M, Hayes C, Dargent-Molina P, Riggan W, Tyroler HA.Changing association between community occupational structure andischaemic heart disease mortality in the United States. Lancet 1987;11(7):1067-1070.

94 Women and Heart Disease

Smoothed County Heart Disease Death Rates, 1991–1995

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older

Smoothed County Heart Disease Death Rates, 1991–1995

Sta

Arizona

All Women White Women

Black Women

American Indian/Alaska Native

Women

State Profile — Arizona

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 1,087,171 339American Indian and AlaskaNative Women 40,739 286Asian and Pacific IslanderWomen 18,275 241Black Women 27,332 492Hispanic Women 146,710 319White Women 1,000,825 338

Local Social

Environment aWomen’s Risk Heart DiseaseMortality

3
36 Women and Heart Disease

Social Environment and Heart Disease

the context within which individuarisk factors (poverty, social isolatironments) and adopt detrimental bephysical inactivity, poor diets).2,3 

prevention of heart disease ccommunitywide improvements in cluding full employment in healthy to affordable healthy foods and recfrom bigotry and discrimination, ainteraction and participation in civic 

In this section of the atlas, we examcal social environments that are reondary prevention of heart disease tors of the quality of the social envwere: race or ethnicity-specific poeconomic resources, social isolatimedical care resources.

Most contemporary heart disease prevention efforts focus on changing the behavior of individuals regardinglifestyle factors: dietary habits, leisure-time physical activity,and tobacco use.1 Health promotion programs that focus onbehavioral risk factors have been effective among adults whoare highly educated, fully employed, and highly motivated toimprove their health (i.e. among relatively privileged populations). However, the lifestyle approach to heart disease prevention has serious limitations for people who are at highest risk:namely, rural residents, the working class, and the poor. Thesegroups, unfortunately, have greater exposure to risk factorssuch as cigarette smoking, physical inactivity, high-fat diets,and psychological stress. These groups also face substantial social, economic, and geographic barriers to risk factor reduction.A holistic alternative to the lifestyle approach to heart diseaseprevention focuses on broad improvements in local social environments, recognizing that the social environment provides1 U.S. Department of Health and Human Services. Healthy People 2000:National Health Promotion and Disease Prevention Objectives. DHHSPub. No.(PHS) 91-50212. Washington DC: U.S. Government PrintingOffice, 1991.2 Sclar ED. Community economic structure and individual well-being: alook behind the statistics. International Journal of Health Services 1980;10:563-579.

3 Armstrong D, Barnett E, Casper M, Wstructure, medical and economic resourceUS blacks and whites, 1980-1988. A8(3):184-191.4 Wing S. Social inequalities in the declincan Journal of Public Health 1988; 78
Local Social Environment and Women’s Risk 

The first set of maps depicts the population distribution foreach of the racial and ethnic groups for whom heart diseasemortality data were analyzed. There are dramatic patterns ofspatial concentration of racial and ethnic minorities in particularlocalities and regions within the United States. Geographic segregation and concentration of particular racial and ethnicgroups are important predictors of access to economic opportunities, social services, and medical care resources.Local economic resources for all counties in the United Stateswere examined through the use of a summary index composedof three measures: white collar employment, unemployment,and family incomes. Local economic resources often determinethe availability of resources for healthful living, including safeand affordable foods and recreational facilities.In general, women in the United States have both longer life expectancy and fewer economic assets than with men. Consequently, the problem of social isolation of elderly women is substantial. Social isolation of women can limit social interac- tion, social support, access to necessities of daily living, access to routine social and health services, and access to acute (emergency) medical care.5 Three measures of women’s social isolation were examined: poverty, living alone, and mobility or self-care limitations. Finally, medical care resources, particularly those related to treatment and rehabilitation of patients with heart disease, were examined. Lack of local availability of medical care re- sources often means prohibitively expensive and time-consum- ing travel to a physician or hospital in a distant location for a patient with heart disease.6,7 We examined local availability of three specific heart disease care resources: cardiovascular dis- ease specialty physicians, coronary care unit beds, and cardiac rehabilitation units.

5 Kaplan GA, Salonen JT, Cohen RD, Brand RJ, Syme SL, Puska P. Social

connections and mortality from all causes and from cardiovascular disease: prospective evidence fom Eastern Finland. American Journal ofEpidemiology 1988; 128(2):370-380.

6 Behringer B. Health care services in Appalachia, in Couto RA, HarrisG, Simpson NK (eds); Sowing Seeds in the Mountains: CommunityBased Coalitions for Cancer Prevention and Control. Bethesda, MD:

National Cancer Institute; 1994:62-80.

7 Whiteis DG. Third world medicine in first world cities: capital accumulation, uneven development and public health. Social Science and Medicine 1998;47:795-808.

Popu

In 1990, there were 127,470,455 women of all ages, races, and ethnicities living in counties across the United States.1Each racial and ethnic group has its own unique geographicpattern of population distribution. The distinctive patterns reflect differences in migration histories, social and economicopportunities, political conditions, immigration rates, culturalpreferences, and fertility rates.The United States population is becoming more diverse byrace and Hispanic origin. For example, from 1994 to 1995 thepopulation of Asian and Pacific Islanders increased 3.8%, theLatino population increased 3.5%, and the black, American Indian, and Alaska Native populations increased 1.5% while thewhite population increased only 0.8%.2 Population projectionsfrom the Bureau of the Census suggest that by 2050 the whitenon-Hispanic population may comprise 52.5% of the UnitedStates population compared with its 1990 level of 75.7%.Latinos may be the second largest group comprising 22.5% ofthe population, followed by blacks (15.7%), Asian and Pacific Islanders (10.3%) and American Indians and Alaska Natives (1.1%).3It is important to remember that in this book, populations defined by race (Asians and Pacific Islanders, American Indiansand Alaska Natives, African Americans, and whites) are not

mutually exclusive of the population defined by Hispanic origin. In other words, each of the four race groups includeswomen of Latina ethnicity; similarly, the Hispanic populationincludes women of all races. The population totals for “allwomen” result from the sum of the population totals for eachof the four race groups.Recent migration patterns within the United States have beencharacterized as responses to the following three forces: 1) amovement away from rural areas into the cities, 2) a countermovement away from cities and suburbs to nearby non-metropolitan counties, and 3) interregional movements predominantly from east to west but increasingly from north to southand from California to the north and east.4The maps in this section portray two dimensions of the population distribution for each of the racial and ethnic groups.Counties are categorized according to the number of women ofeach racial and ethnic group as well as the percentage ofwomen in the county who belong to each racial and ethnicgroup. These two dimensions allow the reader to identify thecounties with the largest populations of women for each racialand ethnic group while also noting where each racial and ethnic group is most heavily concentrated.

1 Bureau of the Census. We the American women. Washington DC: U.S.

Government Printing Office, September 1993.

2 Deardorf KE and Montgomery P. National population trends. In U.S.Bureau of the Census, current population reports, series p23-189, Population Profile of the United States: 1995. Washington DC: U.S. Government Printing Office, 1995.

3 Day JC. National population projections. In U.S. Bureau of the Census,current population reports, series p23-189, Population Profile of theUnited States: 1995. Washington DC: U.S. Government Printing Office: 1995.4 Paterson JH. North America. Oxford: Oxford University Press, 1994,pp.58-60.
40 Women and Heart Disease

American Indian and Alaska Native Women

35 years and older in 1995. Both npopulation on the legend) and thwho were American Indian or Alation on the legend) are displayed. one of nine categories based on boportion of women who were AmeriCounties of the lightest color on thAmerican Indian and Alaska Natfewer than 10% of all women ages counties. Darker-colored counties obers or proportions of American IndiaA detailed guide to interpreting this mCounties with the highest proportioAlaska Native women were locatewestern states: Alaska, Arizona, Nekota, South Dakota, and Montana. United States had populations of ANative women that were larger thaof United States counties had popuand Alaska Native women that wcomprised less than 10% of the poptern reflects the fact that a) only 22and Alaska Native population live 

of the 314 reservations and trust fewer than 1,000 (only 10 reservatithan 7,000; see table). With the exPhoenix, American Indian and Aladominantly in non-metropolitan are

According to the Bureau of the Census, in 1990 there were1,959,234 American Indians and Alaska Natives living in theUnited States.1 With over 500 federally recognized tribes, there

is substantial geographic, cultural, historical and linguistic diversity among American Indian and Alaska Native peoples.

The tribes also vary in size, with only four tribes having greaterthan 100,000 members: Cherokee, Navajo, Chippewa and Sioux.2

In 1990, nearly one-half the American Indian and Alaska Nativepopulation lived in the West, 29% lived in the South, 17% livedin the Midwest and 6% lived in the Northeast.1 The concentration of American Indians and Alaska Natives in the West andthe small population sizes in the Northeast reflect the effects ofthe Indian Removal Bill passed in 1830, which mandated the removal of all Indians east of the Mississippi River.3 Many of the

tribal nations from the East were forced to resettle in what isnow Oklahoma. In 1990, Oklahoma was the state with the largest population of American Indians and Alaska Natives. Morethan one half of the American Indian and Alaska Native population lived in just six states—all located in the West: Oklahoma, California, Arizona, New Mexico, Alaska, and Washington.2 The tribal nations currently residing in the East are descendants of small bands of Indians who escaped removal and

managed to remain on their native lands. The largest AmericanIndian populations in the East are located in New York andNorth Carolina.3The map (opposite page) depicts the county distribution of thepopulation of American Indian and Alaska Native women ages

1 Paisano EL. The American Indian, Eskimo, and Aleut population. InU.S. Bureau of the Census, Current Population Reports, Series P23-189,Population Profile of the United States: 1995. Washington DC: U.S.Government Printing Office: 1995.

2 Bureau of the Census. We the first Am

Government Printing Office: Septembe

3 Snipp CM. American Indians: The First Sage Foundation, 1989.

Ten Reservations with the LargestNumbers of American Indians andAlaska Natives: 1990Navajo (AZ, NM, UT* ) ....... 143,405Pine Ridge (NE, SD*) ............. 11,182

Fort Apache (AZ) .................... 9,825Gila River (AZ) ......................... 9,116

Papago (AZ) ............................ 8,480

Rosebud (SD*) ........................ 8,043San Carlos (AZ) ....................... 7,110

Zuni Pueblo (AZ, NM) ............. 7,073

Hopi (AZ* ) ............................. 7,061

Blackfeet (MT) ......................... 7,025

* includes trust lands
<= 4,999 5,000 - 49,999 >= 50,000

< 10.00 %

10.00 - 34.99 %

>= 35.00 %

POPULATION

PROPORTION A1B1

C1

A2 A3B2 B3C2 C3

Low Population, Low ProMiddle Population, Low PHigh Population, Low ProLow Population, Middle PMiddle Population, Middle High Population, Middle PLow Population, High ProMiddle Population, High PHigh Population, High PrNo Population

A1A2A3B1B2B3C1C2C3

Geographic Distribution of Population 1995

American Indian and A

Age
42 Women and Heart Disease

24%

12%

20%

12%

13%

9%

10%

Chinese

Japanese

Filipino

Korean

South Asian

VietnameseOther Asian

Asian and Pacific Islander Women

The Asian and Pacific Islander population in the United Statesis diverse in ethnicity, language, and country of origin. The1990 Census counted 7.3 million Asians and Pacific Islanders,who comprised about 3% of the total population.1 Asians andPacific Islanders in the United States reside predominantly inmetropolitan areas and are also more likely to reside in centralcities than non-Hispanic whites.1Asians of various ethnicities comprise 95% of the total Asianand Pacific Islander population.2 About one-half of Asians in

the United States are of Chinese, Japanese, or Korean ethnicity(Figure 3.1). Other significant groups include Filipinos, SouthAsians (Indians, Pakistanis, Bangladeshis, and Sri Lankans),and Vietnamese. Overall, 66% of Asians were born in foreigncountries, but the percent of foreign-born individuals variesconsiderably by ethnicity. In 1990, only 32% of persons ofJapanese ancestry were foreign-born.2

Pacific Islanders comprise approxiand Pacific Islander population. MHawaiian (58%) in 1990, followed b(14%) and all other (11%).3 Pacif

nantly in the western United Stateslanders lived in either Hawaii or CaIslanders living in the United Statethe United States.The map (opposite page) depicts thpopulation of Asian and Pacific Island older in 1995. Numbers of wothe legend) and the proportion of alPacific Islander (labeled proportiplayed on the map. Counties were egories based on both populatiowomen who were Asian or Pacific lightest color on the map had fewcific Islander women, who comprwomen ages 35 years and older in ored counties on the map had greof Asian and Pacific Islander wompreting this map can be found on pAlthough only 140 counties in the Islander women ages 35 years and jority of counties (n=2897) were egory of both population size antions of Asian and Pacific Islander waii, several counties in CaliforniaYork (part of New York City). ModAsian and Pacific Islander women tan areas, including New York Citami, Houston, Dallas, and Seattle.

1 Bennett CE, Martin B. The Asian and Pacific Islander Population,

pp.48-49, in U.S. Bureau of the Census, Current Population Reports,Series P23-189. Population Profile of the United States: 1995. Washington DC: U.S. Government Printing Office: 1995.

2 Bureau of the Census. We the AmericanGovernment Printing Office: Septembe3 Bureau of the Census. We the AmericanDC: U.S. Government Printing Office: 

Figure 3.1Asian Populations in theUnited States, 1990
<= 4,999 5,000 - 49,999 >= 50,000

< 10.00 %

10.00 - 34.99 %

>= 35.00 %

PROPORTION A1B1

C1

A2 A3B2 B3C2 C3

Low Population, Low PropMiddle Population, Low PrHigh Population, Low PropLow Population, Middle PrMiddle Population, Middle High Population, Middle PLow Population, High PropMiddle Population, High PHigh Population, High ProNo Population

A1A2A3B1B2B3C1C2C3

Geographic Distribution of Population 1995

Asian and Pac

Ages 

POPULATION
44 Women and Heart Disease

Black Women

The 1990 United States census counted almost 30 millionblacks, who comprised 12% of the total population.1 Most African American people in the United States today are descended

from West Africans who were forcibly relocated to work asslaves in European colonies in the Caribbean and NorthAmerica from the sixteenth to the nineteenth centuries. A small

proportion of U.S. blacks are recent immigrants from Africa.The geographic distribution of the African American population today reflects the original settlement of early African migrants in the South as well as more recent internal migrationsto northeastern and midwestern cities.2 Today most blacks nationwide live in metropolitan areas (83.8%), but a substantial

proportion of African Americans in the South live either in nonmetropolitan areas (28.0%) or outside of central cities (27.9%).3The map (opposite page) depicts the county distribution of thepopulation of black women ages 35 years and older in 1995.Both numbers of women (labeled population on the legend)and the proportion of all women who were black (labeled proportion on the legend) are displayed on the map. Countieswere assigned to one of nine categories based on both population size and proportion of women who were African American.

Counties of the lightest color on thblack women, who comprised fewages 35 years and older in thoscounties on the map had greater nurican American women. A detaile

map can be found on page 31.Black women are the second moscally dispersed group of women in posed 35% or more of the total pocounties in 1995. These counties iphis, Atlanta, Washington DC, New a number of smaller metropolitan southern states of Louisiana, ArkanFlorida, Georgia, South Carolina, NOutside the South, African Americanantly in moderate to large metropcago, Los Angeles, San Francisco, number of counties nationwide h

women residents in 1995 (n=398)had low populations as well as women.

1 Bennett CE, DeBarros KA. The Black Population. pp.44-45, In U.S. Bureau of the Census, Current Population Reports, Series P23-189. PopulationProfile of the United States: 1995. Washington DC: U.S. Government Printing Office: 1995.

2 Smallwood AD. The Atlas of African-Amethe Slave Trace to Modern Times. Boston: 3 Bureau of the Census. We the AmericanGovernment Printing Office: Septembe
<= 4,999 5,000 - 49,999 >= 50,000

< 10.00 %

10.00 - 34.99 %

>= 35.00 %

POPULATION

PROPORTION A1B1

C1

A2 A3B2 B3C2 C3

Low Population, Low ProporMiddle Population, Low PropHigh Population, Low PropoLow Population, Middle PropMiddle Population, Middle PHigh Population, Middle ProLow Population, High PropoMiddle Population, High ProHigh Population, High PropoNo Population

A1A2A3B1B2B3C1C2C3

Geographic Distribution of Population 1995

Ages 
46 Women and Heart Disease

Hispanic Women

The terms “Hispanic” or “Latino/a,” as defined by the FederalOffice of Management and Budget, refer to persons of Spanishculture or origin, regardless of race. This population in theUnited States includes people who refer to themselves asChicana/o, Puerto Rican, and Cuban, among many other designations.1 In 1993 there were 22.8 million persons of Latino origin, comprising nearly 9% of the total population.2 The Hispanic population is diverse in ethnicity, culture, and country oforigin. As shown in Figure 3.2, most Latinos in the UnitedStates are of Mexican origin (61.2%), followed by Puerto Ricanorigin (12.1%), and Central American origin (6%).3 Of all Hispanics in the United States in 1990, the majority were native

born (64.2%), and an additional 9.4% were naturalized citizens.3

The map (opposite page) depicts thpopulation of Latina women ages 3is important to remember that, in tHispanic women was defined to inSimilarly, the populations of womesome women of Latina origin. On women (labeled population on the portion of all women who were Hon the legend) are displayed. Counnine categories based on both popof women who were Latina. Counthe map had fewer than 5,000 Hispafewer than 10% of all women ages counties. Darker-colored counties obers or proportions of Latina womepreting this map can be found on paIn 1995 there were six counties that and a high proportion of Hispanic Bronx in New York City, Miami, Brownsville. Several other countieand the New York City metropolitan large populations or proportions of nia, large populations of moderate Los Angeles, San Francisco, and a nties in central California. In New Meprised at least 10% of all women counties in the United States had ties (n=2753) had fewer than 5,000 

1 Oboler S. Hispanics? That’s what they call us, pp 3-5, In Delgado R,Stefancie J (eds). The Latino/a Condition. New York: New York University Press: 1998.2 Del Pinal J. The Hispanic Population, pp.46-47, In U.S. Bureau of theCensus, Current Population Reports, Series P23-189. Population Profile of the United States: 1995. Washington DC: U.S. Government Printing Office: 1995.

