Cardiovascular Disease Among Black Americans: Comparisons Between the U.S. Virgin Islands and the 50 U.S. States

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1 Reserch Articles Crdiovsculr Disese Among Blck Americns: Comprisons Between the U.S. Virgin Islnds nd the 50 U.S. Sttes Hedwig Lee, PhD Kirri N. Kershw, PhD Mrgret T. Hicken, PhD c Cleoptr M. Adou, PhD d Eric S. Willims, MD e Nereid River-O Reilly, BA f Jmes S. Jckson, PhD g ABSTRACT Ojectives. Consistent findings show tht lck Americns hve high rtes of crdiovsculr disese (CVD) nd relted ehviorl risk fctors. Despite this ody of work, studies on lck Americns re generlly limited to the 50 U.S. sttes. We exmined vrition in CVD nd relted risk fctors mong lck Americns y compring those residing within the U.S. Virgin Islnds (USVI) with those residing in the 50 U.S. sttes nd Wshington, D.C. (US 50/DC) nd residing in different regions of the US 50/DC (Northest, Midwest, South, nd West). Methods. Using dt from the 2007 nd 2009 Behviorl Risk Fctor Surveillnce System, we compred CVD nd CVD risk fctor prevlence in non- Hispnic lck people ($20 yers of ge) in the USVI nd US 50/DC, exmining the reltive contriutions of helth ehviors, helth insurnce, nd socioeconomic sttus (SES). Results. Accounting for ge, sex, eduction, helth insurnce, nd helth ehviors, US 50/DC lck Americns were significntly more likely thn USVI lck people to report ever hving stroke nd coronry hert disese, nd to e hypertensive, dietic, or oese. While there ws heterogeneity y region, similr ptterns emerged when compring the USVI with different regions of the US 50/DC. Conclusion. USVI lck people hve lower CVD nd risk fctor prevlence thn US 50/DC lck people. These lower rtes re not explined y differences in helth ehviors or SES. Understnding helth in this popultion my provide importnt informtion on the etiology of rcil/ethnic vrition in helth in the U.S. nd elsewhere, nd highlight relevnt pulic helth policies to reduce rcil/ethnic group disprities. University of Wshington, Deprtment of Sociology, Settle, WA Northwestern University, Feinerg School of Medicine, Deprtment of Preventive Medicine, Chicgo, IL c University of Michign School of Pulic Helth, Deprtment of Epidemiology, Ann Aror, MI d University of Southern Cliforni, Dvis School of Gerontology, Deprtment of Psychology, Los Angeles, CA e University of Wshington Medicl Center, Deprtment of Medicine, Division of Crdiology, Settle, WA f Legislture of the Virgin Islnds, St. Thoms, VI g University of Michign, Institute for Socil Reserch, Ann Aror, MI Address correspondence to: Hedwig Lee, PhD, University of Wshington, Deprtment of Sociology, 211 Svery Hll, Box , Settle, WA ; tel ; fx ; e-mil <hedylee@u.wshington.edu> Assocition of Schools of Pulic Helth 170 Pulic Helth Reports / My June / Volume 128

2 Crdiovsculr Disese Among Blck Americns 171 Consistent findings show tht lck Americns hve the highest rtes of crdiovsculr disese (CVD) compred with ny other rcil/ethnic group in the United Sttes, seriously diminishing life expectncy nd physicl, socil, nd economic well-eing throughout the life course. 1,2 Despite this lrge nd rpidly growing ody of work, studies on lck Americns re lrgely limited to the 50 U.S. sttes nd District of Columi (herefter clled US 50/DC). Importntly, lck Americns lso reside in U.S. territories, nd including these popultions in helth studies my provide more thorough nd nunced picture of the fctors ssocited with helth nd well-eing mong lck Americns. Previous reserch hs shown tht exmining the ssocition etween rce/ethnicity nd helth in sites outside of the US 50/DC llows us to etter understnd how rce nd context intersect to explin helth. 3 5 Prior reserch indictes tht CVD risk fctor prevlence mong individuls of Africn origin vries cross regions of the U.S. nd throughout the world For exmple, in well-known interntionl collortive study on CVD of popultions in the Africn dispor (collected from 1991 to 1995), lrge vritions in the prevlence of dietes, ody mss index (BMI), nd hypertension were found. 