Figure 3.2Hispanic Populations in theUnited States, 1990

62%

12%

6%

5%

2%

4%

4%

5%

MexicanPuerto RicanCentral AmericanCubanDominicanOther HispanicSpanishSouth American

3 Bureau of the Census. We the AmericaU.S. Government Printing Office, Sept
<= 4,999 5,000 - 49,999 >= 50,000

< 10.00 %

10.00 - 34.99 %

>= 35.00 %

POPULATION

PROPORTION A1B1

C1

A2 A3B2 B3C2 C3

Low Population, Low PropMiddle Population, Low PrHigh Population, Low PropLow Population, Middle PrMiddle Population, Middle High Population, Middle PrLow Population, High PropMiddle Population, High PrHigh Population, High PropNo Population

A1A2A3B1B2B3C1C2C3

Geographic Distribution of Population 1995

Ages 
48 Women and Heart Disease

White Women

Whites are the majority population in the United States, withwhite women (n=102,210,190) comprising 80% of womenfrom all racial and ethnic groups combined in 1990.1 Within the

white population there is also a diversity of cultural and historical backgrounds. The diversity is reflected in the ancestry ofthe US population. Among the top 10 most frequently reportedancestry groups in the nation are the following subgroups ofwhites: Germans (23% of the total population), Irish (16%), English (13%), Italian (6%), French (4%) and Polish (4%). Populations of white women and men live in all counties across thenation, but many of the subgroups are heavily concentrated inspecific regions. For example, more than half the nation’s Italians are found in the northeast, half the Norwegians andCzechs in the Midwest, and more than 40 percent of the ScotsIrish are found in the South.2

The map (opposite page) depicts the county distribution of thepopulation of white women ages 35 years and older in 1995.Both numbers of women (labeled population on the legend)and the proportion of all women who were white (labeled proportion on the legend) are displayed on the map. Countieswere assigned to one of nine categories based on both population size and proportion of women who were white. Counties ofthe lightest color on the map had fewer than 5,000 whitewomen, who comprised fewer than 10% of all women ages 35years and older in those counties. Darker-colored counties on

the map had greater numbers or prodetailed guide to interpreting this map Regardless of population size, whit35% of the population in all but United States, and there were no coaccounted for fewer than 10% of that had several counties where wh35% of all women included Alaska population is Alaska Native), New parts of the land belong to Ameriand several southern states with rdominantly black.The distribution of population sizflects the urban-rural population paCounties with at least 50,000 white along the southern coast of Califordor along the Atlantic and southern ters in the Northeast, Mid West, SoSurrounding each of the urban cemid-population range. Counties wiwere observed in the southern rebama, the Mississippi Delta, and from the northwestern quadrant othe plains and up to the Dakotas.

1 Bureau of the Census. General Population Characteristics: UnitedStates. 1990 Census of Population. 1990 CP-1-1. Washington DC: Bureau of the Census, 1993.

2 Bureau of the Census. We asked...You tionnaire Content, 1990 CQC-14. Washsus, February 1995.
<= 4,999 5,000 - 49,999 >= 50,000

< 10.00 %

10.00 - 34.99 %

>= 35.00 %

POPULATION

PROPORTION A1B1

C1

A2 A3B2 B3C2 C3

Low Population, Low PropMiddle Population, Low PrHigh Population, Low PropLow Population, Middle PrMiddle Population, Middle High Population, Middle PLow Population, High PropMiddle Population, High PHigh Population, High PropNo Population

A1A2A3B1B2B3C1C2C3

Geographic Distribution of Population 1995

Ages 

L

Local Ec

In the United States, uneven development has created a highly variable landscape of socioeconomic conditions andopportunities. Uneven economic development has resulted in aconcentration of wealth and resources in some areas (usuallylarge cities) and underdevelopment of other, predominantly rural areas.1 Underdevelopment is an historical, political, and economic process by which wealth generated within a region (bythe labor of its residents) is exported outside the region (byowners of firms, factories, and mines) rather than being reinvested within the region to benefit local communities.2 Developed economic centers, including many large metropolitan areas, typically enjoy high levels of economic activity and

economies of scale that result in increased median incomes andgreater availability of public, social, cultural, and health services than in smaller urban and rural areas.3-7

Several studies have shown that, compared with high-resourceareas, local communities with low levels of economic resources,

5 Barnett E, Elmes GA, Braham VE, Halverson JA, Lee JY, Loftus S.Heart Disease in Appalachia: An Atlas of County Economic Conditions,Mortality, and Medical Care Resources. Prevention Research Center,West Virginia University, Morgantown, WV, June 1998.6 Whiteis DG. Third world medicine in first world cities: capital accumulation, uneven development and public health. Social Science and Medicine 1998;47:795-808.7 Behringer B. Health care services in Appalachia, in Couto RA, Harris G,Simpson NK (eds); Sowing Seeds in the Mountains: Community-BasedCoalitions for Cancer Prevention and Control. Bethesda, MD: NationalCancer Institute; 1994:62-80.8 Wing S. Social inequalities in the decline of coronary mortality. American Journal of Public Health 1988;78:1415-1416.

1 Fox K. Uneven regional development in the United States. Review ofRadical Political Economy 1978;10:68-86.2 Lyson TA, Falk WW. Forgotten places: poor rural regions in theUnited States, in Lyson TA, Falk WW (eds); Forgotten Places: Uneven

Development in Rural America. Lawrence, University of Kansas Press;1993.

3 Armstrong D, Barnett E, Casper M, Wing S. Community occupationalstructure, medical and economic resources and coronary mortality amongUS blacks and whites, 1980-1988. Annals of Epidemiology 1998;8:184-

191.

4 Sclar ED. Community economic structure and individual well-being: Alook behind the statistics. International Journal of Health Services1980;10:563-579.

as measured by income, occupation, and education profiles,had higher rates of heart disease mortality from the 1960s to the1980s, and were slower to experience the onset of decline inheart disease mortality in the 1960s and 1970s.3,8 Per capita government expenditures for employment, social, and health services

were lower in these areas than in high economic resource areas.3

The uneven distribution of local economic resources within theUnited States poses significant barriers to the development ofstandardized community-wide programs and policies to reducethe burden of heart disease. Differences in the local economicinfrastructure should be considered when community-basedprograms to prevent heart disease are being designed. Documentation of the geographic distribution of local economic resources may also suggest important directions for further research on the determinants of geographic inequalities in heartdisease mortality among women.
52 Women and Heart Disease

Local Economic Resources

The geographic distribution of local economic resources wasexamined in this report using a summary index based on threemeasures. Median family income has been used independently as an indicator of economic development by social scientists.1 Occupational structure was measured by the proportion of employed workers in white collar jobs—i.e., managerial,professional, technical, sales, and administrative support positions. Occupational structure reflects the division of laborwithin a local population and the position of a local communityin the larger national and international economies.2 The unemployment rate is defined as the proportion of workers in the civilian labor force who currently are not employed and are also

actively looking for work. It is a direct indicator of local economic opportunity and underdevelopment. A high unemployment rate negatively affects all members of the labor force, including those who are employed, by providing leverage for employers to keep wages and benefits low.3,4

The three variables that composed the summary index of localeconomic resources (median family income, percent white collar employment, and percent unemployed) were all measured in1990. Data for the index of local economic resources were obtained from the Area Resource File. Details about this datasource can be found in Appendix B. The index was calculatedby ranking all counties separately for each variable. For eachvariable, the counties were then categorized into deciles, andeach decile was assigned a score ranging from zero to nine.Counties in the decile with the poorest economic conditions(lowest median income, lowest occupational structure, highestunemployment rate) were assigned a score of zero and countiesin the decile with the most advantaged economic conditions wereassigned a score of nine. For each county, the scores from thethree variables were added together to arrive at the index score.

Values of the index score ranged frin the lowest decile for all three dim(counties that were in the top decile findex). Counties were divided into firanges of index values on the map. Dwith the least favorable local economcolors represent counties with the mo

A distinctive pattern was apparent tion of local economic resources in with very unfavorable local econofound in several rural, underdeveloThese regions included AppalachiaTexas border counties, and the CSouth. Unfavorable local economfound in many other counties as weClusters of counties with the most fsource profiles were found in the eastern seaboard from the Districthrough the New York City metropopolitan and surrounding counties iFrancisco Bay area, and southern Cvorable local economic resource proThe contrast in levels of local econral and metropolitan counties was mand the South. In Kentucky, the citville had favorable local economic counties to the east had very unfacontrast was evident for NashvillMississippi and the surrounding ru

1 Nielsen F, Alderson AS. The Kuznets curve and the great U-turn:income inequality in U.S. counties, 1970 to 1980. American Sociological Review 1997;62:12-33.2 Armstrong D, Barnett E, Casper M, Wing S: Community occupationalstructure, medical and economic resources and coronary mortality amongUS blacks and whites, 1980-1988. Annals of Epidemiology 1998;8:184-191.

3 Lyson TA, Falk WW (eds): Forgotten rural America. Lawrence: University o4 Lobao LM. Locality and inequality: farm economic conditions. Albany: The State Un
L

Local Economic Resource Index1990

Social 

Social Isolation 

The majority of heart disease deaths among adult women of all racial and ethnic groups during 1991-1995 occurred

among elderly women (60 years and older). Compared withyoung and middle-aged women, elderly women are at increasedrisk of heart disease mortality not just because of their age butalso because of increased social vulnerability. Elderly womenare more likely to live in poverty, to live alone, to suffer fromphysical disabilities, and to lack adequate social support compared with other demographic groups. Longer life expectancyamong women than among men results in many women surviving longer than their spouses. Widowed, divorced, and singleelderly women are particularly vulnerable to social isolation resulting from inadequate economic resources and from living alone.Data on two dimensions of women’s social isolation were obtained from the 1990 Special Tabulation on Aging compiled bythe Bureau of the Census. This data set contains summary statistics for elderly women and men abstracted from the 1990Census of Population and Housing.Two indicators of women’s social isolation were mapped: percent of women living alone, and the percent of women with mobility or self-care limitations. Living alone was defined as an in- dividual living in a household without a spouse, other family members, or friends. A mobility limitation was defined as a health condition, either physical or mental, that lasted for six months or more, that made it difficult to go outside the home alone. A self-care limitation was defined as a health condition, either physical or mental that lasted for six months or more, that made it difficult to take care of personal needs, such as dress- ing, bathing, or getting around inside the home. To produce the maps of women’s social isolation, we first ex- cluded 32 counties with fewer than 100 women over the age of 60 years old in 1990. For each measure of women’s social isola- tion, the distribution of county values was divided into quintiles (five categories with an approximately equal number of counties) respectively. These five categories were used to map each measure of women’s social isolation. Dark colors on the maps indicate high prevalence of social isolation among women and light colors on the map indicate a relatively low prevalence of social isolation among women.
56 Women and Heart Disease

Elderly Women Living Alone

Substantial geographic inequality in ing along was observed, with countto 52.4%. Large areas of the counelderly women living alone, includiEngland, and the Midwest. Regions tionately large Hispanic populationregion, the Southwest, California, portions of elderly women living alelderly women living alone in areas economic resources, such as native arHispanic areas of Texas and the Southnorms and practices that encourage exCentral city counties of several laras Washington DC and New York Cwomen living alone, whereas surrhad low proportions of women livFlorida had very favorable conditiowomen living alone. This may reflement communities and nursing hnomic resources and better health who migrate to Florida after retireme

A study of social isolation and heart disease found a two- tothreefold excess risk of death from heart disease for individualswho were socially isolated.1 Living alone is an important indicator of social isolation for elderly women. Moreover, therealso may be physiological conditions that result from socialisolation, such as increased blood pressure, which is an important heart disease risk factor.1A study of women’s economic status found that women wholived alone were at a significant economic disadvantage compared with women who did not live alone.2 In addition, women

who lived alone in rural areas had only 69% of the income levels of women in urban areas who lived alone.2

Living alone also contributes to women’s risk for heart diseasemortality by increasing barriers to medical care access. Womenliving alone are at greater risk during an emergency. Acuteevents such as chest pain, loss of breath, dizziness, and heartattacks are best treated with immediate intervention, which isless likely to occur if family and friends are not close at hand.For this study, living alone was defined for thenoninstitutionalized population aged 60 years and older as anindividual living in a household without a spouse, other familymembers or friends. In the United States in 1990, 35.3% of allwomen aged 60 years and older lived alone.1 Kaplan GA, Salonen JT, Cohen RD, Brand RJ, Syme SL, Puska P. Socialconnections and mortality from all causes and from cardiovascular disease: prospective evidence from eastern Finland. American Journal ofEpidemiology 1988; 128(2): 370-380.

2 Rogers CC. Changes in the social and 

metro-nonmetro residence. Agriculture Washington DC: Economic Research Seculture.
Social 

Percent of the Elderly Population Living Alone1990
58 Women and Heart Disease

Elderly Women with Mobility or Self-Care Limitations

quintile (7.8%). Low proportions of or self-care limitations were found England, the upper Midwest and mHawaii. An exception to this pattegion of Arizona, New Mexico, Coloralarge American Indian population, women living with mobility or self-carThe highest proportions of elderly or self-care limitations were founCentral Appalachia, and the lower high proportions were found in rurNew York City and Washington, Delderly women living with mobility In general, high proportions of woself-care limitations may reflect higerty and economic disadvantage, as of very elderly people (85 years anareas. Among the elderly (60 years have the highest prevalences of mobil

Mobility limitations and self-care limitations are inherent healthrisk factors for women 60 years of age. A mobility limitation isdefined as a health condition, either physical or mental thatlasts for six months or more, that makes it difficult to go outsidethe home alone. A self-care limitation is defined as a healthcondition, either physical or mental that lasts for six months ormore, that makes it difficult to take care of personal needs, suchas dressing, bathing, and getting around inside the home. Mobility limitations may deter many elderly women from pursuingand maintaining regular preventative health care visits to hospitals or physicians offices. Self-care limitations may preventelderly women from taking prescribed medications, eating regular meals and following physician’s advice for mental andphysical treatment.In the United States in 1990, 19.8% of elderly women sufferedfrom a mobility or a self-care limitation. Substantial geographicvariation in the prevalence of mobility and self-care limitationswas observed, with county values ranging from 2.4% to 40.4%The midrange of the highest quintile (33.9%) was approximately four times higher than the midrange of the lowest
Social 

Percent of the Elderly Population with Mobility or Self-Care Limitations1990

Medica

The availability and accessibility of medical care resources play an important role in the secondary prevention of heartdisease. The American Heart Association defines secondaryprevention as “identifying and treating persons with established disease and those at very high risk of developing disease, and treating and rehabilitating patients who have had aheart attack to prevent a second cardiovascular event”.1There are currently a number of thrombolytic therapies (“clotbusters”) that can save lives if administered within 12 hours after the onset of heart attack symptoms. In clinical studies thrombolytic drugs have been associated with an overall 25% to 30%reduction in mortality from acute myocardial infarction.2 The

greatest improvements in survival occur if drugs are givenwithin 1 to 2 hours after the onset of symptoms. Invasive cardiacprocedures (e.g. angioplasty, coronary artery bypass surgery, andcardiac stents) can also save lives and reduce disabilities related to heart disease if they are performed in a timely fashion.

The benefits of drug treatments and surgical procedures depend on widespread recognition of the signs and symptoms ofa heart attack and rapid access to quality medical care facilitiesand health professionals. For many women in the UnitedStates, however, there are substantial barriers to receivingneeded medical care. These barriers include poverty, lack ofhealth insurance, rural isolation, social isolation, and absenceof cardiac care physicians and facilities in their communities.Women of minority race or ethnic groups may be particularlydisadvantaged in their access to medical care resources, giventhe geographic distribution of these populations, indicatingthese areas may be underserved.Local availability of three specific medical care resources wasexamined: cardiovascular specialty physicians, coronary careunit beds, and cardiac rehabilitation units. County data on theavailability of these resources were obtained from the Area Resource File (see Appendix B for details). County-specific datawere not available for Alaska.

1 American Heart Association. 1998 Heart and Stroke Statistical Update. Dallas, TX: American Heart Association 1997. 2 Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA Guidelines for the management of patients with acute myocardial infarction: executive summary.

A Report of the American College of Cardiology/American Heart AssociationTask Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). Circulation 1996; 94:2341-2350.
62 Women and Heart Disease

Cardiovascular disease (CVD) specialty physicians have specialized training in the diagnosis of heart disease, case management, medical and surgical treatment, and cardiac rehabilitation.Given their specialized training, the presence of CVD specialtyphysicians in a local community increases the availability ofmedical and surgical interventions for heart disease.In 1990, 70% of the counties in the United States had no CVDspecialty physicians. For many counties in the western UnitedStates, the large expanse between counties that had and didnot have CVD specialty physicians posed a serious obstacle totimely and appropriate cardiac care. Patients who lived in acounty with no CVD specialty physicians often faced prohibitively expensive and time-consuming travel to a physician in adistant location. States with few counties that had CVD specialty physicians in 1990 included North Dakota, South Dakota,

Cardiovascular Disease Specialty Physicians

Iowa, Nebraska, Kansas, WyomiSouth, where rural areas were more ral areas in the West, many countphysicians in 1990. Many counties Northeast that did have CVD speciallation to physician ratios, indicatunderserved.Metropolitan counties throughout tlikely to have favorable population ratios than nonmetropolitan counpopulation to physician ratios whighly urbanized and densely poptry—namely, the eastern seaboard ton, DC, industrial centers of the Mthe San Francisco Bay area, and mu
Total Population per Cardiovascular Disease (CVD) Specialty Physician1990
64 Women and Heart Disease

Coronary Care Unit Beds

The coronary care unit (CCU) is a vital component of medicalcare for acute myocardial infarction.1 Intensive monitoring ofcardiac patients for lethal arrhythmias is critical for the care ofcardiac patients and has been shown to reduce hospital deathsby 30%. One method of measuring such care is through theavailability of CCUs. However, in many communities wherespecialized CCUs are not available, cardiac patients may receive appropriate care in intensive care units equipped to conduct noninvasive monitoring of arrhythmias and invasive monitoring of arterial and pulmonary blood pressure. Trained staff andmonitoring equipment should be available 24 hours per day.1

In 1993, 84% of the counties in the single coronary care unit hospital panses of the country were withouters of counties with coronary care metropolitan counties of the eastnorth central and southern CalifornYork, Philadelphia, Baltimore, and metropolitan areas had high populhowever. The most favorable popuhospital bed ratios were found in secluding Washington DC, PittsburghAntonio, and Reno.

1Task Force on the Management of Acute Myocardial Infarction of theEuropean Society of Cardiology. Acute myocardial infarction: pre hospitaland in hospital management. European Heart Journal 1996; 17:43-63.
Total Population per Coronary Care Unit (CCU) Bed1993
66 Women and Heart Disease

Cardiac Rehabilitation Units

Cardiac rehabilitation units are designed to provide rehabilitative services to patients who have serious heart disease or arerecovering from a heart attack. Cardiac rehabilitation servicesare usually provided in general hospitals, and their main purpose is to lower the risk of complications and death from heartdisease.1 The goal for many patients in cardiac rehabilitation isto develop a tailored exercise program that will work toward increasing their strength and aerobic fitness, reducing their bloodpressure and cholesterol levels, and maintaining their weight loss.Cardiac rehabilitation units serve more than one individual at atime; therefore we mapped the total number of facilities offeringcardiac rehabilitation services in each county instead of usingthe population ratio.

In 1993, a majority (60%) of U.S. diac rehabilitation unit. Counties wrehabilitation services were clusterand rural areas throughout the conear major metropolitan areas such Angeles, and Miami had three or units. Many metropolitan areas thrleast one cardiac rehabilitation unidiac rehabilitation services in metrononmetropolitan areas meant that with traveling long distances to rece

1Agency for Health Care Policy and Research Cardiac Rehabilitation.Clinical Practice Guidelines No.17. AHCPR Publication No. 96-0672.Rockville, MD: October 1995.
Cardiac Rehabilitation Units (CRUs)1993

National Map

of Heart DiseaMortality amoWomen

4

National Maps of Heart Dise

In this section, national geographic disparities in heart dis- ease death rates are examined for all women, Asian and Pacific Islander women, American Indian and Alaska Native

women, black women, Hispanic women, and white women.Women ages 35 years and older who resided in the UnitedStates during 1991 to 1995 were the study population.Each national map portrays spatially smoothed heart diseasedeath rates for all counties, including Alaska, Hawaii, and theDistrict of Columbia. Hawaii, New York City, and the District ofColumbia are shown separately on each map, at a larger scalethan the other states, to aid in visualization. Because of its verylarge land area, Alaska is shown at a smaller scale than theother states. The distribution of county heart disease deathrates for each group of women was divided into quintiles (fivecategories with an equal number of counties) for the purposesof mapping. Counties in the highest quintile of heart diseasemortality are the darkest color on the maps, while counties inthe lowest quintile are the lightest color.

On the maps for African Americans, Asian and Pacific Islanders, American Indians and Alaska Natives, and Latinas, heartdisease death rates were not calculated for a majority of counties nationwide. These counties are labeled “insufficient data”on the maps. In these counties and their surrounding areas,there were fewer than 20 heart disease deaths among women ofthe specified race or ethnic group over our five-year study period. For these areas of very low population and infrequentheart disease deaths, statistically reliable death rates could notbe calculated (see Appendix B for more details).For part of the study period, Oklahoma and New Hampshire didnot collect data on Hispanic origin on death certificates. Consequently, we were unable to report heart disease death ratesfor Latina women in these states. During 1991-1993, “unknown” Hispanic origin was recorded on approximately 22 percent of death certificates for women ages 35 years and older inNew York City. Therefore, the heart disease death rates we report for Latinas in New York City may be underestimates.
72 Women and Heart Disease

05

10152025303540

200 250 300 350 500 550 600 650 700

Percent of Counties

Smoothed Heart Disease Death Rates (deaths per 100,000)

400 450

Figure 4.1Frequency Distribution ofSmoothed Heart DiseaseDeath Rates for Counties,All Women, Ages 35 andOlder, 1991-1995

Heart Disease Mortality – All Women

Piedmont and coastal regions of GNorth Carolina. In Florida, the majorates in the lowest two quintiles, wcounties had rates in the higher quiMost counties in the Pacific Northareas of Colorado and New Mexico Another region of counties with loNorth Dakota, and South Dakota. Aties had rates in the lowest two quitween Nevada and California and counties had heart disease death raA Note on MethodsHeart disease deaths were defined derlying cause of death listed on theases of the heart,” defined accoClassification of Diseases, Ninth 402, and 404-429). Heart disease justed, with the 1970 U.S. populaand spatially smoothed by using a detailed explanation of the methodeath rates and create the map can b

Overall, women aged 35 years and older in the United Statesexperienced a heart disease death rate of 401 per 100,000 population during 1991-1995. However, there was considerablevariation in the magnitude of heart disease death rates amongthe 3,103 counties for which data were available. Rates forcounties ranged from 212 to 670 per 100,000, and the heartdisease death rate at the midpoint of the top quintile (560 per100,000) was twice as high as the midpoint of the lowestquintile (275 per 100,000). The frequency distribution graph(Figure 4.1) illustrates the range of geographic variation indeath rates. The color bar along the x-axis of the graph showsthe range of values for each of the five groups used for mapping the geographic variation in heart disease death ratesamong all women.On the map (opposite page) counties were divided into fivegroups (quintiles) with an approximately equal number ofcounties in each group. The colors were graded so that counties of the darkest color were in the highest-rate quintile, andcounties of the lightest color were in the lowest-rate quintile.There was a clear east-west gradient in heart disease mortalityamong women during 1991-1995. Counties in the top twoquintiles were located primarily within Appalachia, the OhioMississippi River Valley, the Mississippi Delta, and the eastern
National Maps of Heart Dise

Smoothed County Heart Disease Death Rates1991-1995

Age
74 Women and Heart Disease

05

10152025303540

0 100 200 300 400 500 600 700 800 900 1000

Percent of Counties

Smoothed Heart Disease Death Rates (deaths per 100,000)

Figure 4.2Frequency Distribution ofSmoothed Heart DiseaseDeath Rates for Counties,American Indian and AlaskaNative Women, Ages 35 andOlder, 1991-1995

Heart Disease Mortality – American Indian and Alaska Native Women

Indian and Alaska Native women disease varies greatly among the dirates of heart disease mortality wertan counties and surrounding areas cisco, Los Angeles, Seattle, Anchorease mortality were also experienc(predominantly Cherokee Nation) anantly Navajo Nation). High rates were experienced by women in SoDakota Nation), Montana, and Chippewa Nation). An area of souhome to a large group of Lumbee Ially recognized tribe. American Indexperienced high rates of heart diseaA Note on MethodsHeart disease deaths were defined derlying cause of death listed on theases of the heart,” defined accordisification of Diseases, Ninth Revisio404-429). Heart disease death rates 1970 United States population usetially smoothed by using a spatial explanation of the methods used tand create the map can be found in ApA Cautionary NoteThe race and ethnicity of decedenaccurately on death certificates. Vathat certain racial and ethnic misreported as “white” on death Therefore, an unknown proportioamong American Indian and Alaskbe included in the data analyses fothe true heart disease death rates Alaska Native women were probabthan indicated in Figures 4.2 and misreporting of race on death certilem in certain parts of the country tgraphic patterns presented here cou

American Indian and Alaska Native women comprised 0.6% ofall women aged 35 years and older in the United States in 1991.For the period 1991-1995, the heart disease death rate forAmerican Indian and Alaska Native women was 259 per 100,000population. Considerable geographic variation in the burden ofheart disease mortality was evident across the 375 counties forwhich data were available (Figure 4.2). Rates for countiesranged from 97 to 1,000 per 100,000. There was nearly a fivefolddifference in the heart disease death rate at the midpoint of thetop quintile compared with the midpoint of the lowest quintile(784 deaths per 100,000 vs. 165 deaths per 100,000). The colorbar along the x-axis of the graph shows the range of values foreach of the five groups used for mapping the geographic variation in heart disease death rates among American Indian andAlaska Native women.On the map (opposite page), counties were divided into fivegroups (quintiles) with an approximately equal number ofcounties in each group. The colors were graded so that counties of the darkest color were in the highest-rate quintile, andcounties of the lightest color were in the lowest-rate quintile.The American Indian and Alaska Native population in theUnited States is composed of many politically and culturallydistinct Tribal Nations residing both in defined rural areas (insome cases reservations with limited political sovereignty) andin urban areas (see page 41 for a map of the geographic distribution of the American Indian and Alaska Native population ofwomen). The map of heart disease death rates among American
National Maps of Heart Dise

Smoothed County Heart Disease Death Rates1991-1995

American Indian and A

Age
76 Women and Heart Disease

05

10152025303540

0 50 100 250 300 350

Percent of Counties

Smoothed Heart Disease Death Rates (deaths per 100,000)

150 200

Figure 4.3Frequency Distribution ofSmoothed Heart DiseaseDeath Rates for Counties,Asian and Pacific IslanderWomen, Ages 35 and Older,1991-1995Heart Disease Mortality – Asian and Pacific Islander Women

The heart disease death rate among Asian and Pacific Islanderwomen aged 35 years and older during 1991-1995 was 221 per100,000. Asian and Pacific Islander women comprised 2.7% ofall women in this age group in 1991. There were 275 countiesfor which there were sufficient data to calculate heart diseasedeath rates for Asian and Pacific Islander women. There was asubstantial difference in the level of heart disease mortality between the counties in the highest and lowest quintiles. Theheart disease death rate at the midpoint of the top quintile (261per 100,000) was two times higher than the midpoint of the bottom quintile (124 per 100,000). Rates for counties ranged from94 to 295 per 100,000 (Figure 4.3). The color bar along the x-axisof the frequency distribution graph shows the range of valuesfor each of the five groups used for mapping the geographicvariation in heart disease death rates among Asian and PacificIslander women.On the map (opposite page) counties were divided into fivegroups (quintiles) with an approximately equal number ofcounties in each group. The colors were graded so that counties of the darkest color were in the highest-rate quintile, andcounties of the lightest color were in the lowest-rate quintile.With the exception of Hawaii, the overwhelming majority ofAsian and Pacific Islander women in the United States residedin metropolitan areas during 1991-1995 (see page 43 for thegeographic distribution of the Asian and Pacific Islander population of women). Low rates of heart disease mortality were observed for the Houston, Dallas, and San Antonio metropolitanareas of Texas; central and southern Florida; northern New Jersey; Connecticut, and the Boston, 

metropolitan areas. High rates of hexperienced by Asian and Pacific ICity, most of California, southern Louis, and Atlanta. Asian and Pacifington, DC and Cleveland experiendisease death rates. A Note on Methods Heart disease deaths were defined alying cause of death listed on the deof the heart,” defined according to tion of Diseases, Ninth Revision (c429). Heart disease death rates w1970 United States population usetially smoothed by using a spatial explanation of the methods used tand create the map can be found in A Cautionary Note The race and ethnicity of decedents curately on death certificates. Valthat certain racial and ethnic minorities “white” on death certificates (see pagproportion of heart disease deaths amlander women could not be includthis report. Consequently, the true Asian and Pacific Islander women 1991-1995 than shown in Figures 4.misreporting of race on death certifiin certain parts of the country thgraphic patterns presented here cou
National Maps of Heart Dise

Smoothed County Heart Disease Death Rates1991-1995

Asian and 

Age
78 Women and Heart Disease

Percent of Counties

Smoothed Heart Disease Death Rates (deaths per 100,000)

05

101520253035404550

200 400 600 800 1000 1200

Figure 4.4Frequency Distribution ofSmoothed Heart DiseaseDeath Rates for Counties,Black Women, Ages 35 andOlder, 1991-1995

Heart Disease Mortality – Black Women

centrated primarily in the southern River Valley and Delta region. Higwere also found in some countieTexas, and the Detroit and Chicagwomen experienced the lowest heaDistrict of Columbia, Minneapolis

metropolitan areas, and in parts of NNorthwest.

A Note on MethodsHeart disease deaths were defined alying cause of death listed on the deof the heart,” defined according to tion of Diseases, Ninth Revision (co429). Heart disease death rates w1970 United States population usetially smoothed by using a spatial explanation of the methods used to and create the map can be found in 

Blacks were the largest racial and ethnic minority group amongwomen aged 35 years and older in 1991, comprising 10.5% ofall women. Overall, African American women experienced aheart disease death rate of 553 per 100,000 during 1991-1995.However, the 1,930 counties for which sufficient data wereavailable exhibited considerable variation in the magnitude ofheart disease death rates for black women. Rates for countiesranged from 124 to 1,275 per 100,000 (Figure 4.4), and theheart disease death rate at the midpoint of the top quintile (973per 100,000) was three times higher than the rate at the midpoint of the bottom quintile (133 per 100,000). The color baralong the x-axis of the frequency distribution graph shows therange of values for each of the five groups used for mapping thegeographic variation in women’s heart disease death rates.On the map (opposite page) counties were divided into fivegroups (quintiles) with an approximately equal number ofcounties in each group. The colors were graded so that countiesof the darkest color were in the highest-rate quintile, and counties of the lightest color were in the lowest-rate quintile.The map of heart disease mortality among African American

women indicates that the counties in the top quintile are con-
National Maps of Heart Dise

Smoothed County Heart Disease Death Rates1991-1995

Age
80 Women and Heart Disease

05

10152025303540

0 100 200 400 500 600 700

Percent of Counties

Smoothed Heart Disease Death Rates (deaths per 100,000)

300

Figure 4.5Frequency Distribution ofSmoothed Heart DiseaseDeath Rates for Counties,Hispanic Women, Ages 35and Older, 1991-1995Heart Disease Mortality – Hispanic Women

of Florida, and in the Boston, Pittsbton-Baltimore, Atlanta, and New OThe highest rates of heart disease by women in New York City, easterin the rural areas of Texas, New MexCalifornia. Hispanic women in metrwest such as Houston, Dallas, Albuperienced intermediate-level heart dA Note on MethodsHeart disease deaths were defined alying cause of death listed on the deof the heart,” defined according to tion of Diseases, Ninth Revision (co429). Heart disease death rates w1970 United States population usetially smoothed by using a spatial explanation of the methods used to and create the map can be found in A Cautionary NoteThe race and ethnicity of decedenaccurately on death certificates. Vathat Hispanics are sometimes misrdeath certificates (see page 21). Tportion of heart disease deaths amobe included in the data analyses foCity, approximately 22% of death 35 and older recorded Hispanic o1991-1993. Consequently, the true Hispanic women were probably higshown in Figures 4.5 and this map. of Hispanic origin on death certificin certain parts of the country, thpresented here could be biased.

Latinas were the second largest racial and ethnic minoritygroup among women aged 35 years and older in 1991, comprising 6.1% of all women. For the period 1991-1995, theheart disease death rate for Hispanic women was 265 per100,000 population. Considerable geographic variation in theburden of heart disease mortality was evident across the 718counties for which data were sufficient to calculate a rate (Figure 4.5). Rates for counties ranged from 82 to 656 per 100,000.There was nearly a fourfold difference in the heart diseasedeath rate at the midpoint of the top quintile compared with themidpoint of the lowest quintile (481 deaths per 100,000 and 131deaths per 100,000). The color bar along the x-axis of the frequency distribution graph shows the range of values for eachof the five groups used for mapping the geographic variationin women’s heart disease death rates.On the map (opposite page) counties were divided into fivegroups (quintiles) with an approximately equal number ofcounties in each group. The colors were graded so that counties of the darkest color were in the highest-rate quintile, andcounties of the lightest color were in the lowest-rate quintile.The Latina population in the United States is concentrated inboth rural (predominantly Southwest) and urban/metropolitanareas (see page 47 for the geographic distribution of the Hispanic population on women). The map of heart disease deathrates among Latina women shows marked geographic variation. Low rates of heart disease mortality were experienced bywomen in northern California and the Pacific Northwest, most
National Maps of Heart Dise

Smoothed County Heart Disease Death Rates1991-1995

Age
82 Women and Heart Disease

05

10152025303540

200 250 300 350 450 500 550 600

Percent of Counties

Smoothed Heart Disease Death Rates (deaths per 100,000)

400

Figure 4.6Frequency Distribution ofSmoothed Heart DiseaseDeath Rates for Counties,White Women, Ages 35 andOlder,1991-1995Heart Disease Mortality – White Women

primarily within much of AppalaRiver Valley, Mississippi Delta, angions of Georgia, South CarolinFlorida, most counties had rates ibut several northern counties had rLarge sections of the northwestern rado and New Mexico had countiheart disease mortality. Another arewas in Wisconsin, North Dakota, and Hawaii both had counties in thborder between Nevada and California, intermediate levels of heart diswomen were observed.A Note on MethodsHeart disease deaths were defined alying cause of death listed on the deof the heart,” defined according to tion of Diseases, Ninth Revision (co429). Heart disease death rates w1970 U.S. population used as tsmoothed by using a spatial movinnation of the methods used to gencreate the map can be found in App

White women comprised 86.3% of all women aged 35 yearsand older in 1991. Overall, the heart disease death rate amongwhite women was 388 per 100,000 for the period 1991-1995.Substantial geographic variation in heart disease death rateswas observed among the 3,096 counties for which sufficientdata were available to calculate rates. There was a substantialdifference in the level of heart disease mortality between thecounties in the highest and lowest quintiles (Figure 4.6). Theheart disease death rate at the midpoint of the top quintile (514per 100,000) was nearly two times higher than the midpoint ofthe bottom quintile (273 per 100,000). Rates for counties rangedfrom 212 to 591 per 100,000. The color bar along the x-axis ofthe frequency distribution graph shows the range of values foreach of the five groups used for mapping the geographic variation in women’s heart disease death rates.On the map (opposite page), counties were divided into fivegroups (quintiles) with an approximately equal number ofcounties in each group. The colors were graded so that counties of the darkest color were in the highest-rate quintile, andcounties of the lightest color were in the lowest-rate quintile.A clear east-west gradient in heart disease death rates amongwhite women was evident for 1991-1995, with the highest ratesoccurring predominantly in the eastern portion of the UnitedStates and the lowest rates occurring predominantly in thewestern section. Counties in the top two quintiles were located
National Maps of Heart Dise

Smoothed County Heart Disease Death Rates1991-1995

Ag

State Maps of

Heart DiseaseMortality amoWomen

5

State Maps of Heart Diseas

State Maps of Hea

In this section, county heart disease death rates are presented separately for each state, the District of Columbia, and NewYork City. Separate maps are presented for all women, and foreach racial and ethnic group for whom sufficient data wereavailable to calculate rates. A map for a particular racial or ethnic group is presented if there were sufficient data to calculatesmoothed heart disease death rates for at least two of thecounties in that state. Therefore, states may have as few astwo maps, one for all women and one for white women (e.g.Idaho), or as many as six maps (e.g. California). The heart disease death rates on each map are spatially smoothed, and thereare separate legend cutpoints (quintiles) for each separate map.For each state, we also provide a summary table containingstate-level population totals and heart disease death rates for

all women and for each racial and ethnic group. While thepopulation totals are for 1995 only, the state heart diseasedeath rates were calculated for the study period, 1991-1995. Inaddition, the state heart disease death rates presented in thetables were not spatially smoothed.For part of the study period, 1991-1995, Oklahoma and NewHampshire did not collect data on Hispanic origin on death certificates. Consequently, we were unable to report heart diseasedeath rates for Hispanic women in these states. During 1991-1993, “unknown” Hispanic origin was recorded on approximately 22% of heart disease death certificates for women ages35 years and older in New York City. Therefore, the heart disease death rates we report for Hispanics in New York City maybe underestimates.
88 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

All Women 

Alabama

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 1,136,130 445American Indian and AlaskaNative Women 3,557 Insufficient DataAsian and Pacific IslanderWomen 5,945 Insufficient DataBlack Women 254,021 552Hispanic Women 5,448 273White Women 872,607 419

State Profile — Alabama
State Maps of Heart Diseas

Restaurant workers in Washington, DC.
90 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Alaska

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 122,878 285American Indian and AlaskaNative Women 15,407 308Asian and Pacific IslanderWomen 5,816 Insufficient DataBlack Women 3,580 439Hispanic Women 3,331 Insufficient DataWhite Women 98,075 285

State Profile — Alaska
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Diseas

Black Women 
92 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Arizona

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 1,087,171 339American Indian and AlaskaNative Women 40,739 286Asian and Pacific IslanderWomen 18,275 241Black Women 27,332 492Hispanic Women 146,710 319White Women 1,000,825 338

State Profile — Arizona
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Diseas

American Indian and

Alaska Native Women
94 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Arkansas

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 667,464 413American Indian and AlaskaNative Women 2,948 Insufficient DataAsian and Pacific IslanderWomen 3,351 Insufficient DataBlack Women 86,422 576Hispanic Women 4,663 183White Women 574,743 393

State Profile — Arkansas
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Diseas

Black Women 

A
96 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

All Women 

California

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 7,455,185 373American Indian and AlaskaNative Women 63,648 161Asian and Pacific IslanderWomen 826,450 221Black Women 510,022 574Hispanic Women 1,418,037 260White Women 6,055,065 372