6,11 Geogrphic vrition in hypertension nd stroke mong lck people in the US 50/DC hs lso een exmined. 9,16 However, this work hs not een extended to study lck Americns in U.S. territories. We sought to fill n importnt gp in the literture y providing comprtive study of lck Americns in the US 50/DC nd the U.S. Virgin Islnds (USVI). Although the helth of individuls of Africn origin in the US 50/DC is often compred with individuls of Africn origin orn nd/or living outside of U.S. oundries, such s Nigeri nd Jmic, little is known out the helth of lck Americns residing in the USVI. This comprison group might help to refine our understnding of rcil disprities in CVD within the U.S. context. The USVI is U.S. territory locted in the Crien, nd residents re predominntly lck (76.2%) Similr to the US 50/DC, mny USVI lck people re the descendnts of slves. However, unlike the rest of the U.S., slves in the USVI were freed in 1848 following slve revolt (while under the rule of Denmrk), 17 yers prior to emnciption in the U.S. The USVI ws sold to the U.S. y Denmrk in The USVI comprises three min islnds St. Croix, St. Thoms, nd St. John with pproximtely 106,405 residents ccording to 2010 U.S. Census dt. 22 Despite eing U.S. citizens, the USVI popultion nd its helth hve een lrgely overlooked in reserch, s well s in ntionl policy nd pulic helth inititives. In this study, we sought to nswer two questions: (1) How does the CVD prevlence of lck Americns in the US 50/DC compre with tht of lck Americns in the USVI?; nd (2) If there re differences in CVD prevlence, wht re the ehviorl nd sociodemogrphic mechnisms underlying these differences? Specificlly, we exmined the explntory role of helth ehviors, helth insurnce, nd socioeconomic sttus (SES). Our findings my provide some insight into the helth of n understudied popultion tht, while shring rcil designtion nd ntionl identity with lck Americns in the US 50/DC, hs significnt culturl nd historicl differences. Furthermore, compring U.S. popultions tht shre rcil chrcteristics ut not necessrily socioculturl ones my illuminte the role of socil context nd plce in physicl helth sttuses nd their determinnts. METHODS The Behviorl Risk Fctor Surveillnce System (BRFSS) is n nnul stte-sed, popultion-representtive telephone helth survey system of dults living in the US 50/DC, Puerto Rico, Gum, nd the USVI. BRFSS dt from 2007 nd 2009 were comined to ensure tht sufficient numer of USVI prticipnts were included in these nlyses. The Council of Americn Survey nd Reserch Orgniztions medin response rte ws 50.6% (53.3% in the USVI nd rnging from 26.9% 65.4% in the U.S.) in 2007 nd 52.5% (57.8% in the USVI nd rnging from 37.9% 66.9% in the U.S.) in ,24 Further BRFSS detils re reported elsewhere. 25 Of the 62,964 US 50/DC nd 3,005 USVI 2007 nd 2009 self-identified non-hispnic lck BRFSS prticipnts $20 yers of ge, 4,109 (7.0%) US 50/ DC nd 179 (6.0%) USVI prticipnts were excluded for missing dt on one or more helth outcomes or other covrites. Another 4,661 (7.4%) US 50/DC nd 243 (8.1%) USVI prticipnts were excluded for missing dt on eduction, insurnce sttus, or helth ehviors. These exclusions left 54,194 US 50/DC nd 2,583 USVI prticipnts for these nlyses. We used 2007 nd 2009 dt (s opposed to or dt) ecuse hypertensive sttus, one of our CVD outcomes, ws only sked every other yer in the BRFSS. Becuse our questions focused on the helth of non-hispnic lck Americns, we did not include other U.S. territories (i.e., Puerto Rico nd Gum) due to smll smple sizes. We exmined US 50/DC vs. USVI differences in three CVD outcomes (hypertension, stroke, nd