State Profile — California
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Diseas

American Indian and

Alaska Native Women
98 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Colorado

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 955,382 296American Indian and AlaskaNative Women 6,865 181Asian and Pacific IslanderWomen 18,343 160Black Women 31,765 383Hispanic Women 95,016 260White Women 898,409 296

State Profile — Colorado
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Diseas

American Indian and

Alaska Native Women
100 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Connecticut

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 905,238 371American Indian and AlaskaNative Women 1,638 313Asian and Pacific IslanderWomen 13,759 105Black Women 63,799 484Hispanic Women 41,544 197White Women 826,042 364

State Profile — Connecticut
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
102 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Delaware

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 187,157 431American Indian and AlaskaNative Women 527 Insufficient DataAsian and Pacific IslanderWomen 2,954 Insufficient DataBlack Women 29,220 509Hispanic Women 3,164 218White Women 154,456 419

State Profile — Delaware
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Black Women 
104 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

District of Columbia

All Women 

DC Population DC Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 153,763 444American Indian and AlaskaNative Women 389 Insufficient DataAsian and Pacific IslanderWomen 3,401 209Black Women 103,777 514Hispanic Women 7,079 94White Women 46,196 279

District of Columbia Profile
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Asian and Pacific

Islander Women

The map of heart disease death rates for the District of Columbia displays spatially smoothed rates for the District of Columbia and all conColumbia has a dashed border on the map. The statistical process for spatial smoothing (described in Appendix B) was performed for all coheart disease death rates presented in the table for the District of Columbia (opposite) are for the District of Columbia alone, and do not incoing counties.
106 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Florida

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 4,079,724 353American Indian and AlaskaNative Women 10,878 112Asian and Pacific IslanderWomen 54,316 124Black Women 434,876 532Hispanic Women 477,796 276White Women 3,579,654 339

State Profile — Florida
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Asian and Pacific

Islander Women
108 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

All Women 

Georgia

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 1,785,363 440American Indian and AlaskaNative Women 3,568 Insufficient Data

Asian and Pacific IslanderWomen 24,878 197Black Women 436,167 564Hispanic Women 24,059 132White Women 1,320,750 408

State Profile — Georgia
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Asian and Pacific

Islander Women
110 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Hawaii

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 297,222 297American Indian and AlaskaNative Women 1,161 Insufficient DataAsian and Pacific IslanderWomen 199,714 293Black Women 3,877 212Hispanic Women 15,700 293White Women 92,470 307

State Profile — Hawaii
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Asian and Pacific

Islander Women
112 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Idaho

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 279,469 323American Indian and AlaskaNative Women 2,857 202Asian and Pacific IslanderWomen 2,476 248Black Women 765 Insufficient DataHispanic Women 9,365 195White Women 273,371 324

State Profile — Idaho

All Women 
State Maps of Heart Disease 

Pueblo resident in Taos, New Mexico.
114 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Illinois

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 3,053,481 429American Indian and AlaskaNative Women 5,544 114Asian and Pacific IslanderWomen 81,436 179Black Women 406,616 610Hispanic Women 163,766 195White Women 2,559,885 407

State Profile — Illinois
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Asian and Pacific

Islander Women
116 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Indiana

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 1,519,445 422American Indian and AlaskaNative Women 3,156 Insufficient DataAsian and Pacific IslanderWomen 10,059 183Black Women 106,443 571Hispanic Women 20,837 209White Women 1,399,787 413

State Profile — Indiana

All Women 
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Black Women 
118 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Iowa

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 776,201 357American Indian and AlaskaNative Women 1,439 Insufficient DataAsian and Pacific IslanderWomen 5,252 272Black Women 9,662 500Hispanic Women 6,582 229White Women 759,848 356

State Profile — Iowa
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Black Women 

A
120 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Kansas

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 664,026 361American Indian and AlaskaNative Women 4,649 352Asian and Pacific IslanderWomen 7,719 142Black Women 30,301 477Hispanic Women 17,191 192White Women 621,357 357

State Profile — Kansas
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
122 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Kentucky

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 1,023,219 441American Indian and AlaskaNative Women 1,344 Insufficient DataAsian and Pacific IslanderWomen 4,832 325Black Women 64,758 533Hispanic Women 4,546 315White Women 952,285 436

State Profile — Kentucky
State Maps of Heart Disease 

Vegetable shopping in San Francisco, California. 
124 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Louisiana

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 1,086,374 469American Indian and AlaskaNative Women 3,780 188Asian and Pacific IslanderWomen 10,181 175Black Women 301,133 595Hispanic Women 24,002 159White Women 771,280 428

State Profile — Louisiana
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Asian and Pacific

Islander Women
126 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Maine

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 340,181 366American Indian and AlaskaNative Women 1,091 Insufficient DataAsian and Pacific IslanderWomen 1,697 Insufficient DataBlack Women 645 Insufficient DataHispanic Women 1,394 Insufficient Data

White Women 336,748 367

State Profile — Maine

All Women
State Maps of Heart Disease 

Slicing vegetables.
128 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Maryland

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 1,316,398 395American Indian and AlaskaNative Women 3,258 Insufficient DataAsian and Pacific IslanderWomen 42,134 201Black Women 315,633 480Hispanic Women 30,620 89White Women 955,373 376

State Profile — Maryland
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Asian and Pacific

Islander Women
130 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Massachusetts

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 1,650,271 349American Indian and AlaskaNative Women 2,955 Insufficient Data

Asian and Pacific IslanderWomen 34,362 158Black Women 71,810 367Hispanic Women 52,023 149White Women 1,541,144 349

State Profile — Massachusetts
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
132 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Michigan

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 2,469,069 442American Indian and AlaskaNative Women 11,749 617Asian and Pacific IslanderWomen 26,332 201Black Women 312,205 610Hispanic Women 38,610 229White Women 2,118,783 419

State Profile — Michigan
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
134 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Minnesota

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 1,174,749 284American Indian and AlaskaNative Women 8,901 472Asian and Pacific IslanderWomen 15,363 99Black Women 18,256 339Hispanic Women 10,009 138White Women 1,132,229 282

State Profile — Minnesota

All Women 
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
136 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Mississippi

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 680,726 531American Indian and AlaskaNative Women 1,728 337Asian and Pacific IslanderWomen 3,434 Insufficient DataBlack Women 206,728 686Hispanic Women 3,600 Insufficient DataWhite Women 468,836 472

State Profile — Mississippi
State Maps of Heart Disease 

Walking home from church alongMassachusetts Avenue in Boston,Massachusetts.
138 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Missouri

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 1,427,553 430American Indian and AlaskaNative Women 4,672 182Asian and Pacific IslanderWomen 10,978 219Black Women 134,854 585Hispanic Women 13,194 248White Women 1,277,049 417

State Profile — Missouri
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
140 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Montana

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 230,331 292American Indian and AlaskaNative Women 8,751 390Asian and Pacific IslanderWomen 1,017 Insufficient Data

Black Women 380 Insufficient DataHispanic Women 2,545 Insufficient DataWhite Women 220,183 289

State Profile — Montana Am

Alas
State Maps of Heart Disease 

Portrait of friends.
142 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Nebraska

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 428,121 360American Indian and AlaskaNative Women 2,289 603Asian and Pacific IslanderWomen 3,284 Insufficient DataBlack Women 12,241 618Hispanic Women 8,058 151White Women 410,307 353

State Profile — Nebraska
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
144 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Nevada

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 374,589 416American Indian and AlaskaNative Women 5,567 277Asian and Pacific IslanderWomen 15,808 222Black Women 21,680 493Hispanic Women 30,860 180White Women 331,534 417

State Profile — Nevada
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
146 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

New Hampshire

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 296,286 360American Indian and AlaskaNative Women 463 Insufficient DataAsian and Pacific IslanderWomen 2,283 Insufficient DataBlack Women 1,256 Insufficient DataHispanic Women 2,311 Missing DataWhite Women 292,284 361

State Profile — New Hampshire 
State Maps of Heart Disease 

Ninety-seven year old resident ofDetroit, Michigan. 
148 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

New Jersey

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 2,189,302 407American Indian and AlaskaNative Women 4,356 180Asian and Pacific IslanderWomen 86,485 147Black Women 265,616 490Hispanic Women 178,286 210White Women 1,832,845 399

State Profile — New Jersey
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
150 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

New Mexico

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 412,053 315American Indian and AlaskaNative Women 26,714 213Asian and Pacific IslanderWomen 4,726 Insufficient Data

Black Women 7,878 408Hispanic Women 134,004 282White Women 372,735 320

State Profile — New Mexico
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
152 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

New York

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 4,929,714 487American Indian and AlaskaNative Women 15,646 212Asian and Pacific IslanderWomen 198,243 236Black Women 769,949 573Hispanic Women 521,506 307White Women 3,945,876 477

State Profile — New York
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native

Women
154 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

New York City

All Women 

City Population City Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 2,019,225 561American Indian and AlaskaNative Women 7,227 97Asian and Pacific IslanderWomen 147,202 248Black Women 589,674 587Hispanic Women 431,080 320White Women 1,275,122 559

New York City Profile
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women

During 1991-1993, information on Hispanic origin was not reported on approximately 22% ofheart disease death certificates for women aged 35 years and older residing in New York City.During 1994-1995, the percent of death certificates for women that were missing informationon Hispanic origin dropped to less than 3%. Based on a detailed examination of the New YorkCity death certificate data for our five-year study period, we concluded that the majority of thedeaths with “unknown” Hispanic origin occurred among non-Hispanic women. As evident in thetable below, the percent of heart disease deaths for Hispanic women rose only slightly between1991-1993 and 1994-1995, while the percent of heart disease deaths for non-Hispanic womenrose markedly after reporting improved in 1994. From 1991-1993 to 1994-1995, the averageannual number of heart disease deaths increased 7% for Hispanic women and 22% for non-Hispanic women, while the number of deaths with unknown Hispanic origin declined 96%.However, since a small proportion of the deaths with missing Hispanic origin data did occuramong Hispanic women, it is almost certain that the heart disease death rates reported here forHispanic women are modestly (but not severely) underestimated. In addition, the extent of underestimation may have varied among the five city boroughs; therefore prudence should be exercised in comparing individual county rates.

Percent Distribution of Heart Disease Deaths by Hispanic Origin forWomen in New York City, 1991-1995Hispanic Origin 1991 1992 1993 1994 1995

Non-Hispanic 74.0 71.0 70.3 89.6 90.4Hispanic 6.7 6.7 6.3 7.2 7.4Unknown 19.3 22.3 23.5 3.3 2.2
156 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

North Carolina

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 1,902,353 400American Indian and AlaskaNative Women 18,118 485Asian and Pacific IslanderWomen 16,052 174Black Women 372,023 513Hispanic Women 15,013 74White Women 1,496,160 375

State Profile — North Carolina
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Black Women A

A
158 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

North Dakota

All Women 

Am

Alas

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 163,941 307American Indian and AlaskaNative Women 4,264 525Asian and Pacific IslanderWomen 868 Insufficient DataBlack Women 319 Insufficient DataHispanic Women 659 Insufficient DataWhite Women 158,490 303

State Profile — North Dakota
State Maps of Heart Disease 

Resident of Allen Parkway Villagein Houston, Texas. 
160 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Ohio

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 2,987,355 437American Indian and AlaskaNative Women 5,255 129Asian and Pacific IslanderWomen 24,325 194Black Women 294,545 556Hispanic Women 29,027 157White Women 2,663,230 426

State Profile — Ohio
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Asian and Pacific

Islander Women
162 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Oklahoma

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 862,701 440American Indian and AlaskaNative Women 53,204 278Asian and Pacific IslanderWomen 8,588 216Black Women 52,022 582Hispanic Women 15,176 Insufficient Data

White Women 748,887 442

State Profile — Oklahoma
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Black Women A

A
164 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Oregon

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 848,184 307American Indian and AlaskaNative Women 8,954 277Asian and Pacific IslanderWomen 19,208 187Black Women 10,036 463Hispanic Women 21,680 142White Women 809,986 307

State Profile — Oregon
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
166 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Pennsylvania

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 3,435,632 433American Indian and AlaskaNative Women 3,868 106Asian and Pacific IslanderWomen 36,363 196Black Women 283,564 532Hispanic Women 46,254 278White Women 3,111,837 425

State Profile — Pennsylvania
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Asian and Pacific

Islander Women
168 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Rhode Island

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 274,257 371American Indian and AlaskaNative Women 930 442Asian and Pacific IslanderWomen 3,563 Insufficient DataBlack Women 8,855 461Hispanic Women 9,380 150White Women 260,909 370

State Profile — Rhode Island
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
170 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

South Carolina

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 953,621 438American Indian and AlaskaNative Women 1,693 Insufficient DataAsian and Pacific IslanderWomen 6,518 167Black Women 252,836 562Hispanic Women 6,351 132White Women 692,574 399

State Profile — South Carolina
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Black Women 

A
172 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

South Dakota

All Women 

Am

Alas

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 185,333 344American Indian and AlaskaNative Women 7,682 577Asian and Pacific IslanderWomen 803 Insufficient DataBlack Women 376 Insufficient DataHispanic Women 960 Insufficient DataWhite Women 176,472 335

State Profile — South Dakota
State Maps of Heart Disease 

Teaching local children to make cornballs

in Fort Berthold, North Dakota.
174 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Tennessee

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 1,409,344 435American Indian and AlaskaNative Women 2,703 Insufficient Data

Asian and Pacific IslanderWomen 9,418 259Black Women 195,276 604Hispanic Women 7,956 214White Women 1,201,947 412
State Maps of Heart Disease 

Navajo weaver.
176 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Texas

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 4,474,077 388American Indian and AlaskaNative Women 18,482 56Asian and Pacific IslanderWomen 99,761 154Black Women 490,439 540Hispanic Women 919,319 296White Women 3,865,395 374

State Profile — Texas
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
178 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Utah

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 386,521 313American Indian and AlaskaNative Women 4,081 311Asian and Pacific IslanderWomen 7,724 220Black Women 2,094 324Hispanic Women 16,112 210White Women 372,622 314

State Profile — Utah
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
180 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Vermont

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 154,251 374American Indian and AlaskaNative Women 284 Insufficient DataAsian and Pacific IslanderWomen 732 Insufficient DataBlack Women 400 Insufficient DataHispanic Women 812 Insufficient DataWhite Women 152,835 374

State Profile — Vermont
State Maps of Heart Disease 

Senior aerobics class.
182 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Virginia

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*All Women 1,700,258 404American Indian and AlaskaNative Women 3,869 Insufficient Data

Asian and Pacific IslanderWomen 48,527 178Black Women 299,522 539Hispanic Women 35,958 184White Women 1,348,340 380

State Profile — Virginia
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

Asian and Pacific

Islander Women
184 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Washington

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 1,386,393 319American Indian and AlaskaNative Women 18,663 283Asian and Pacific IslanderWomen 65,208 204Black Women 31,706 441Hispanic Women 39,850 181White Women 1,270,816 320

State Profile — Washington
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
186 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

West Virginia

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 523,354 472American Indian and AlaskaNative Women 707 Insufficient DataAsian and Pacific IslanderWomen 2,035 Insufficient DataBlack Women 15,358 566Hispanic Women 2,217 Insufficient DataWhite Women 505,254 470

State Profile — West Virginia
State Maps of Heart Disease 

Looking at family photographs.
188 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Wisconsin

All Women 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 1,330,533 354American Indian and AlaskaNative Women 7,525 445Asian and Pacific IslanderWomen 10,461 154Black Women 49,917 491Hispanic Women 16,695 117White Women 1,262,630 350

State Profile — Wisconsin
Smoothed County Heart Disease Death Rates, 1991-1995

State Maps of Heart Disease 

American Indian and

Alaska Native Women
190 Women and Heart Disease

Smoothed County Heart Disease Deat

* Average annual age-adjusted rate (deaths per 100,000) for women ages 35 years and older. Data for Hispanics are also included within each of the four categories of race.

Wyoming

All Women 

State Profile — Wyoming 

State Population State Heart Disease

Race or Ethnicity 1995 Death Rate, 1991-1995*

All Women 118,822 322American Indian and AlaskaNative Women 1,784 Insufficient DataAsian and Pacific IslanderWomen 758 Insufficient DataBlack Women 628 Insufficient DataHispanic Women 4,872 266White Women 115,652 322
State Maps of Heart Disease 

Pruning flowers.

State Ranking

of Heart DiseaMortality amoWomen

A
194 Women and Heart Disease

State Ranking of Heart Disease Death Rates for All Women

Alabama 33,033 1,136,130 4Alaska 862 122,878 2Arizona 22,259 1,087,171 3

Arkansas 20,381 667,464 4

California 169,912 7,455,185 3Colorado 15,150 955,382 2Connecticut 25,265 905,238 3Delaware 4,908 187,157 4Dist. of Columbia 4,577 153,763 4Florida 114,975 4,079,724 3Georgia 42,632 1,785,363 4Hawaii 4,640 297,222 2Idaho 5,614 279,469 3Illinois 90,790 3,053,481 4Indiana 43,542 1,519,445 4Iowa 24,446 776,201 3Kansas 19,652 664,026 3Kentucky 29,501 1,023,219 4Louisiana 30,728 1,086,374 4

Maine 9,179 340,181 3

Maryland 29,769 1,316,398 3Massachusetts 45,082 1,650,271 3Michigan 70,046 2,469,069 4

Minnesota 24,931 1,174,749 2

Mississippi 24,008 680,726 5Missouri 47,181 1,427,553 4

Number Deat

of Deaths Population per 1

State 1991-1995 1995 1991
Appendix A: State Ranking

Montana 4,482 230,331 292 3Nebraska 13,048 428,121 360 19Nevada 7,130 374,589 416 33New Hampshire 7,127 296,286 360 19New Jersey 60,934 2,189,302 407 31New Mexico 7,237 412,053 315 9New York 171,533 4,929,714 487 50North Carolina 46,846 1,902,353 400 29North Dakota 4,306 163,941 307 6Ohio 89,015 2,987,355 437 40Oklahoma 27,492 862,701 440 42Oregon 17,635 848,184 307 6Pennsylvania 112,999 3,435,632 433 38Rhode Island 8,575 274,257 371 23South Carolina 24,029 953,621 438 41South Dakota 5,587 185,333 344 14Tennessee 39,164 1,409,344 435 39Texas 99,564 4,474,077 388 27Utah 6,852 386,521 313 8Vermont 3,964 154,251 374 26Virginia 39,302 1,700,258 404 30Washington 27,027 1,386,393 319 10West Virginia 17,530 523,354 472 49Wisconsin 35,603 1,330,533 354 17Wyoming 2,222 118,822 322 11

* Age-adjusted to the 1970 United States population

** The state with the lowest rate was ranked 1.

The state with the highest rate was ranked 51.States that had identical rates were assigned the same rank.New York City was not ranked separately.

Number Death Rate

of Deaths Population per 100,000 State

State 1991-1995 1995 1991-1995* Ranking**
196 Women and Heart Disease

State Ranking of Heart Disease Death Rates for American Indian and Alask

Alabama 17 3,557 Alaska 171 15,407 3Arizona 427 40,739 2Arkansas 18 2,948 California 379 63,648 1Colorado 36 6,865 1Connecticut 22 1,638 3Delaware 12 527 Dist. Of Columbia 2 389 Florida 44 10,878 1Georgia 8 3,568 Hawaii 15 1,161 Idaho 20 2,857 2Illinois 22 5,544 1Indiana 14 3,156 Iowa 7 1,439 Kansas 66 4,649 3Kentucky 10 1,344 Louisiana 28 3,780 1Maine 7 1,091 Maryland 17 3,258 Massachusetts 18 2,955 Michigan 238 11,749 6Minnesota 137 8,901 4Mississippi 23 1,728 3Missouri 38 4,672 1

Number Death 

of Deaths Population per 1

State 1991-1995 1995 1991
Appendix A: State Ranking

Montana 118 8,751 390 24Nebraska 51 2,289 603 31Nevada 51 5,567 277 14New Hampshire 3 463 *** ***New Jersey 33 4,356 180 7New Mexico 226 26,714 213 13New York 137 15,646 212 12North Carolina 344 18,118 485 28North Dakota 77 4,264 525 29Ohio 26 5,255 129 5Oklahoma 831 53,204 278 16Oregon 84 8,954 277 14Pennsylvania 21 3,868 106 2Rhode Island 24 930 442 25South Carolina 17 1,693 *** ***South Dakota 178 7,682 577 30Tennessee 14 2,703 *** ***Texas 37 18,482 56 1Utah 40 4,081 311 20Vermont 0 284 *** ***Virginia 13 3,869 *** ***Washington 167 18,663 283 17West Virginia 4 707 *** ***Wisconsin 120 7,525 445 26Wyoming 19 1,784 *** ***

* Age-adjusted to the 1970 United States population

** The state with the lowest rate was ranked 1.

The state with the highest rate was ranked 32.States that had identical rates were assigned the same rank.New York City was not ranked separately.

*** Insufficient data to calculate a heart disease death rate

Number Death Rate

of Deaths Population per 100,000 State

State 1991-1995 1995 1991-1995* Ranking**
198 Women and Heart Disease

State Ranking of Heart Disease Death Rates for Asian and Pacific Islander W

Alabama 17 5,945 Alaska 16 5,816 Arizona 85 18,275 2Arkansas 19 3,351 California 6,189 826,450 2Colorado 68 18,343 1Connecticut 28 13,759 1Delaware 5 2,954 Dist. Of Columbia 22 3,401 2Florida 139 54,316 1Georgia 84 24,878 1Hawaii 3,227 199,714 2Idaho 20 2,476 2Illinois 389 81,436 1Indiana 39 10,059 1Iowa 24 5,252 2Kansas 23 7,719 1Kentucky 29 4,832 3Louisiana 35 10,181 1Maine 7 1,697 Maryland 189 42,134 2Massachusetts 140 34,362 1Michigan 119 26,332 2Minnesota 39 15,363 Mississippi 18 3,434 Missouri 44 10,978 2

Number Deat

of Deaths Population per 1

State 1991-1995 1995 1991
Appendix A: State Ranking

Montana 7 1,017 *** ***Nebraska 8 3,284 *** ***Nevada 70 15,808 222 28New Hampshire 7 2,283 *** ***New Jersey 275 86,485 147 5New Mexico 12 4,726 *** ***New York 1,298 198,243 236 29North Carolina 47 16,052 174 11North Dakota 2 868 *** ***Ohio 109 24,325 194 17Oklahoma 41 8,588 216 24Oregon 98 19,208 187 16Pennsylvania 170 36,363 196 18Rhode Island 15 3,563 *** ***South Carolina 20 6,518 167 10South Dakota 4 803 *** ***Tennessee 40 9,418 259 32Texas 288 99,761 154 6Utah 44 7,724 220 26Vermont 4 732 *** ***Virginia 182 48,527 178 13Washington 380 65,208 204 22West Virginia 3 2,035 *** ***Wisconsin 39 10,461 154 6Wyoming 5 758 *** ***

* Age-adjusted to the 1970 United States population

** The state with the lowest rate was ranked 1.

The state with the highest rate was ranked 35.States that had identical rates were assigned the same rank.New York City was not ranked separately.

*** Insufficient data to calculate a heart disease death rate

Number Death Rate

of Deaths Population per 100,000 State

State 1991-1995 1995 1991-1995* Ranking**
200 Women and Heart Disease

State Ranking of Heart Disease Death Rates for Black Women

Alabama 8,020 254,021 5Alaska 31 3,580 4Arizona 502 27,332 4Arkansas 3,143 86,422 5California 12,764 510,022 5Colorado 436 31,765 3Connecticut 1,232 63,799 4Delaware 623 29,220 5Dist. Of Columbia 3,381 103,777 5Florida 9,873 434,876 5Georgia 10,967 436,167 5Hawaii 23 3,877 2Idaho 12 765 Illinois 11,331 406,616 6Indiana 2,936 106,443 5Iowa 232 9,662 5Kansas 754 30,301 4Kentucky 1,920 64,758 5Louisiana 8,947 301,133 5Maine 11 645 Maryland 5,682 315,633 4Massachusetts 1,053 71,810 3Michigan 9,033 312,205 6Minnesota 190 18,256 3Mississippi 8,102 206,728 6Missouri 4,087 134,854 5

Number Dea

of Deaths Population per 1

State 1991-1995 1995 1991
Appendix A: State Ranking

Montana 5 380 *** ***Nebraska 334 12,241 618 42Nevada 349 21,680 493 17New Hampshire 9 1,256 *** ***New Jersey 5,551 265,616 490 14New Mexico 133 7,878 408 6New York 19,534 769,949 573 33North Carolina 9,791 372,023 513 20North Dakota 2 319 *** ***Ohio 8,090 294,545 556 28Oklahoma 1,679 52,022 582 36Oregon 194 10,036 463 10Pennsylvania 8,045 283,564 532 22Rhode Island 153 8,855 461 9South Carolina 6,985 252,836 562 29South Dakota 6 376 *** ***Tennessee 6,043 195,276 604 39Texas 12,158 490,439 540 26Utah 26 2,094 324 2Vermont 7 400 *** ***Virginia 7,787 299,522 539 25Washington 468 31,706 441 8West Virginia 616 15,358 566 31Wisconsin 796 49,917 491 15Wyoming 5 628 *** ***

* Age-adjusted to the 1970 United States population

** The state with the lowest rate was ranked 1.

The state with the highest rate was ranked 43.States that had identical rates were assigned the same rank.New York City was not ranked separately.

*** Insufficient data to calculate a heart disease death rate

Number Death Rate

of Deaths Population per 100,000 State

State 1991-1995 1995 1991-1995* Ranking**
202 Women and Heart Disease

State Ranking of Heart Disease Death Rates for Hispanic Women

Alabama 63 5,448 2Alaska 3 3,331 Arizona 1,608 146,710 3Arkansas 28 4,663 1California 12,561 1,418,037 2Colorado 953 95,016 2Connecticut 267 41,544 1Delaware 21 3,164 2Dist. Of Columbia 23 7,079 Florida 7,554 477,796 2Georgia 105 24,059 1Hawaii 156 15,700 2Idaho 48 9,365 1Illinois 939 163,766 1Indiana 152 20,837 2Iowa 62 6,582 2Kansas 120 17,191 1Kentucky 54 4,546 3Louisiana 194 24,002 1Maine 5 1,394 Maryland 80 30,620 Massachusetts 240 52,023 1Michigan 331 38,610 2Minnesota 47 10,009 1Mississippi 19 3,600 Missouri 138 13,194 2

Number Deat

of Deaths Population per 1

State 1991-1995 1995 1991
Appendix A: State Ranking

Montana 14 2,545 *** ***Nebraska 44 8,058 151 11Nevada 159 30,860 180 14New Hampshire 10 2,311 *** ***New Jersey 1,291 178,286 210 23New Mexico 1,717 134,004 282 36New York 6,126 521,506 307 39North Carolina 33 15,013 74 1North Dakota 5 659 *** ***Ohio 167 29,027 157 12Oklahoma 7 15,176 *** ***Oregon 82 21,680 142 8Pennsylvania 454 46,254 278 35Rhode Island 45 9,380 150 10South Carolina 28 6,351 132 5South Dakota 2 960 *** ***Tennessee 63 7,956 214 25Texas 10,227 919,319 296 38Utah 108 16,112 210 23Vermont 6 812 *** ***Virginia 179 35,958 184 17Washington 182 39,850 181 15West Virginia 13 2,217 *** ***Wisconsin 57 16,695 117 4Wyoming 49 4,872 266 32

Number Death Rate

of Deaths Population per 100,000 State

State 1991-1995 1995 1991-1995* Ranking**

* Age-adjusted to the 1970 United States population

** The state with the lowest rate was ranked 1.

The state with the highest rate was ranked 41.States that had identical rates were assigned the same rank.New York City was not ranked separately.

*** Insufficient data to calculate a heart disease death rate
204 Women and Heart Disease

State Ranking of Heart Disease Death Rates for White Women

Alabama 24,979 872,607 4Alaska 644 98,075 2Arizona 21,245 1,000,825 3

Arkansas 17,201 574,743 3

California 150,580 6,055,065 3Colorado 14,610 898,409 2Connecticut 23,983 826,042 3Delaware 4,268 154,456 4Dist. Of Columbia 1,172 46,196 2Florida 104,919 3,579,654 3Georgia 31,573 1,320,750 4Hawaii 1,375 92,470 3Idaho 5,562 273,371 3Illinois 79,048 2,559,885 4Indiana 40,553 1,399,787 4Iowa 24,183 759,848 3Kansas 18,809 621,357 3Kentucky 27,542 952,285 4Louisiana 21,718 771,280 4Maine 9,154 336,748 3Maryland 23,881 955,373 3Massachusetts 43,871 1,541,144 3Michigan 60,656 2,118,783 4

Minnesota 24,565 1,132,229 2

Mississippi 15,865 468,836 4Missouri 43,012 1,277,049 4

Number Deat

of Deaths Population per 1

State 1991-1995 1995 1991
Appendix A: State Ranking

Montana 4,352 220,183 289 4Nebraska 12,655 410,307 353 19Nevada 6,660 331,534 417 39New Hampshire 7,108 292,284 361 22New Jersey 55,075 1,832,845 399 33New Mexico 6,866 372,735 320 10New York 150,564 3,945,876 477 51North Carolina 36,664 1,496,160 375 29North Dakota 4,225 158,490 303 6Ohio 80,790 2,663,230 426 45Oklahoma 24,941 748,887 442 48Oregon 17,259 809,986 307 7Pennsylvania 104,763 3,111,837 425 44Rhode Island 8,383 260,909 370 25South Carolina 17,007 692,574 399 33South Dakota 5,399 176,472 335 14Tennessee 33,067 1,201,947 412 37Texas 87,081 3,865,395 374 27Utah 6,742 372,622 314 9Vermont 3,953 152,835 374 27Virginia 31,320 1,348,340 380 31Washington 26,012 1,270,816 320 10West Virginia 16,907 505,254 470 49Wisconsin 34,648 1,262,630 350 18Wyoming 2,193 115,652 322 12

* Age-adjusted to the 1970 United States population

** The state with the lowest rate was ranked 1.

The state with the highest rate was ranked 51.States that had identical rates were assigned the same rank.New York City was not ranked separately.

*** Insufficient data to calculate a heart disease death rate

Number Death Rate

of Deaths Population per 100,000 State

State 1991-1995 1995 1991-1995* Ranking**

Methodologic

and Technical

B

Notes
208 Women and Heart Disease

Table of Contents Page

A. County Definitions ............ 208B. Data Sources...................... 210C. Map Projections ................ 212D. Race/Ethnicity Definitions 213E. Spatial Geometry............... 214F. Spatial Smoothing of Heart Disease Death Rates ........... 214G. References ......................... 216

A. County Definitions

1. Overview

Data from several different sources were used in this publication, and one of our chief methodological concing comparability of county definitions across datasets. We used the Federal Information Processing Standato link county definitions across datasets, and to reconcile differences. For the majority of states, there was 100% county definitions among all the datasets used. Details about modifications to county definitions for specific states The following cities were retained as independent cities and the FIPS codes were modified to conform to the geog

Original Modified

Independent City FIPS Code FIPS Code State

Baltimore City 24510 24007 MarylandSt. Louis City 29510 29191 MissouriCarson City 32510 32025 NevadaSuffolk City 51800 51123 Virginia

2. Alaska

In the Area Resource File (ARF), Alaska was treated as a single geographic unit. The ARF did not provAlaska county equivalents. Therefore, for each of the maps that present data from the ARF, we were unable Alaska. These maps include the following:Total Population per Cardiovascular Disease (CVD) Physician, 1990Total Population per Cardiac Intensive Care Unit (CCU) Bed, 1993Cardiac Rehabilitation Units, 1993Local Economic Resources, 1990Due to differences in county coding over time, and differential coding among the various data sourcechanges were also made to county FIPS codes. The coding changes are indicated in the following tables. In nal Aleutian Islands (county code 2010) was subdivided into Aleutian Islands East (county code 2013) and AWest (county code 2016).

Original County Incorporated into Modified

Original County FIPS Code Adjacent County FIPS Code 

Aleutian Islands East 2013 Aleutian Islands 2010 Aleutian Islands West 2016 Aleutian Islands 2010 Denali Borough 2068 Yukon-Koyukuk 2290 Kobuk 2140 Yukon-Koyukuk 2290 Skagway-Hoonah-Angoon 2232 Skagway-Yakutat-Angoon 2231 Yakutat 2282 Skagway-Yakutat-Angoon 2231 
Appendix B: Methodo

3. Arizona

Original County Incorporated into Modified

Original County FIPS Code Adjacent County FIPSCode State

Yuma 4027 LaPaz 4012 Arizona

4. Hawaii

Original County Incorporated into Modified

Original County FIPS Code Adjacent County FIPS Code State

Kalawao 15005 Maui 15009 Hawaii

5. Virginia

Virginia is comprised of counties and independent cities that are treated as county-equivalents in many datasets. However,not all of the datasets we used contained data for the Virginia independent cities. Many of these cities are also difficult torepresent on a map because of their small land area. Therefore, the spatial geometry for most of Virginia independent citieswas removed from the geographic database and data for those cities was collapsed into those counties with which they aremost geographically associated. We followed the conventions of the 1996 Area Resource File. The changes made to FIPScodes to combine Virginia independent cities with their surrounding or adjacent counties are shown in the table below.

Independent City Incorporated into Modified

Independent City FIPS Code Adjacent County FIPSCode State

Bedford 51515 Bedford 51019 VirginiaBristol 51520 Washington 51191 Virginia

Buena Vista 51530 Rockbridge 51163 Virginia

Charlottesville 51540 Albemarle 51003 VirginiaClifton Forge 51560 Allegheny 51005 VirginiaColonial Heights 51570 Chesterfield 51041 VirginiaCovington 51580 Allegheny 51005 VirginiaDanville 51590 Pittsylvania 51143 VirginiaEmporia 51595 Greensville 51081 VirginiaFairfax 51600 Fairfax 51059 VirginiaFalls Church 51610 Fairfax 51059 VirginiaFranklin 51620 South Hampton 51175 VirginiaFredericksburg 51630 Spotaylvania 51177 VirginiaGalax 51640 Grayson 51077 VirginiaHarrisonburg 51660 Rockingham 51165 VirginiaHopewell 51670 Prince George 51149 VirginiaLexington 51678 Rockbridge 51163 VirginiaLynchburg 51680 Campbell 51031 VirginiaManassas 51683 Prince William 51153 Virginia 
210 Women and Heart Disease

(continued from previous page) Independent City Incorporated into Modified

Independent City FIPS Code Adjacent County FIPS Code 

Manassas Park 51685 Prince William 51153 Martinsville 51690 Henry 51089 Norfolk 51710 Norfolk 51129 Norton 51720 Wise 51195 Petersburg 51730 Dinwiddie 51053 Portsmouth 51740 Norfolk 51129 Radford 51750 Montgomery 51121 Richmond 51760 Henrico 51087 Roanoke 51770 Roanoke 51161 Salem 51775 Roanoke 51161 South Boston 51780 Halifax 51083 Staunton 51790 Augusta 51015 Waynesboro 51820 Augusta 51015 Williamsburg 51830 James City 51095 Winchester 51840 Frederick 51069 

5. Yellowstone National Park

Original County Incorporated into Modified

Original County FIPS Code Adjacent County FIPS Code 

Yellowstone National 30113 Park 30067 Park (Part)

B. Data Sources

1. Economic Resources Data

Data for the Index of Local Economic Resources were obtained from the Area Resource File (February 199compilation of health-related data that have been abstracted from multiple data sources by the Bureau of sions, Department of Health and Human Services. The three variables that were used to create the index wfrom the 1990 Census of Population and Housing, STF3A data files. The Index of Economic Resources was dimensions of the local socioeconomic infrastructure: median family income, occupational structure, and rate. Occupational structure was defined as the percent of all employed persons who were engaged in white managerial and professional specialty occupations and technical, sales, and administrative support jobs).The index was calculated by ranking all counties separately for each variable. For each variable, the countieegorized into deciles, and each decile was assigned a score ranging from 0 to 9. Counties in the decile with tnomic conditions (lowest median income, lowest occupational structure, highest unemployment rate) were a
Appendix B: Methodo

counties in the decile with the most advantaged economic conditions were assigned a 9. For each county, the scores fromthe three variables were added together to arrive at the index score. The range of the score is from 0 (counties that were inthe lowest decile for all three dimensions of the Index) to 27 (counties that were in the top decile for all three dimensions ofthe Index). The distribution of index values across all counties was then divided into five groups with roughly equal rangesof index values.

2. Heart Disease Mortality Data

Death certificate data for the years 1991-1995 were obtained through the National Vital Statistics System maintained by theNational Center for Health Statistics. Deaths from heart disease were defined as those for which the underlying cause ofdeath listed on the death certificate was coded according to the International Classification of Diseases - 9th Revision(ICD-9) as: 390-398, 402, 404-429. These codes comprise the category ‘Diseases of the Heart’ as defined by the NationalCenter for Health Statistics.1 For each decedent, underlying cause of death, age, race/ethnicity, gender, and county of residence at the time of death were abstracted from computerized death certificate files. Information on Hispanic ethnicity was

not collected on death certificates in Oklahoma throughout the 1991-1995 study period, and prior to 1993 was not collectedfor New Hampshire. Consequently, we could not analyze decedents of Hispanic ethnicity for Oklahoma and New Hampshire.

3. Medical Care Resources Data

Data on medical care resources were obtained from the Area Resource File, (February 1996 edition) a compilation ofhealth-related data abstracted from multiple data sources by the Bureau of Health Professions, Department of Health andHuman Services. Maps were created for the following indicators of medical care resources relevant to secondary prevention of heart disease mortality: population per cardiovascular disease specialty physician, population per coronary careunit bed, and number of cardiac rehabilitation units. The primary source for the data on cardiovascular disease physicians

was the American Medical Association Physician Master File. The primary source for the data on coronary care unit bedsand cardiac rehabilitation units was the County Hospital File for 1993.Rather than map the number of physicians per county, we chose to map the ratio of county population size to each cardiovascular specialty physician. This approach provides a better comparative measure of the availability of physicians whenexamining counties with large populations vs. counties with small populations. Similarly, we chose to map the ratio ofcounty population size to each coronary care unit bed. Because cardiac rehabilitation units are intended to serve more thanone individual at a time, we mapped the total number of cardiac rehabilitation units in each county.