3 172 Reserch Articles coronry hert disese [CHD]) nd two CVD-relted outcomes (oesity [BMI $30 kilogrms per squre meter, clculted from self-reported height nd weight] nd dietes). All outcomes were self-reported. We djusted for seven covrites: ge (continuous), eduction (ctegorized s,high school, high school diplom or generl equivlency diplom [GED], nd.high school), current smoking, recommended physicl ctivity (dichotomized s $20 minutes of vigorous ctivity t lest three times week or $30 minutes of moderte ctivity t lest five times week), hevy lcohol use (men:.2 drinks dy, women:.1 drink dy), recommended fruit nd vegetle consumption ($5 servings dy), nd ny kind of helth insurnce coverge. We first evluted the ge-djusted prevlence of ll vriles nd tested for US 50/DC vs. USVI sttisticl differences using logistic regression. We then exmined US 50/DC vs. USVI differences in the five helth outcomes, sequentilly djusting for the seven covrites. Bsed on previous reserch showing heterogeneity in CVD outcomes mong lck people within the US 50/ DC, 9,16,26 we lso ssessed differences in these outcomes etween lck people living in different regions of the US 50/DC (Northest, Midwest, South, nd West) nd in the USVI. Regions re sed on the U.S. Census definitions. 27 We conducted ll nlyses using SAS version RESULTS USVI lck people reported significntly lower levels of ll CVD nd CVD-relted outcomes thn US 50/ DC lck people (Tle 1). For exmple, CHD nd stroke prevlence were 1.7% nd 1.6%, respectively, for USVI lck people, ut 3.7% nd 4.0%, respectively, for US 50/DC lck people. In ddition, hypertension prevlence ws 29.3% for USVI lck people ut 41.1% mong US 50/DC lck people. Differences were smller ut remined significnt for dietes nd oesity. USVI lck people were more likely thn US 50/DC lck people to lck high school diplom/ GED nd to e without helth insurnce. USVI lck people were more likely thn US 50/DC lck people to consume recommended levels of fruit nd vegetles, nd they were less likely to e current smokers. There were no differences in physicl ctivity or hevy lcohol use etween USVI nd US 50/DC lck people. Findings were similr when we compred US 50/ DC lck people cross different regions with USVI lck people (Tle 2). There were significnt overll differences y U.S. re of residence for ll CVD nd CVD-relted outcomes s well s insurnce sttus nd eduction. One notle difference for helth ehviors ws tht while there ws no significnt difference in physicl ctivity etween USVI nd US 50/DC lck people, we found tht lck people living in the West were sustntilly more likely to report meeting recommended levels of physicl ctivity thn lck people living in the other res of the U.S. (17.9% in the West vs. 10.8% 12.4% in the other regions nd the USVI). After djusting for ge, sex, nd eduction, US 50/ DC lck people were 2.37 (95% confidence intervl [CI] 1.63, 3.43) times s likely to hve CHD compred with USVI lck people (Tle 3). These lower odds for USVI lck people were somewht ttenuted fter djusting for helth ehviors, oesity, hypertension, nd dietes (odds rtio [OR] ; 95% CI 1.14, 2.43), ut the difference remined significnt. As with CHD, US 50/DC lck people were significntly more likely to hve hd stroke compred with USVI lck people (ge-, sex-, nd eduction-djusted OR52.81; 95% CI 1.93, 4.08), nd this difference ws only prtilly Tle 1. Age-djusted prevlence of CVD nd risk fctors for non-hispnic lck dults >20 yers of ge mong U.S. nd USVI residents: Behviorl Risk Fctor Surveillnce System, U.S., 2007 nd 2009 CVD nd risk fctors U.S. (n554,194) USVI (n52,583) CVD outcomes Coronry hert disese Stroke Hypertension CVD-relted outcomes Dietes Oesity CVD risk fctors,high school eduction No helth insurnce Helth ehviors Hevy lcohol use Recommended fruit nd vegetle intke Recommended physicl ctivity Current smoker Prevlence of ll outcomes, with the exception of oesity (clculted from self-reported height nd weight), were sed on self-reported history of dignosis from doctor. Chrcteristics were weighted using weights provided y the Behviorl Risk Fctor Surveillnce System. p,0.05 for the U.S. vs. USVI difference sed on logistic regression model dditionlly djusted for ge CVD 5 crdiovsculr disese USVI 5 U.S. Virgin Islnds