4. Population Data

Population count data for all counties in the U.S. were obtained from the Bureau of the Census for the years 1991-1995.These intercensal estimates were calculated by the Bureau of the Census through extrapolation of linear trends in population growth and inter-county migration patterns between census years 1980 and 1990.
212 Women and Heart Disease

5. Social Isolation of Women Data

Data on several dimensions of women’s social isolation were obtained from the 1990 Special Tabulation piled by the Bureau of the Census. This dataset contains a variety of variables, abstracted from the 1990 Cetion and Housing, for elderly women and men. We examined data for women aged 60 years and older. The mdisease deaths for women aged 35 years and older actually occur to women aged 60 years and older, becauassociation between increasing age and heart disease risk.Two indicators of women’s social isolation were mapped for this atlas: percent of women living alone, anwomen with either mobility or self-care limitations. Living alone was defined as an individual living in a hou

a spouse or other family members or friends. A mobility limitation was defined as a health condition, eimental that lasted for 6 or more months, which made it difficult to go outside the home alone. A self-care 

defined as a health condition, either physical or mental that lasted for 6 or more months, which made it diffiof personal needs, such as dressing, bathing, or getting around inside the home.To produce the maps of women’s social isolation, we first excluded 32 counties with fewer than 100 women 60 years old in 1990. For each of the two measures of women’s social isolation, the range between the 1st a

tiles of the distribution of the percentage values was divided into 5 equal categories. Counties below the firs99th percentiles of the distribution were included in the lowest and highest categories respectively. These 

provided the cutpoints for mapping.

C. Map Projections

1. National Maps

To facilitate the presentation of information for all U.S. counties, several different map projections were userminous United States an Albers-Conic Equal Area projection was used. Alaska was projected to the Miprojection and Hawaii is presented using geographic coordinates (latitude and longitude). Neither Alaska nproper geographic scale relative to the continental United States. The combinations of projections and scapresentation of a relatively familiar orientation of these geographic features.The coordinate information for the contiguous United States was projected using the Albers Equal-Area the following parameters:

Spheroid: Clarke 1866 1st Standard Parallel: 29.500 False Easting: 0.0Central Meridian: -96.000 2nd Standard Parallel: 45.500 False Northing: 0.000

Reference Latitude: 37.500

The coordinate information for Alaska has been projected using the Miller Cylindrical project with the following p

Spheroid: Sphere Central Meridian: 0.000
Appendix B: Methodo

2. State Maps

All state maps were projected using the State-Plane coordinate systems of each state. The state maps are presented to maximize the reader’s ability to interpret results for each state and are therefore not to proper geographic scale relative to one another. However, State-Plane coordinate systems are commonly used by state agencies and therefore their use here maximizes the reader’s ability to compare these maps with other information.Many states did not have significant populations of women of particular racial and ethnic groups. In many cases racial andethnic specific rates could not be calculated for any of the counties within the state. Rather than present blank maps for thesestates, we elected only to generate race and ethnicity-specific state maps if there were at least two counties with heart diseasemortality rates for any given racial and ethnic group.

D. Race and Ethnicity Definitions

The race and ethnicity categories used in Women and Heart Disease were defined according to Office of Management and

Budget, Directive 15,2 and are not based upon biological or anthropological concepts. The categories were developed in response to needs for collecting standardized data to be used by federal agencies for record keeping, collection and presentation of data (i.e., Federal surveys, the decennial census and monitoring various civil rights laws).

According to the Office of Management and Budget, the federal agency that defines standards for government publications,there are six minimum categories for race and ethnicity classification (listed below). Hispanic or Latino is considered a designation of ethnicity, not race, and people of Hispanic or Latino origin may be of any race.

♦ American Indian or Alaska Native. A person having origins in any of the original peoples of

North and South America (including Central America), and who maintains tribal affiliation or community attachment.

♦ Asian or Pacific Islander. A person having origins in: a) any of the original peoples of the Far

East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India,Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam or b) a personhaving origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

♦ Black or African American. A person having origins in any of the black racial groups of Africa.♦ Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central Ameri

can, or other Spanish culture or origin, regardless of race.

♦ Native Hawaiian or Other Pacific Islander. A person having origins in any of the original

peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

♦ White. A person having origins in any of the original peoples of Europe, the Middle East, or North

Africa.
214 Women and Heart Disease

E. Spatial Geometry

The geographic database, which includes spatial geometry and attribute information for all U.S. countiefrom Environmental Systems Research Institute’s (ESRI) ArcUSA database. ESRI has modified source datDigital Line Graph (DLG) data produced by the U.S. Geological Survey to improve the currency of the counformation to 1988. The geographic scale of the spatial geometry (linework) is 1:2,000,000, and is sufficienjor county features. Mortality, population, socioeconomic, and medical resource data were linked to county ing the Federal Information Processing Standards (FIPS) codes.

F. Spatial Smoothing of Heart Disease Mortality Rates

1. Spatial Smoothing Methods

Heart disease death rates were calculated for women 35 years and older for the period 1991-1995. Separate culated for the following population groups: all women, American Indian and Alaska Native women, Asian lander women, black women, Hispanic women, and white women. For each population group, a smootheheart disease, based on a spatial moving average, was calculated for each county.For each county, heart disease deaths (numerators) and population counts (denominators) for ten-year age 44 years old, 45-54 years old, etc.) were summed for the five-year study period 1991-1995. County numeratnators were then summed together with death count numerators and population count denominators of all neties, and then divided by the number of neighbors plus one to produce an average rate. “Neighbors” wersolely on contiguity (as opposed to distance). This process produced spatially smoothed age-specific (by10-heart disease death rates. The spatially smoothed age-specific heart disease death rates were then directly the 1970 United States population, for the age range 35 years and older.Two constraints were applied to the calculation of county-level heart disease death rates for each race and For a particular population group (e.g. Latina women aged 35 years and older), a heart disease death rate wafor any county for which the total number of deaths in that county plus its neighbors was fewer than 20 durTo avoid calculating rates for counties that had no population themselves but whose neighbors had significrates were calculated only for counties that had a population count of 5 or greater for 1991-1995 (i.e. had son-years).Information on Hispanic ethnicity was not collected on death certificates in Oklahoma throughout the 1991riod, and prior to 1993 was not collected for New Hampshire. Consequently, we removed all counties in New Hampshire from the contiguity matrix when the rates for Latinas were spatially smoothed, and no rates Oklahoma and New Hampshire were calculated.
Appendix B: Methodo

2. Standard Population Weights

Age-specific heart disease death rates were directly age-adjusted using the 1970 U.S. population as the standard. The 1970standard weights were based on the total resident population in the United States as of April 1, 1970.Because we generated heart disease death rates only for men ages 35 and over, and weights used in the age-adjustment of mortalityrates are required to sum to 1, the weights for 10-year age groups for ages 35 and over were recalculated from the 1970 standardweights. The 1970 standard weights were summed for age groups 35-44 through ages 85+. New weights for each of these agegroups were calculated by dividing the original weight by the sum of the weights for ages 35 and older (i.e. .418101). The newweights were rounded to two decimal places for subsequent calculation of age-adjusted heart disease death rates.

2. Standard Population Weights

During 1991-1993, information on Hispanic origin was not reported on approximately 22% of heart disease death certificates for women aged 35 years and older residing in New York City. During 1994-1995, the percent of death certificatesfor women that were missing information on Hispanic origin dropped to less than 3%. Based on a detailed examination ofthe New York City death certificate data for our five-year study period, we concluded that the majority of the deaths with“unknown” Hispanic origin occurred among non-Hispanic women. As evident in the table below, the percent of heart disease deaths for Hispanic women rose only slightly between 1991-1993 and 1994-1995, while the percent of heart diseasedeaths for non-Hispanic women rose markedly after reporting improved in 1994. From 1991-1993 to 1994-1995, the average annual number of heart disease deaths increased 7% for Hispanic women and 22% for non-Hispanic women, whilethe number of deaths with unknown Hispanic origin declined 96%.However, since a small proportion of the deaths with missing Hispanic origin data did occur among Hispanic women, itis almost certain that the heart disease death rates reported here for Hispanic women are modestly (but not severely)underestimated. In addition, the extent of underestimation may have varied among the five city boroughs; therefore prudence should be exercised in comparing individual county rates.

 Percent Distribution of Heart Disease Deaths by Hispanic Origin forWomen in New York City, 1991-1995

Hispanic Origin 1991 1992 1993 1994 1995Non-Hispanic 74.0 71.0 70.3 89.6 90.4Hispanic 6.7 6.7 6.3 7.2 7.4Unknown 19.3 22.3 23.5 3.3 2.2

3. Contiguity Matrix for Alaska

A contiguity matrix for all U.S. counties was obtained from the 1996 Area Resource File (ARF). The matrix identifies amaximum of fourteen contiguous neighbors for every U.S. county. Because Alaska was treated as a single geographic unitin the ARF, we created our own contiguity matrix for Alaska (shown below). Columns n1-n9 identify contiguous neighborsto each county.

1

19
216 Women and Heart Disease

County n1 n2 n3 n4 n5 n6 n7 n8 n9 2010 2164 0 0 0 0 0 0 0 0 2020 2170 2261 2122 0 0 0 0 0 0 2050 2070 2270 2170 2164 2290 2122 0 0 0 2060 2164 2070 0 0 0 0 0 0 0 2070 2164 2060 2050 0 0 0 0 0 0 2090 2290 2240 0 0 0 0 0 0 0 2100 2231 2110 0 0 0 0 0 0 0 2110 2100 2280 0 0 0 0 0 0 0 2122 2020 2170 2050 2164 2150 2261 0 0 0 2130 2201 2280 0 0 0 0 0 0 0 2150 2122 2164 0 0 0 0 0 0 0 2164 2060 2070 2050 2122 2010 0 0 0 0 2170 2290 2240 2261 2020 2050 2122 0 0 0 2180 2270 2290 2188 0 0 0 0 0 0 2185 2188 2290 0 0 0 0 0 0 0 2188 2185 2290 2180 0 0 0 0 0 0 2201 2280 2130 0 0 0 0 0 0 0 2220 2231 2280 0 0 0 0 0 0 0 2231 2261 2100 2220 2110 2280 0 0 0 0 2240 2290 2090 2170 2261 0 0 0 0 0 2261 2240 2170 2020 2231 2122 0 0 0 0 2270 2290 2050 2180 0 0 0 0 0 0 2280 2220 2201 2231 2130 0 0 0 0 0 2290 2185 2188 2270 2050 2170 2240 2090 2180 0

G. References

1National Center for Health Statistics. Public Use Data Tape Documentation, MortalityDetail, 1992. Rockland, MD: National Center for Health Statistics, 1992.2Wallman KK, Hodgdon J. Race and ethnic standards for federal statistics and administrative reporting. Statistical Reporter, July 1977 (no. 77-10):450-454.


Resources

C
220 Women and Heart Disease

Table of Contents PageA. Federal Government Agencies .........220B. State and Territorial Agencies..........221C. Minority Health

Organizations..................................227

D. African American

Health Organizations ......................227

E. American Indian and Alaska

Native Health Organizations ...........228

F. Asian and Pacific Islander

Health Organizations ......................229

G. Hispanic Health Organizations........229H. Women’s Health Organizations.......230I. Heart Disease Organizations ...........231J. Patient Resources ............................231

 A. Federal Government AgenciesOffice of the Associate Director for Minority HealthCenters for Disease Control and Prevention1600 Clifton Road, Atlanta, GA 30033Phone: 404-639-7210Website: http://www.cdc.gov/od/admh/The mission of the Office of the Associate Director for Minority Healthis to improve the health of African-American, Pacific Islander, Hispanic American, Native American and Alaska Native citizens, and,where appropriate, similar ethnic/racial subgroups both in and outof the United States.Office of Women’s HealthCenters for Disease Control and Prevention1600 Clifton Road, MS: D-51, Atlanta, GA 30033Phone: 404-639-7230 Fax: 404-639-7331Website: http://www.cdc.gov/od/owhThe Office of Women’s Health is dedicated to in-depth research, dissemination of information and public policy regarding women’shealth.Office of Minority HealthDivision of Information and EducationRockwall II Building, Suite 10005600 Fishers Lane, Rockville, MD 20857Phone: 301-443-5224 Fax: 301-443-8280Website: http://www.omhrc.govThe Office of Minority Health works to improve collection and analyses of data on the health of racial and ethnic minority populations,and it monitors efforts to achieve Healthy People 2000 goals forminority health.

The Office of Minority Health ResoDivision of Information and EducatRockwall II Building, Suite 10005600 Fishers Lane, Rockville, MD Phone: 1-800-444-6472Website: http://www.info@omhrc.gThe Office of Minority Health Resourassist in the exchange of information aissues. The center collects and distrvariety of health topics and facilitates on minority health issues.Office of Research on Women’s HeNational Institutes of HealthBuilding 1, Room 201, Bethesda, MWebsite: http://www4.od.nih.gov/orThe goal of the Office of Research on that research conducted and supporteHealth addresses issues of women’s hpriate inclusion of women in clinical rtrials.National Heart, Lung, and Blood InNational Institutes of Health, Buildi31 Center Drive, Bethesda, MarylanWebsite: http://www.nhlbi.nih.gov/nThe National Heart, Lung, and Bloogram dedicated to research related to nosis, and treatment of heart, blood veand sleep disorders.
Appendix C: Resou

Indian Health ServiceChief, Special Initiative BranchDivision of Legislation and RegulationsParklawn Building, Room 6-055600 Fishers Lane, Rockville, MD 20857Phone: 301-443-1083 Fax: 301-443-4794Website: http://www.ihs.govThe Indian Health Service (IHS) is an agency within the US Department of Health and Human Services that is responsible for providingfederal health services to American Indians and Alaska Natives. TheIHS is the principal federal health care provider and health advocate for Indian people, and its goal is to assure that comprehensive,culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people.National Institutes of HealthAssociate Director, Office of Research on Minority HealthNational Institutes of HealthBuilding 1, Room 2581 Center Drive, MSC 0164, Bethesda, MD 20892-0164Phone: 301-402-1366 Fax: 301-402-7040The Office of Research on Minority Health (ORMH) was founded in1999 by the National Institutes of Health (NIH) in order to help solveresearch questions that result from the disparity of health status amongAmericans. The ORMH mission is to support and promote biomedical research aimed at improving the health status of minority Americans across the lifespan and programs aimed at expanding the participation of underrespresented minorities in all aspects of biomedicaland behavioral research.

Agency for Healthcare Research and QualityMinority Health CoordinatorCenter for Cost and Financing Studies2101 East Jefferson Street, Suite 500, Rockville, MD 20852Phone: 301-594-1406, ext. 1477 Fax: 304-594-2157Website: http://www.ahcpr.govThe Agency for Healthcare Research and Quality (AHRQ) was established in 1989 as the Agency for Health Care Policy and Research. Re-authorizing legislation passed in November 1999 established AHRQ as the lead Federal agency on quality research. AHRQ,part of the U.S. Department of Health and Human Services, is thelead agency charged with supporting research designed to improvethe quality of health care, reduce its cost, and broaden access toessential services. AHRQ’s broad programs of research bring practical, science-based information to medical practitioners and to consumers and other health care purchasers.B. State and Territorial AgenciesCardiovascular Health Council of theAssociation of State and Territorial Chronic DiseaseProgram DirectorsRobert R. Hafner, MHA, JD, DirectorHypertension DivisionAlabama Department of Public Health201 Monroe Street, RSA Tower, Montgomery, AL 36130-3017Phone: 334-206-5128 Fax: 334-206-2064Catherine Schumacher, MD, MSPHAlaska Division of Public HealthSection of Epidemiology3601 C Street, Suite 540P.O. Box 240249, Anchorage, AK 99524-0249Phone: 907-269-8036 Fax: 907-561-1896E-mail: cathies@health.state.ak.us
222 Women and Heart Disease

Valerie JamesHealth Educator II, Stroke AwarenessArizona Department of Health1400 West Washington, Room 330, Phoenix, AZ 85007Phone: 602-542-7501 Fax: 602-542-7520David Bourne, MD, MPH, DirectorChronic Disease and PreventionArkansas Department of Health4815 West Markham Street, MS #3Little Rock, AR 72205-3867Phone: 501-661-2168 Fax: 501-661-2055E-mail: dbourne@mail.doh.state.ar.usKathleen H. Acree, MD, JD, MPH, ChiefChronic Disease Control BranchCalifornia Department of Health Services

P.O. Box 942732, Sacramento, CA 94234-7320Phone: 916-327-6985 Fax: 916-324-7764E-mail: kacree@dhs.ca.gov

Sharon L. Michael, RN, MS, ChiefChronic Disease SectionColorado Department of Public Health & Environment4300 Cherry Creek Drive SouthEMSPD-DC-A5, Denver, CO 80246-1530Phone: 303-692-2505 Fax: 303-782-0095E-mail:sharon.michael@state.co.usNancy E. Berger, MPH, DirectorHealth Education & Intervention DivisionState of Connecticut Dept. of Public Health/BCH410 Capitol Ave., MS-11MATP.O. Box 340308, Hartford, CT 06134Phone: 860-509-8073 Fax: 860-509-7720E-mail: nancy.berger@po.state.ct.us

Timothy VanWave, DrPH, MPH, CChronic Disease Prevention and HeDelaware Department of Health anJessie Cooper BuildingP.O. Box 637, Dover, DE 19903Phone: 302-739-4724 Fax: 302-73E-mail: tvanwave@state.de.usKurt Brandt, M.D., ChiefDivision of Cancer ControlPreventive Health Services AdminiDistrict of Columbia Department o800 9th St. SW, 3rd Floor, WashingtoPhone: 202-645-5501 Fax: 202-64E-mail: kurtbrandt@hotmail.comSusan AllenCardiovascular Health ProgramFlorida Department of HealthBureau of Chronic Disease, Bin #A2020 Capital Circle, SE, TallahassePhone: 850-487-2772 Fax: 850-41E-mail:susan_allen@doh.state.fl.usJerry Brown, DirectorCardiovascular Health SectionGeorgia Dept. of Human Resource2 Peachtree Street, NE, Room 6-50Phone: 404-657-2550 Fax: 404-65E-mail: jpb@dhr.state.ga.us

Angelina Mummert, MPAHealth Services AdministratorDepartment of Health and Social SeP.O. Box 2816, Hagatna, Guam 96Phone: 671-475-0671 Fax: 671-47E-mail: angmum@ns.gov.gu
Appendix C: Resou

Flory Quarto, RN, MPHProgram Coordinator, Preventive Health Services BranchHawaii State Department of HealthP.O. Box 3378, Honolulu, HI 96801-3378Phone: 808-587-3916 Fax: 808-587-3911E-mail: fcquarto@lava.net

Joanne Mitten, MHE, ChiefBureau of Health PromotionIdaho Dept. of Health and WelfarePO Box 83720, Boise, ID 83720-0036Phone: 208-334-5933 Fax: 208-334-6573E-mail: mittenj@idhw.state.id.us

Julie A. Harvill, MPACVD CoordinatorIllinois Department of Public Health535 West Jefferson Street, Springfield, IL 62761Phone: 217-785-2060 Fax: 217-782-1235E-mail: jharvill@idph.state.il.us

Sue Percifield, MSN, DirectorChronic/Communicable Disease DivisionIndiana State Department of Health2 North Meridian Street 6-A, Indianapolis, IN 46204-3003Phone: 317-233-7816 Fax: 317-233-7805E-mail: spercifi@isdh.state.in.usSandra Ryan, MS, RDCVD Program Coordinator, Bureau of Health PromotionIowa Department of Public HealthLucas State Office Building, Des Moines, IA 50319-0075Phone: 515-281-7097 Fax: 515-281-4535E-mail:sryan@idph.state.ia.us

Paula F. Marmet, MS, RD/LD, DirectorBureau for DiseasePrevention & Health ProgramKansas Department of Health & Environment109 SW 9th Street, Mills Building, Ste. 605, Topeka, KS 66612-1290Phone: 785-296-8126 Fax: 785-296-4197E-mail: pmarmet@kdhe.state.ks.usGreg Lawther, BS, MS, ManagerCommunity Health BranchKentucky Department of Health275 East Main Street, Frankfort, KY 40621Phone: 502-564-7996 Fax: 502-564-4553E-mail: greg.lawther@mail.state.ky.usShirley Kirkconnell, MSW, MPH, AdministratorChronic Disease ControlLouisiana Department of Health, Office of Public HealthP.O. Box 60630, New Orleans, LA 70160Phone: 504-568-7210 Fax: 504-568-1075Pat Jones, MPA, CHES, DirectorCardiovascular Risk Reduction ProgramMaine Department of Human Services151 Capitol Street, 11 State House Station, Augusta, ME 04333Phone: 207-287-5180 Fax: 207-287-4631E-mail: patricia.r.jones@state.me.usDiana K. Schmidt, BS, RD, MPHCardiovascular Disease Program ChiefDivision of Cardiovascular Health and NutritionMaryland Dept. of Health and Mental Hygiene6 St. Paul St., 12th Floor, Baltimore, MD 21201Phone: 410-767-6785 Fax: 410-333-8926E-mail: schmidtd@dhmh.state.md.us
224 Women and Heart Disease

Cynthia L. Boddie-WillisMassachusetts Department of Public HealthBFCH, Division of Health Promotion250 Washington St., 4th Floor, Boston, MA 02108

Phone: 617-624-5434 Fax: 617-624-5075E-mail: cynthia.boddie-willis@state.ma.us

Rochelle Hurst, ManagerCardiovascular Disease & Nutrition SectionMichigan Dept. of Community Health3423 N. Martin Luther King, Jr. Blvd., Lansing, MI 48909Phone: 517-335-9811 Fax: 517-335-9056E-mail: hurstr@state.mi.usDon Bishop, Ph.D., ChiefCenter for Health PromotionMinnesota Department of HealthP.O. Box 64882, St. Paul, MN 64882Phone: 651-215-9889 Fax: 651-215-3959E-mail: don.bishop@health.state.mn.usSusan LoydWorksite Health/CVD CoordinatorMississippi State Dept. of Health2423 N. State Street, A-304P.O. Box 1700, Jackson, MS 39215-1700Phone: 601-576-7725 Fax: 601-576-7497E-mail: sloyd@msdh.state.ms.usDiana Hawkins, MedCardiovascular Health Program ManagerBureau of Chronic Disease Control/CDPHPMissouri Dept. of Health101 Park DeVille, Suite A, Columbia, MO 65203Phone: 573-876-3207 Fax: 573-446-8777E-mail: hawkid@mail.health.state.mo.us

Crystelle Fogle, MBA, MS, RDPublic Health NutritionistMontana Dept. of Public Health & 1400 Broadway, Cogswell Bldg., RHelena, MT 59620-2951Phone: 406-444-2672 Fax: 406-44E-mail: cfogle@state.mt.usBarb Fraser, BA, MS, RDCommunity Health Educator IIINebraska Department of Health301 Centennial Mall South, P.O. BoLincoln, NE 68509-5044Phone: 402-471-2101 Fax: 402-47E-mail: barb.fraser@hhss.state.ne.uBeverly BayanNevada Department of Human Res505 East King Street, Room 204, CPhone: 702-687-4797 Fax: 702-68E-mail: bbayan@govmail.state.nv.u

Elizabeth Donahue-DavisHealth Promotion Advisor, DivisioHealth PromotionOffice of Community & Public HeaNew Hampshire Department of He6 Hazen Drive, Concord, NH 0330Phone: 603-271-4551 Fax: 603-27E-mail: bdonahue@dhhs.state.nh.us

Elizabeth Congdon, RN, MAProgram Manager Child and Adult New Jersey Dept. of Health and SeP.O. Box 364, 50 E. State Street, 6t

0364Phone: 609-984-6137 Fax: 609-29E-mail: ebc@doh.state.nj.us
Appendix C: Resou

Martin Rosenblatt, M.A., J.D.New Mexico Department of HealthP.O. Box 26110, Room 9-1106, Santa Fe, NM 87502Phone: 505-827-0259 Fax: 505-827-2329E-mail: martinr@doh.state.nm.us

Sonja Hedlund, MS, DirectorHealthy Heart ProgramNew York State Department of HealthCorning Tower Building/Empire State PlazaRoom 710, Albany, NY 12237Phone: 518-474-1515 Fax: 518-474-3356E-mail: sah05@health.state.ny.us

Brenda M. Motsinger, MS, RD, LDN, Chief,Disease Prevention SectionAdult Health PromotionNorth Carolina Dept. of Environment, Health & Natural ResourcesP.O. Box 27687, Raleigh, NC 27611-7687Phone: 919-715-0415 Fax: 919-715-0433Melissa J. Olson, RD, DirectorCVD Prevention ProgramDivision of Health Promotion and EducationNorth Dakota Department of Health600 E. Boulevard Avenue Dept. 301, Bismarck, ND 58505-0200Phone: 701-328-2367 Fax: 701-328-1412E-mail: mjolson@state.nd.us

Kathy Boyle, RN, MSProgram Director, CVD Risk ReductionBureau of Health Promotion and Risk ReductionOhio Dept. of Health246 N. High Street, P.O. Box 118, Columbus, OH 43266-0118Phone: 614-466-2144 Fax: 614-564-2409E-mail: kboyle@gw.odh.state.oh.us

Adeline M. Yerkes, RN, MPH, Chief,Chronic Disease ServiceOklahoma State Department of Health1000 North East 10th Street, Oklahoma City, OK 73117-1299Phone: 405-271-4072 ext.57123 Fax: 405-271-5181E-mail: adeliney@health.state.ok.usJane M. Moore, PhD, RD, ManagerHealth Promotion & Chronic Disease PreventionOregon Health Division800 NE Oregon St., Suite 730, Portland, OR 97232Phone: 503-731-4272 Fax: 503-731-4082E-mail: jane.m.moore@state.or.usLila Darling, ManagerCardiovascular Risk Reduction ProgramPennsylvania Dept. of HealthP.O. Box 90, Harrisburg, PA 17108Phone: 717-783-7978 Fax: 717-772-0608E-mail: ldarling@health.state.pa.usGabriel Diaz Rivera, MD, MPHDirector Geriatrics and Nonintentional InjuriesPreventive Medicine DivisionDept. of Health of Puerto RicoPO Box 70184, San Juan, PR 00936Phone: 787-274-6861 Fax: 787-274-8008Ann Thacher, ChiefPrimary PreventionDisease Prevention and ControlRhode Island Department of Health3 Capitol Hill, Room 409, Providence, RI 02908-5097Phone: 401-222-1394, ext. 148 Fax: 401-222-4415E-mail: annt@doh.state.ri.us
226 Women and Heart Disease

Brenda C. Nickerson, MSN, DirectorDivision of Chronic Disease Prevention and ControlSouth Carolina Department of Health & Environmental ControlRobert Mills/Jarrett Complex, Box 101106Columbia, SC 29211Phone: 803-898-0757 Fax: 803-253-4001E-mail: nickerbc@columb6l.dhec.state.sc.usKristen Biskeborn, MS, RDState Nutrionist, Division of Health and Medical ServicesSouth Dakota Dept. of Health300 S. Courtland, Ste 109, Chamberlain, SD 57325-1599Phone: 605-734-5486 Fax: 605-734-6537E-mail: kristenb@hech1.state.sd.usMartin Miller, DirectorChronic Disease ServicesTennessee Dept. of Health,Cordell Hull, 6th Floor425 5th Avenue North, Nashville, TN 37247-7366Phone: 615-532-1105 Fax: 615-532-8478E-mail: mmiller2@mail.state.tn.usJennifer Smith, DirectorCommunity and Worksite Wellness ProgramTexas Department of Health1100 W. 49th, Austin, TX 78756-7446

Phone: 512-458-7111, ext. 2209 Fax: 512-458-7618E-mail: jennifer.smith@tdh.state.tx.us

Joan L. Ware, RN, MSPHCardiovascular Program DirectorUtah Department of Health288 N. 1460 West, P.O. Box 142107, Salt Lake City, UT84114-2107Phone: 801-538-6228 Fax: 801-538-9495E-mail: jware@doh.state.ut.usDeborah Dameron, MSPHHealth Services Coordinator

Vermont Department of HealthP.O. Box 70, Burlington, VT 0540Phone: 802-863-7359 Fax: 802-65E-mail: ddamero@vdhvax.vdh.stateJody L. Stones, MSCardiovascular Project ManagerVirginia Department of HealthRoom 132, P.O. Box 2448, RichmoPhone: 804-786-5420 Fax: 804-37E-mail: jstones@vdh.state.va.usKaren Krueger, RN, MN, MBAHeart Health Program ManagerOffice of Community Wellness and Washington State Health DepartmChronic Disease and Risk ReductioP.O. Box 47855New Market Industrial Campus 98904-7855Phone: 360-236-3611 Fax: 360-23E-mail: karen.kreuger@doh.wa.govJessica WrightCVD Program Manager, Division oWest Virginia Department of Heal1411 Virginia Street, East, CharlestPhone: 304-558-0644 Fax: 304-55E-mail: jessicawright@wvdhhr.orgNancy Chudy, MPH, RNPublic Health EducatorWisconsin Division. of Health1 W. Wilson Street, P.O. Box 309, MPhone: 608-266-2593 Fax: 608-266E-mail: chudyne@dhfs.state.wi.usCardiovascular ProgramWyoming Department of HealthHathaway Bldg., 4th Floor, Cheyenn

Phone: 307-777-3732 Fax: 307-77
Appendix C: Resou

Julia Sheen-Aaron, MS, DirectorChronic Disease Prevention ProgramU.S. Virgin Islands Department of HealthChronic Disease Prevention ProgramCharles Harwood Complex3500 Richmond, Christiansted St. Croix, U.S. Virgin Islands 00820Phone: 340-773-1311, ext. 3057 Fax: 340-692-9505E-mail: jsheen@islands.vi.usC. Minority Health OrganizationsMinority Health Professions Foundation3 Executive Drive, NE, Suite 100, Atlanta, GA 30329Phone: 404-634-1993 Fax: 404-634-1903Website: http://www.minorityhealth.orgThe Minority Health Professions Foundation is a non-profit educational, scientific and charitable organization that provides supportfor professional education, research and community service that promote optimum health among poor and minority people.National Association for the Advancement of Colored People4805 Mt. Hope Drive, Baltimore, MD 21215Phone: 410-358-8900 Fax: 410-486-9255Website: http://www.naacp.orgThe National Association for the Advancement of Colored People(NAACP) is the oldest, largest, and strongest civil rights organization in the United States. The principal objective of the NAACP is toensure the political, educational, social and economic equality ofminority group citizens of the United States. The NAACP is committed to non-violence and relies upon the press, the petition, and theballot to fulfill its mission.

D. African American Health OrganizationsAssociation of Black CardiologistsPeachtree Center, South Tower225 Peachtree Street NE, Suite 1420, Atlanta, GA 30303Phone: 404-582-8777 Fax: 404-582-8778Website: http://www.abcardio.orgThe Association of Black Cardiologists’ mission is to unite health providers,particularly those who provide cardiovascular care to African-Americans,as a group to promote primary prevention, quality of life and culturallysensitive clinical management of cardiovascular diseases.Association of Black PsychologistsP.O. Box 55999, Washington, DC 20040-5999Phone: 202-722-0808 Fax: 202-722-5941Website: http://www.abpsi.orgThe Association of Black Psychologists is an independent not-forprofit organization of over 1400 members. The goal of the ABPSI isto have a positive impact upon the mental health of the nationalBlack community by means of planning, programs, services, training, and advocacy.International Society on Hypertension in Blacks2085 Manchester St., NE, Atlanta, GA 30324Phone: 404-875-6323 Fax: 404-875-6334Website: http://www.ishib.orgThe International Society on Hypertension in Blacks (ISHIB) is anot-for-profit professional, medical, membership society devoted toimproving the health and life expectancy of ethnic populations. ISHIBwas founded in 1986 to respond to the problem of high blood pressure among ethnic groups. Its organizational scope includes diabetes, stroke, lipid disorders, renal disease and other related cardiovascular diseases.
228 Women and Heart Disease

National Black Nurses Association1511 K Street, NW, Suite 415, Washington, DC 20005Phone: 202-393-6870 Fax: 202-347-3808Website: http://www.nbna.orgThe National Black Nurses Association was founded to develop abetter health care system for black people, where black nurses andother nurses of color played a prominent role in the system. TheNBNA encourages African American nurses to take the lead in orderto make a difference in the quality of life in communities of color.National Association of Black Social Workers8436 W. McNichols Street, Detroit, MI 48221Phone: 313-862-6700 Fax: 313-862-6998The National Association of Black Social Workers was formed inresponse to issues related to providing human services in the Blackcommunity, educating social workers for effective service in the Blackcommunity, and providing opportunities for participation of Blacksocial workers in the social welfare arena.National Medical Association1012 10th Street, NW, Washington, DC 20001Phone: 202-347-1895 Fax: 202-842-3293Website: http://www.nmanet.org/index.aspThe National Medical Association is committed to preventing the diseases, disabilities and adverse health conditions that disproportionately or differentially impact African American and underserved populations, supporting efforts that improve the quality and availability ofhealth care to poor and underserved populations, and increasing therepresentation and contribution of African Americans in medicine.

E. American Indian and AOrganizationsNative American Women’sHealth Education Resource CenterP.O. Box 572, Lake Andes, SD 573Phone: 605-487-7072Website: http://www.nativeshop.orgThe Native American Community Boarby a group of Native Americans living Reservation in South Dakota to addreducation, land and water rights, aNative American people. The NACB oWomen’s Health Education Resource National Indian Health Board1385 S. Colorado Blvd., Suite A707Phone: 303-759-3075 Fax: 303-75Website: http://www.nihb.orgThe National Indian Health Board (NIHBthat operate their own health care delivand compacting, as well as those that recIndian Health Service. The National Indiorganization that conducts research, poliand development, national and regional agement, and training and technical assiare provided to Tribes, Area Health Boardagencies, and private foundations.Association of American Indian Phy1235 Sovereign Row, Suite C-9Oklahoma City, Oklahoma 73108Phone: 405-946-7072 Fax: 405-94Website: http://www.aaip@ionet.neThe Association of American Indian Psue excellence in Native American heation in the medical disciplines, honortices and restoring the balance of min
Appendix C: Resou

Association of Native American Medical Students1235 Sovereign Row, C-9, Oklahoma City, OK 73108Phone: 405-946-7072Website: http://www.aaip.com/student/anams.htmlThe Association of Native American Medical Students was foundedto provide support and resource network for all Native Americanscurrently enrolled in the various allied health professions schools,to increase the number of Native American students in medicine andother health professions, and to promote its exposure and recognition on a national level throughout the medical community.Indians into MedicineUniversity of North DakotaSchool of Medicine and Health ScienceP.O. Box 9037, Grand Forks, ND 58202-9037Phone: 701-777-3037 Fax: 701-777-3277Indians into Medicine addresses three major problem areas: (1) toofew health professionals in American Indian communities, (2) toofew American Indian health professionals, and (3) the substandardlevel of health and health care in American Indian communities.F. Asian and Pacific Islander Health OrganizationsNational Asian Women’s Health Organization250 Montgomery Street, Suite 410, San Francisco, CA 94104Phone: 415-989-9747Website: http://www.nawho.orgThe National Asian Women’s Health Organization is dedicated to publichealth advocacy for Asian Americans and empowerment of Asian American women beyond accessing existing opportunities. Programs focus onproviding research data and changing public policy to address the reproductive health status of under-served Asian communities.

The Asian and Pacific Islander American Health Forum942 Market Street, Suite 200, San Francisco, CA 94102Phone: 415-954-9959The Asian and Pacific Islander American Health Forum is a national advocacy organization dedicated to promoting policy, program and research efforts for the improvement of health status of allAsian and Pacific Islander Americans.The Association of Asian Pacific Islander Community HealthOrganizations1440 Broadway, Suite 510, Oakland CA 94612Website: http://www.aapcho.orgThe Association of Asian Pacific Community Health Organizations is anational association representing community health organizations dedicated to improving the health status of Asians and Pacific Islanders in theUnited States and its territories, especially the medically under-served.Chinese American Medical Society281 Edgewood Avenue, Teaneck, NJ 07666Phone: 201-833-1506 Fax: 201-833-8252Website: http://www.camsociety.orgThe Chinese American Medical Society is dedicated to promoting the scientific association of medical professionals of Chinese descent, to advancing Chinese medical knowledge and scientific research, to establishing scholarships and endowments to medical and dental students, and to providingendowments to medical schools and hospitals of good standing.G. Hispanic Health OrganizationsNational Coalition of HispanicHealth and Human Services Organizations1501 Sixteenth Street, NW, Washington, DC 20036Phone: 202-387-5000 Fax: 202-797-4353E-mail: info@cossmho.orgThe National Coalition of Hispanic Health and Human ServicesOrganizations is dedicated to connecting communities and creatingchange to improve the health and well-being of Hispanics in theUnited States, through consumer education and outreach, training programs, policy analysis, development and dissemination, and advocacy.
230 Women and Heart Disease

The National Council of La Raza1111 19th, NW Suite 1000, Washington, DC 20036Website: http://www.nclr.org/The National Council of La Raza, with over 200 formal affiliateswho together serve 37 states, Puerto Rico, and the District of Columbia, was established to reduce poverty and discrimination, andimprove life opportunities for Hispanic Americans.National Association of Hispanic Nurses1501 16th Street, NW, Washington, DC 20006Phone: 202-387-2477 Fax: 202-483-7183Website: http://www.incacorp.com/nahnThe National Association of Hispanic Nurses is the only nationalorganization representing Hispanic registered nurses in the UnitedStates. Its goal is to increase the leadership development of Hispanicnurses and to improve the quality of health of Latino communities.National Hispanic Medical Association1700 17th Street, NW, Suite 405, Washington, DC 20009Phone: 202-265-4297 Fax: 202-234-5468Website: http://home.earthlink.net/~nhma/The National Hispanic Medical Association was organized to address the interests and concerns of 26,000 licensed physicians and1,800 full-time Hispanic medical faculty dedicated to strengtheninghealth service delivery to Hispanic communities across the nation.Interamerican College of Physicians and Surgeons915 Broadway, Suite 1105, New York, NY 10010-7108Phone: 212-777-3642 Fax: 202-505-7984Website: http://www.icps.orgThe Interamerican College of Physicians and Surgeons was foundedto improve the health of the Hispanic community, reduce the incidence of preventable diseases, improve educational and leadershipopportunities for Hispanic physicians, and encourage Hispanicyouths to pursue careers in the healthcare field.