4 Crdiovsculr Disese Among Blck Americns 173 Tle 2. Age-djusted prevlence of CVD nd risk fctors for non-hispnic lck dults >20 yers of ge mong U.S. nd USVI residents, y U.S. re of residence: Behviorl Risk Fctor Surveillnce System, U.S., 2007 nd 2009 U.S. (n554,194) USVI (n52,583) CVD nd risk fctors Northest Midwest South West CVD outcomes Coronry hert disese Stroke Hypertension CVD-relted outcomes Dietes Oesity CVD risk fctors,high school eduction No helth insurnce Helth ehviors Hevy lcohol use Recommended fruit nd vegetle intke Recommended physicl ctivity Current smoker Prevlence of ll outcomes, with the exception of oesity (clculted from self-reported height nd weight), were sed on self-reported history of dignosis from doctor. Chrcteristics were weighted using weights provided y the Behviorl Risk Fctor Surveillnce System. p,0.05 for test of overll ssocition etween U.S. re of residence (Northest, Midwest, South, West, nd USVI) nd ech of the covrites, sed on logistic regression model dditionlly djusted for ge CVD 5 crdiovsculr disese USVI 5 U.S. Virgin Islnds explined y djusting for covrites (fully djusted OR52.13; 95% CI 1.45, 3.12). While the mgnitude of the ssocitions ws weker, USVI lck people were lso significntly less likely to e hypertensive, dietic, or oese compred with US 50/DC lck people fter djusting for ge, sex, nd eduction. These differences were not explined fter djusting for insurnce sttus or helth ehviors. In supplementl nlysis (dt not shown), we lso included interctions etween US 50/DC nd eduction to determine whether socioeconomic ptterning of helth outcomes ws different for US 50/DC compred with USVI lck people, ut none of these interctions were significnt (p.0.05). While there is heterogeneity y region, US 50/DC lck people in ll regions were more likely to hve dverse CVD nd CVD-relted outcomes compred with USVI lck people (Tle 4). In fully djusted models, ORs for CHD compring US 50/DC nd USVI lck people rnged from 1.98 (95% CI 1.14, 3.47) for lck people in the West to 2.53 (95% CI 1.69, 3.77) for lck people in the Midwest. Blck people living in ll regions of the US 50/DC were more thn twice s likely to hve hd stroke compred with USVI lck people. Blck people living in the US 50/ DC were etween 1.50 (West: 95% CI 1.19, 1.88) nd 1.88 (South: 95% CI 1.66, 2.13) times s likely to e hypertensive nd etween 1.19 (Northest: 95% CI 1.03, 1.39) nd 1.45 (South: 95% CI 1.29, 1.64) times s likely to e oese. Blck people living in the South, the Northest, nd the Midwest were significntly more likely to e dietic thn USVI lck people. However, differences etween lck people living in the West nd USVI lck people were not significnt (OR51.29; 95% CI 0.95, 1.74). DISCUSSION The results of this study reveled tht USVI lck people hve etter crdiovsculr helth profiles nd helthier lifestyles thn their US 50/DC counterprts, despite hving lower eduction nd helth insurnce coverge. While there ws some heterogeneity y region, similr ptterns emerged when compring the USVI with different regions of the US 50/DC. In fct, CVD differences were lrgely unchnged fter ccounting for helth ehviors or SES, suggesting tht there my e contextul fctors, oth socil nd physicl, tht influence these differences in helth ehviors nd CVD outcomes mong lck people living in the US 50/DC nd the USVI.

5 174 Reserch Articles The results support the notion tht the lck rce is fluid construct. This notion is criticl considertion given tht eing ctegorized s lck is generlly treted s sttic risk fctor for disese nd given its persistent reltion to poor helth, 29,30 even fter considering SES, helth-cre coverge, nd helth ehviors. This trend in the literture presents significnt chllenges to the implementtion of policies nd interventions tht could improve helth within the diverse lck Americn popultion. 11,31 A growing ody of reserch provides evidence of the contextul nture of rcil-group ctegoriztion, reveling tht the helth of individuls of Africn origin, prticulrly CVD risk fctor prevlence, vries cross regions of the U.S. nd throughout the world These within-group differences mong lck people in different ntionl nd culturl contexts highlight the importnce of sociostructurl determinnts of helth tht cn most effectively e ddressed t locl nd ntionl policy levels to reduce rcil/ethnic helth disprities in the U.S. nd elsewhere nd to improve the helth of lck Americns specificlly. Given the incresingly well-documented helth consequences of rcil discrimintion nd other forms of socil mrginliztion, such s segregtion, one plusile explntion for the present findings is tht the unique sociodemogrphic context of the USVI (i.e., mjority lck t 76.2%) compred with the US 50/DC (only 12.6% lck people 32 ) reduces the incidence of rcilized experiences of chronic stress nd stigm, which my, in turn, differentilly influence helth ehviors nd outcomes The mjority of the USVI popultion is lck, possily mking rcil residentil segregtion nd its consequent socil, economic, nd politicl mrginliztion less prevlent nd experiences with rcil discrimintion less likely. Thus, these stressors ssocited with poor physicl nd mentl helth my e less prevlent nd slient in the USVI thn in the US 50/DC. 35,36 It is lso possile tht the unique sociohistoricl differences in the understnding of rce nd rcil identity differ for USVI lck people. As discussed previously, slvery in the USVI ws olished in 1848 while under Dnish rule, 17 yers prior to the olition of slvery in the continentl U.S. 21 Therefore, USVI lck people my hve longer legcy of ledership positions nd some level of economic freedom thn US 50/DC lck people. In ddition, ecuse the Dnish slve trde ws olished in the erly 19th century (1803), slve helth nd helth cre ecme centrl concern for plnttion owners nd colonil dministrtors in the Dnish West Indies, who were trying to reduce the high mortlity rtes of slves who could not e replced with dditionl slves from Afric. 37 Due to these economic resons, there my hve een more estlished infrstructure serving the sic helth needs of this popultion of lck people tht ws not ville in the continentl U.S. until considerly lter. Reserch compring Crien-orn lck people currently residing in the U.S. with ntive-orn lck Tle 3. Odds rtios of CVD nd CVD-relted outcomes for U.S. vs. USVI (reference group) non-hispnic lck dults: Behviorl Risk Fctor Surveillnce System, U.S., 2007 nd 2009 Outcome Model 1 Model 2 Model 3 c Model 4 Coronry hert disese 2.37 (1.63, 3.43) 2.33 (1.60, 3.38) 2.11 (1.45, 3.07) 1.66 (1.14, 2.43) d Stroke 2.81 (1.93, 4.08) 2.78 (1.91, 4.03) 2.47 (1.66, 3.68) 2.13 (1.45, 3.12) d Hypertension 1.96 (1.74, 2.21) 1.95 (1.73, 2.20) 1.90 (1.68, 2.14) 1.79 (1.58, 2.02) e Dietes 1.63 (1.39, 1.91) 1.61 (1.37, 1.89) 1.73 (1.45, 2.07) 1.61 (1.35, 1.93) e Oesity 1.32 (1.19, 1.47) 1.32 (1.18, 1.47) 1.41 (1.26, 1.58) 1.40 (1.25, 1.57) f Adjusted for ge, sex, nd eduction Adjusted for ge, sex, eduction, nd helth insurnce sttus c Adjusted for ge, sex, eduction, helth insurnce sttus, current smoking, nd hevy lcohol use d Adjusted for ge, sex, eduction, helth insurnce sttus, current smoking, hevy lcohol use, physicl ctivity, fruit/vegetle intke, oesity, hypertension sttus, nd dietes sttus e Adjusted for ge, sex, eduction, helth insurnce sttus, current smoking, hevy lcohol use, physicl ctivity, fruit/vegetle intke, nd oesity f Adjusted for ge, sex, eduction, helth insurnce sttus, current smoking, hevy lcohol use, physicl ctivity, nd fruit/vegetle intke CVD 5 crdiovsculr disese USVI 5 U.S. Virgin Islnds OR 5 odds rtio CI 5 confidence intervl