H. Women’s Health OrganNational Women’s Health Network514 10th Street NW, Suite 400Washington, DC 20004Phone: 202-347-1140The National Women’s Health Netwoarm of its organization is a policy-mawomen’s health issues. The other compresearch service for women across the Jacob’s Institute of Women’s Health409 12th Street, SW, Washington, DPhone: 202-863-4990Website: http://www.jiwh.org/indexThe Jacobs Institute of Women’s Health is a cated to advancing knowledge and practiMembers of the Jacobs Institute are a mcare providers, researchers, policy makerNational Women’s Health Resource 120 Albany Street, Suite 820, New Phone: 877-986-9472 Fax: 732-82Website: http://www.healthywomenThe National Women’s Health Resouringhouse for information and resourcprimary goal is to educate healthcare to make intelligent decisions by proveasy-to-reach information and service
Appendix C: Resou

American Medical Women’s Association801 N. Fairfax Street, Suite 400, Alexandria, VA 22314Phone: 703-838-0500 Fax: 703-549-3864E-mail: info@amwa-doc.orgThe American Medical Women’s Association is a national organization of women physicians and medical students, dedicated to promoting women’s health, improving the professional development andpersonal well-being of its members and increasing the influence ofwomen in all aspects of the medical profession.I. Heart Disease OrganizationsAmerican Heart Association, National Center7272 Greenville Avenue, Dallas, TX 75231Website: http://www.americanheart.org/The American Heart Association is a not-for-profit, voluntary healthorganization funded by private contributions. Its mission is to reduce disability and death from cardiovascular diseases and stroke.InterAmerican Heart FoundationAmerican Heart Association, National Center7272 Greenville Avenue, Dallas, TX 75231Phone: 214-706-1218Fax: 214-373-0268 or 972-562-3807Website: http://www.iahf.orgThe goals of the InterAmerican Heart Foundation are to promote anenvironment throughout North, Central and South America and theCaribbean conducive to the prevention of heart diseases and stroke;to facilitate the development and growth of heart foundations; andto foster partnerships between health professionals and other sectors of society including business and government for the accomplishment of its mission.

J. Patient ResourcesNational Heart, Lung, and Blood InstituteNational Institutes of Health, Building 3131 Center Drive, Bethesda, Maryland 20892Website: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htmThe National Heart, Lung, and Blood Institute can supply a wealthof information regarding heart, blood and lung diseases for patients.Resources are available on the internet as well as via telephone anddirect mail.American Heart Association, National Center7272 Greenville Avenue, Dallas, TX 75231Website: http://www.americanheart.org/The American Heart Association offers resources for heart diseasepatients regarding health, fitness and dietary guidelines. Information may be obtained via internet, telephone or direct mail.Centers for Disease Control and Prevention1600 Clifton Road, Atlanta, GA 30033Phone: 404-639-7000Website: http://www.cdc.govThe Centers for Disease Control and Prevention (CDC) is a government agency dedicated to the promotion of health and quality of lifeby preventing and controlling disease, injury, and disability. The CDCwebsite provides information about a variety of health topics including women’s, cardiovascular, and minority health.

Acute myocardial infarction 64African Americans 213 See also BlacksAlabama 44, 48, 78, 88, 194, 196, 198, 200, 202, 204Alaska 29, 40, 48, 56, 61, 71, 82, 90–91, 194,

196, 198, 200, 202, 204, 208-209, 212–213,215-216

Aleutian Islands 208Anchorage 74Denali Borough 208Skagway-Hoonah-Angoon 209Skagway-Yakutat-Angoon 209Yakutat 209Yukon-Koyukuk 208, 209

Alaska Natives 16, 17, 22-24, 28, 33, 39, 40, 48,

71, 74, 91, 93, 95, 97, 99, 101, 119, 121,131, 133, 135, 139, 140, 143, 145, 149, 151,153, 155, 157, 158, 163, 165, 169, 171-172,177, 179, 185, 189, 196, 213 See also American

Indian

Albers Equal Area Projection 29Albuquerque See New MexicoAleutian Islands See Alaska

American Indians 16, 17, 21–24, 33, 39, 40, 71, 74,

88, 90–102, 104, 106, 108, 110, 112, 114,116, 118-122, 124, 126, 128, 130–136, 138-140,142–146, 148-158, 160, 162–166, 168–172, 174,176–180, 182, 184–186, 188-190, 196, 213-214

Anchorage See AlaskaAppalachia 37, 51-52, 58, 72, 82Area Resource File 52, 61, 208–211, 215ARF See Area Resource FileArizona 32, 40, 48, 58, 76, 80, 92, 93, 194, 196,

198, 200, 202, 204, 209

Yuma 209

Arkansas 44, 94-95, 194, 196, 198, 200, 202, 204Asian Americans 16-17, 20–24, 33, 76, 88, 90, 92

94, 96-102, 104–112, 114, 115, 116, 118, 120,122, 124–126, 128–134, 136, 138, 140, 145,149, 153, 155, 161, 165, 167, 177, 179, 183,185, 189, 198, 213-214 See also Pacific Islanders

Atlanta See Georgia

Baltimore See MarylandBehavior 16, 36

behavioral risk factors 36

health 16

Blacks 16, 22-24, 28-29, 31, 33, 39, 44, 78, 88,

90-92, 94-96, 98, 100, 102-104, 106, 108,110, 112, 114, 116-120, 122, 124, 126, 128,130, 132, 134, 136, 138, 140, 142, 144, 146,148, 150, 152, 154, 156-158, 160, 162-164,

166,

168, 170-172, 174, 176, 178, 180, 182, 184,186, 188, 190, 200, 213-214 See also AfricanAmericans

Blood pressure 56, 64, 66Boston 64 See MassachusettsCalifornia 39, 40, 42, 46, 48, 52, 56, 62, 64, 72,

74, 76, 80, 87, 96, 97, 123, 194, 196, 198,200, 202, 204

Los Angeles 40, 44, 46, 66, 74San Diego 64, 80San Francisco 44, 46, 52, 62, 74

Cardiac rehabilitation unit 30, 37, 61, 66, 208, 211Cardiovascular disease 20, 208Cardiovascular disease specialty physicians 37, 62Carson City See NevadaCensus 28, 39, 40, 42, 44, 55, 210, 212-213Chicago See IllinoisChicanas 46 See also Hispanics, Latinas, Puerto Ricans

Cholesterol 66Cleveland See Ohio

Colorado 58, 72, 80, 82, 98-99, 194, 196, 198, 200,

202, 204

Connecticut 87, 100-101, 194, 196, 198, 200, 202, 204Contiguity matrix 215-216Coronary care unit 30, 37, 61, 64, 211County level 28Cylindrical projection 30, 212
234 Women and Heart Disease

Index

Dallas See TexasDeath certificates 71, 74, 76, 78, 80, 87, 211, 214Delaware 102-103, 194, 196, 198, 200, 202, 204Denali Borough See Alaska

Diet 16, 36 See also Weight loss

Distribution See Frequency DistributionDistrict of Columbia 52, 71, 87, 104-105Economic development 51-52Economic resources 17, 30, 36-37, 51-52, 55, 56,

208, 210-211

Elderly women 17, 22, 30, 36-37, 55-56, 58, 212Ethnic group 17, 22-23, 32-33, 37, 39, 48, 55, 71

See also Ethnicity

Ethnicity 17, 28–33, 39, 42, 46, 74, 76, 80, 87-88,

90, 92, 94, 96, 98, 100, 102, 104, 106, 108,110, 112, 114, 116, 118, 120, 122, 124, 126,128, 130, 132, 134, 136, 138, 140, 142, 144,146, 148, 150, 152, 154, 156, 158, 160, 162,164, 166, 168, 170, 172, 174, 176, 178, 180,182, 184, 186, 188, 190, 208, 211, 213-214See also Ethnic group

Exercise 66FIPS codes 208-210Florida 44, 46, 48, 52, 56, 62, 64, 72, 76, 78, 80,

82, 106-107, 194, 196, 198, 200, 202, 204

Miami 42, 46, 66, 80

Frequency distribution 23, 72, 74, 76, 78, 80, 82Geographic variation 72, 74, 76, 78, 80, 82Georgia 44, 48, 72, 78, 82, 108-109, 194, 196, 198,

200, 202, 204

Atlanta 44, 64, 76, 80

Grid format 31Hawaii 23, 29, 30, 42, 56, 58, 71-72, 76, 82, 110,

111, 194, 196, 198, 200, 202, 204, 209, 212-213

Kalawao 209Maui 209

Health insurance 61Health outcomes 16Health promotion 36Heart 16

attack 56, 61, 66

Heart disease mortality 22-23, 28

71-72, 74, 76, 78, 80, 8

Hispanics 16, 20–23, 28, 33, 

87–88, 90, 92–94, 96–112124–125, 126, 128–136, 143–146, 148–156, 158, 174, 176–180, 182-186, 1213–214 See also Latinas, C

Houston See TexasHypertensive heart disease 22ICD See International ClassificatioIdaho 87, 112, 194, 196, 198Illinois 114-115, 194, 196, 198

Chicago 44, 66, 76

Independent cities See VirginiaIndiana 116-117, 194, 196, 19International Classification of Dise

78, 80, 82, 211

Iowa 118-119, 194, 196, 198, Ischemic heart disease 22 See als

rheumatic heart disease

Kalawao See HawaiiKansas 62, 120–121, 194, 196Kentucky 52, 122, 194, 196, Latinas 20, 22–23, 39, 46, 71

See also Hispanics, Chicanas

Latinos 39, 46, 213 See also Hisp

Ricans

Layout 28–33Legend 29, 31–32, 40, 42, 44Living alone 30, 37, 55, 56, 2Los Angeles See also California
Louisiana 44, 124–125, 194, 196, 198, 200, 202,

204

New Orleans 80

Maine 126, 194, 196, 198, 200, 202, 204Map projection 28–30, 32, 208, 212-213Map scale 28, 30, 33, 71, 212-214Maryland 128-129, 194, 196, 198, 200, 202, 204,

208

Baltimore 64, 208

Massachusetts 130-131, 137, 194, 196, 198, 200, 202,

204

Boston 42, 52, 62, 64, 76, 80, 210

Maui See HawaiiMedical care resources 17, 30, 36–37, 61, 211Metro See MetropolitanMetropolitan 42, 44, 46, 51-52, 56, 62, 64, 66, 74,

76, 80 See also Urban

Miami See FloridaMichigan 132-133, 147, 194, 196, 198, 200, 202,

204

Minneapolis See MinnesotaMinnesota 74, 134–135, 194, 196, 198, 200, 202,

204

Minneapolis 76

Mississippi 40, 44, 48, 52, 72, 78, 82, 136, 194,

196, 198, 200, 202, 204

Missouri 138-139, 194, 196, 198, 200, 202, 204, 208

St. Louis 44, 76St. Louis City 208

Mobility limitations 30, 37, 55, 58, 212Montana 40, 62, 74, 140, 195, 197, 199, 201, 203,

205, 210

Yellowstone National Park 210

Native Alaskans See Alaska Natives

Native Americans See American IndiansNebraska 62, 142-143, 195, 197, 199, 201, 203, 205Nevada 72, 78, 82, 144-145, 195, 197, 199, 201,

203, 205, 208

Carson City 208

New Hampshire 71, 87, 146, 195, 197, 199, 201,

203, 205, 211, 214

New Jersey 76, 148-149, 195, 197, 199, 201, 203,

205

New Mexico 40, 46, 48, 58, 72, 74, 78, 80, 82,

113, 150-151, 195, 197, 199, 201, 203, 205

Albuquerque 80

New Orleans See LouisianaNew York 40, 42, 64, 152-153, 195, 197, 199, 201,

203, 205

New York City 29-30, 42, 44, 46, 52, 56, 58, 71,

 74, 76, 80, 87, 154-155

Non-metro See Non-metropolitanNon-metropolitan 39, 40, 44, 62 See also RuralNorth Carolina 40, 44, 72, 74, 82, 156-157, 195,

197, 199, 201, 203, 205

North Dakota 40, 62, 72, 82, 158, 173, 195, 197,

199, 201, 203, 205

Ohio 82, 160-161, 195, 197, 199, 201, 203, 205

Cleveland 76, 80Ohio-Mississippi River Valley 72, 82

Oklahoma 40, 71, 74, 78, 162-163, 195, 197, 199,

201, 203, 205, 211, 214

Oregon 164–165, 195, 197, 199, 201, 203, 205Pacific Islanders 16–17, 21–24, 28, 33, 39, 42, 71,

76, 88, 90, 92, 94, 96, 98, 100, 102, 104,106, 108, 110, 112, 114, 116, 118, 120, 122,124, 126, 128, 130, 132, 134, 136, 138, 140,142, 144, 146, 148, 150, 152, 154, 156, 158,160, 162, 164, 166, 168, 170, 172, 174, 176,178, 180, 182, 184, 186, 188, 190, 198, 213See also Asian Americans

Pacific Northwest 48, 72, 80Pennsylvania 80, 166-167, 195, 197, 199, 201, 203, 205

Pittsburgh 64, 80

Piedmont 72, 82Pittsburgh See Pennsylvania
236 Women and Heart Disease

Index

Population distribution 30-31, 36-37, 39Population weights 215Poverty 16, 36-37, 55, 58, 61Prevention

primary 36secondary 36, 61, 211

Puerto Ricans 46, 213 See also Chicanas, Hispanics,

Latinas

Pulmonary heart disease 22, 64

See also heart, hypertensive, ischemic, rheumatic

Race 20-24, 87-88, 90, 92, 94, 96, 98, 100, 102,

104, 106, 108, 110, 112, 114, 116, 118, 120,122, 124, 126, 128, 130, 132, 134, 136, 138,140, 142, 144, 146, 148, 150, 152, 154, 156,158, 160, 162, 164, 166, 168, 170, 172, 174,176, 178, 180, 182, 184, 186, 188, 190, 213

Rheumatic heart disease 22 See also heart, ischemic,

pulmonary

Rhode Island 168-169, 195, 197, 199, 201, 203, 205Risk factor 16, 36, 56, 58Rural 28, 36, 39, 44, 48, 51-52, 56, 58, 61-62, 66,

74, 80 See also Non-metropolitan

Salt Lake City See Utah

San Antonio See TexasSan Diego See CaliforniaSan Francisco See CaliforniaSeattle See WashingtonSelf-care limitations 37, 55, 58, 212Skagway See AlaskaSkagway-Hoonah-Angoon See AlaskaSkagway-Yakutat-Angoon See Alaska

Social environment 16-17Social isolation 16-17, 30, 36–37, 55–56, 61, 212South Carolina 44, 72, 78, 82, 170-171, 195, 197,

199, 201, 203, 205

South Dakota 40, 62, 72, 74, 82, 172, 195, 197,

199, 201, 203, 205

Spatial

geometry 209, 214smoothing 29, 208, 214

St. Louis See Missouri

St. Louis City See MissouriStress 36Temporal aggregation 28-29Tennessee 52, 174, 195, 197, Texas 48, 52, 56, 76, 78, 80

197, 199, 201, 203, 205

Dallas 42, 76, 80Houston 42, 76, 80San Antonio 46, 64, 76

Thrombolytic drugs 61Tobacco 36Unemployment 30, 37, 52, 211Urban 48, 51, 56, 58, 74, 80 Utah 40, 58, 178-179, 195, 19

Salt Lake City 76

Vermont 180, 195, 197, 199, Virginia 44, 182-183, 195, 197

208, 209-210

Independent cities 208-210Suffolk City 208

Washington 78, 184-185, 195, 

205

Seattle 42, 74

Washington DC See District of CoWeight loss 66West Virginia 186, 195, 197, 1White collar 37, 52, 211Whites 17, 20–24, 48-49, 71, 

96, 98, 100, 102, 104, 114, 116, 118, 120, 122, 132, 134, 136, 138, 140150, 152, 154, 156, 158
168, 170, 172, 174, 176, 178, 180, 182, 184,186, 188, 190, 204

Wisconsin 72, 82, 188–189, 195, 197, 199, 201,

203, 205

Wyoming 190, 195, 197, 199, 201, 203, 205Yakutat See Alaska

Yellowstone National Park See MontanaYukon Koyukuk See Alaska

Yuma See Arizona

Michele L. Casper is an epidemiologist in the Cardiovascular Health Branch of the Centers for Disease Control and Prevention.She received her PhD in epidemiology from the University of North Carolina School of Public Health. Her research focuses primarilyon the geographic, racial and ethnic disparities in cardiovascular disease.Elizabeth Barnett is assistant professor of community medicine and director of the Office for Social Environment and Health Research at West Virginia University. Dr. Barnett received her PhD in epidemiology from the University of North Carolina at ChapelHill. Her research focuses on racial disparities in health and on the impact of uneven development on geographic inequalities inhealth.Joel A. Halverson is research instructor in the Department of Community Medicine and associate director of the Office for SocialEnvironment and Health Research at West Virginia University, with over 15 years research experience. His current research interestsinclude the interrelationship of health outcomes and socioeconomic change, with an emphasis on industrial restructuring anddeindustrialization.Gregory A. Elmes is professor of Geography at West Virginia University where he has taught and performed research for twentyyears. In addition to the applications of geographic information systems (GIS) to issues related to health and resources, Dr. Elmes isinterested in unraveling the complex relationships resulting from the interactions between GIS and society.Valerie E. Braham is an applications programmer and publications designer for the Office for Social Environment and Health Research at West Virginia University. She received her MA in geography from West Virginia University. Her research interests focuson environmental health.Zainal A. Majeed was a graduate research assistant, pursuing his master degree in geography at West Virginia University. He holdsan undergraduate degree in surveying and mapping from a university in Kuala Lampur, Malaysia. He has 15 years of working experience in the surveying, mapping, GIS and remote sensing areas. He is interested in extending his knowledge and expertise in the application of GIS in the context of management and development.Amy S. Bloom is a graduate student in Community Medicine at West Virginia University. She was also a research assistant for theOffice for Social and Environmental Health Research, a division of the Department of Community Medicine. Amy Bloom graduated from Haverford College with a degree in philosophy and after completing her Masters in Public Health plans to pursue a doctorate in bioethics.Shaun Stanley was a web developer for the Office for Social Environment and Health Research at West Virginia University. He received his BA in psychology from West Virginia University. His interests focus on Unix and Windows NT system administration aswell as web design and development.