6 Crdiovsculr Disese Among Blck Americns 175 people lso finds helth dvntge mong lck Crien Americns residing in the U.S. minlnd. 26,38 41 Although issues of selection (e.g., helthier individuls my e more likely to migrte thn less helthy individuls) might explin some of these differences, there re dditionl explntions tht cn e pplied to our study. One importnt exmple is tht Crien lck people who immigrte to the U.S. my hve fewer experiences with rcilized stress nd discrimintion, which hve een linked to poor helth. 36,42,43 As discussed previously, Crien islnds such s the USVI hve profoundly different rcil context thn tht of the U.S. minlnd. Blck people re unlikely to e the minority in ny socil setting. These mjority lck settings fford Crien lck people the opportunities nd the ility to gin culturl Tle 4. Odds rtios of CVD nd CVD-relted outcomes for U.S. vs. USVI non-hispnic lck dults y U.S. region of residence: Behviorl Risk Fctor Surveillnce System, U.S., 2007 nd 2009 Region of residence Model 1 Model 2 Model 3 c Model 4 Coronry hert disese South 2.21 (1.52, 3.22) 2.60 (2.05, 3.31) 2.19 (1.50, 3.19) 2.01 (1.38, 2.93) Northest 2.42 (1.58, 3.71) 2.38 (1.87, 3.04) 2.36 (1.54, 3.61) 2.14 (1.40, 3.27) Midwest 2.88 (1.94, 4.28) 2.40 (1.89, 3.05) 2.83 (1.90, 4.21) 2.53 (1.69, 3.77) West 2.25 (1.29, 3.92) 1.96 (1.54, 2.50) 2.20 (1.27, 3.84) 1.98 (1.14, 3.47) USVI d Stroke South 2.76 (1.90, 4.01) 2.73 (1.88, 3.97) 2.46 (1.65, 3.66) 2.08 (1.42, 3.05) Northest 2.82 (1.79, 4.43) 2.76 (1.76, 4.34) 2.43 (1.50, 3.95) 2.14 (1.34, 3.41) Midwest 3.11 (2.10, 4.61) 3.07 (2.07, 4.55) 2.67 (1.75, 4.07) 2.33 (1.56, 3.49) West 2.50 (1.48, 4.20) 2.45 (1.46, 4.13) 2.17 (1.25, 3.79) 2.03 (1.19, 3.44) USVI d Hypertension South 2.07 (1.83, 2.34) 2.06 (1.82, 2.33) 2.01 (1.77, 2.27) 1.88 (1.66, 2.13) Northest 1.69 (1.44, 1.99) 1.68 (1.42, 1.97) 1.62 (1.38, 1.91) 1.57 (1.33, 1.85) Midwest 2.02 (1.74, 2.33) 2.01 (1.74, 2.32) 1.93 (1.67, 2.23) 1.81 (1.56, 2.10) West 1.66 (1.32, 2.09) 1.65 (1.31, 2.08) 1.59 (1.27, 2.00) 1.50 (1.19, 1.88) USVI e Dietes South 1.70 (1.44, 2.00) 1.68 (1.43, 1.98) 1.80 (1.50, 2.16) 1.67 (1.38, 2.00) Northest 1.64 (1.34, 2.00) 1.60 (1.31, 1.95) 1.73 (1.40, 2.16) 1.66 (1.33, 2.07) Midwest 1.55 (1.29, 1.86) 1.52 (1.27, 1.83) 1.64 (1.34, 2.00) 1.53 (1.24, 1.87) West 1.26 (0.96, 1.67) 1.24 (0.94, 1.63) 1.38 (1.03, 1.86) 1.29 (0.95, 1.74) USVI e Oesity South 1.38 (1.23, 1.54) 1.38 (1.23, 1.54) 1.47 (1.31, 1.65) 1.45 (1.29, 1.64) Northest 1.12 (0.97, 1.30) 1.12 (0.97, 1.29) 1.20 (1.03, 1.40) 1.19 (1.03, 1.39) Midwest 1.35 (1.19, 1.54) 1.35 (1.19, 1.53) 1.45 (1.26, 1.66) 1.44 (1.25, 1.65) West 1.28 (1.03, 1.59) 1.27 (1.02, 1.58) 1.35 (1.08, 1.69) 1.36 (1.09, 1.71) USVI f Adjusted for ge, sex, nd eduction Adjusted for ge, sex, eduction, nd helth insurnce sttus c Adjusted for ge, sex, eduction, helth insurnce sttus, current smoking, nd hevy lcohol use d Adjusted for ge, sex, eduction, helth insurnce sttus, current smoking, hevy lcohol use, physicl ctivity, fruit/vegetle intke, oesity, hypertension sttus, nd dietes sttus e Adjusted for ge, sex, eduction, helth insurnce sttus, current smoking, hevy lcohol use, physicl ctivity, fruit/vegetle intke, nd oesity f Adjusted for ge, sex, eduction, helth insurnce sttus, current smoking, hevy lcohol use, physicl ctivity, nd fruit/vegetle intke CVD 5 crdiovsculr disese USVI 5 U.S. Virgin Islnds OR 5 odds rtio CI 5 confidence intervl

7 176 Reserch Articles nd socil cpitl tht is less ville to ntive-orn US 50/DC lck people nd is protective of helth. 40,43 In ddition to the sociodemogrphic nd sociohistoricl contexts, the culturl nd tropicl climtes in the USVI my fcilitte helth-promoting ctivities nd venues for socil interction nd support, including outdoor ctivities with fmily, neighors, nd friends, s well s vilility nd ffordility of loclly grown fruit nd vegetles for consumption (dry goods nd other grocery store items, however, tend to e more expensive in the USVI thn in the US 50/DC) Dt limittions prohiit explortion of these potentil explntions for the helth dvntges evidenced mong USVI lck people t the present time, mking this n importnt re for future reserch. Disentngling these ptterns will require dditionl dt collection efforts tht include otining detiled socil, demogrphic, nd helth (including iologicl) informtion for this popultion. Our work supports growing literture on the importnce of plce nd context for the helth of lck people nd people of Africn origin in the U.S. nd throughout the world These studies highlight the fluid nture of the reltionship etween rce nd helth, s well s differences in socil, economic, nd environmentl contexts cross geogrphicl spce, complicting questions regrding the nture of policies tht cn improve the helth of Americns of Africn origin. Beyond the sic nd necessry provision of insurnce coverge nd helth-cre ccess, we must consider the role of pulic policies tht re not often directly linked to helth in populr discourse. Exmples of these policies include urn plnning nd zoning lws, which hve direct implictions for ccess to helthy foods, opportunities for physicl ctivity, nd fcilittion of community socil cohesion Additionl reserch ttention nd funding directed t exmining vriility in helth, oth within nd etween ethnic groups, will help to pinpoint relevnt policies nd pulic helth strtegies for reducing disprities nd improving helth mong lck people nd people in other rcil/ethnic minority groups. Limittions This study hd severl limittions. The telephone smpling my hve underrepresented those without regulr ccess to telephones nd those who exclusively use cellulr telephones. In ddition, the BRFSS hs low response rte. The BRFSS dt were weighted to djust for oth selection nd nonresponse, 52 ut lower response rtes my hve incresed the potentil for is. However, ntionl estimtes from stte-ggregted BRFSS dt hve een shown to e comprle with estimtes from the Ntionl Helth Interview Survey nd other surveys with higher response rtes. 53 Another limittion ws tht the dt were self-reported nd, thus, suject to recll nd misclssifiction is. However, our results for U.S. outcomes re comprle with reports using ville clinicl exmintion mesures. 54 Some of our estimtes differ from the only USVI study conducted with mesured helth outcomes, possily due to differences in the study popultion nd design (e.g., dt from tht study cme exclusively from the islnd of St. Croix nd were collected etween 1995 nd 1999). 18,19 The BRFSS does not include dt on ntivity, citizenship, nd cculturtion, which re importnt contextul fctors for CVD nd other relted helth outcomes tht might hve impcted our results. For exmple, lck people in the US 50/DC my include foreign-orn lck people whose helth profile might e etter thn ntive-orn lck people, which could likely underestimte the differences in CVD outcomes etween U.S. lck people nd USVI lck people found in this study. Future reserch in this re should ttempt to ccount for these importnt fctors. Lstly, we could not ccount for potentil differences in lower CVD risk fctor screening rtes in the USVI, which might contriute to the lower prevlence oserved in the present study. It should e noted tht our findings do not diminish considerle helth nd helth-cre needs for the USVI popultion, s levels of underinsurnce re higher for USVI lck people thn for US 50/DC lck people. CONCLUSION We provide one of the first comprisons of helth ehviors, sociodemogrphic fctors, nd CVD nd relted outcomes etween US 50/DC nd USVI non- Hispnic lck people. We highlight the vlue of exmining geogrphic nd culturl vrition in the helth nd well-eing of the U.S. lck popultion. Treting rce s fluid construct tht is lrgely dependent upon context cn help to illuminte how we think out rce s it reltes to helth. Further, understnding helth in the USVI lck popultion my provide importnt informtion on the etiology of rcil/ethnic vrition in helth nd helth disprities in the U.S. nd the Crien. The uthors thnk the Roert Wood Johnson Foundtion Helth & Society Scholrs Progrm for its finncil support, nd the Roert Wood Johnson Senior Helth Policy Progrm, the Ntionl Institute on Minority Helth nd Helth Disprities, the Ntionl Institutes of Helth (NIH), nd the Ntionl Institute on Aging.

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