Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States.
Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States.
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DOI：
10.1371/journal.pmed.0030260
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发表时间：
2006-09
期刊：
影响因子：
15.8
通讯作者：
Ezzati M
中科院分区：
文献类型：
--
作者：
Murray CJ;Kulkarni SC;Michaud C;Tomijima N;Bulzacchelli MT;Iandiorio TJ;Ezzati M
美国种族县组合的最高和最低预期寿命之间的差距超过 35 岁。我们将美国人口的种族和县组合分为八个不同的组，称为“八个美洲”，以探索差异的原因，从而为具体的公共卫生干预政策和计划提供信息。这八个美洲是根据种族、居住县的位置、人口密度、特定种族的县级人均收入和累计凶杀率来定义的。人口和死亡率数据的数据来源是人口普查局和国家卫生统计中心。我们估算了美洲八个国家的预期寿命、特定疾病的死亡风险、健康保险和医疗保健利用率。 2001年，340万高危城市黑人男性和560万亚洲女性之间的预期寿命差距为20.7岁。在性别中，最富裕群体和最贫困群体之间的预期寿命差距为：男性15.4岁（亚洲人与高风险城市黑人），女性12.8岁（亚洲人与低收入南部农村黑人）。美洲八个国家中年轻人（15-44 岁）和中年（45-59 岁）的死亡率差异最大，尤其是男性。这种差异主要是由一些具有明确危险因素的慢性疾病和伤害造成的。 1982年至2001年间，美洲八个国家的预期寿命排序以及优势群体与劣势群体之间的绝对差异基本没有变化。西部美洲原住民和低收入南部农村黑人的自我报告健康计划覆盖率最低。然而，弱势群体的粗略自我报告医疗保健利用率略高。以所有国际标准衡量，八个美洲地区的死亡率差异巨大，每个美洲地区都有数百万或数千万美国人。观察到的预期寿命差异不能仅用种族、收入或基本医疗保健的获取和利用来解释。由于美国目前实际上缺乏旨在减少基本社会经济不平等的政策，因此必须通过减少慢性病和伤害风险因素的公共卫生战略来至少部分解决健康差异。美国的死亡率是按照“种族县”单位计算的，并分为“八个美洲”，各个美洲的预期寿命存在巨大差异。人们很早就认识到，美国人的预期寿命（“预期寿命”）差异巨大。例如，美国白人往往比美国黑人寿命更长，而且美国大约 3,000 个县中的一些县的预期寿命比其他县长得多。然而，对于特定疾病和伤害、危险因素（如烟草、酒精和肥胖）以及获得有效医疗保健的机会差异在“健康不平等”中所起的作用，人们缺乏信息和了解。研究人员希望找到一种方法，根据少数特征（例如居住县的位置、种族和收入）将美国人分为不同的群体，这将有助于证明造成预期寿命差异的最重要因素。研究人员利用美国人口普查局和国家卫生统计中心的数据计算了 1982 年至 2001 年的死亡率。他们记录了居住县以及在那段时期内死亡的所有人员的种族。这使他们能够计算所有 8,221 个“种族县单位”（特定县内特定种族的所有个体）的死亡率。他们尝试了不同的方法，将种族县合并为数量较少且易于管理的组。他们最终确定了“八个美洲”的想法，根据种族县、人口密度、收入和凶杀率进行定义。每个群体都有数百万人或数千万人。研究人员估计了这八组中每一组的预期寿命、特定疾病的死亡风险、拥有健康保险的人数比例以及人们日常接受医疗保健服务的情况。 （研究人员还绘制了美国各县的预期寿命地图。）他们对八个美洲进行了如下描述：亚洲人、北部低收入农村白人、中美洲、阿巴拉契亚和密西西比河流域的低收入白人、西部美洲原住民、中美洲黑人、低收入南部农村黑人和高风险城市黑人。八组人之间的预期寿命存在许多显着差异。例如，2001年，340万高危城市黑人男性和560万亚洲女性之间的预期寿命差距接近21岁。在性别方面，最富裕群体和最贫困群体之间的预期寿命差距，男性为 15.4 岁（亚洲人与高风险城市黑人），女性为 12.8 岁（亚洲人与南方低收入农村黑人）。造成这些变化的主要原因是各种慢性疾病和损伤。 2001 年富裕阶层和最差阶层之间的差距与 1987 年相似。美国的健康不平等现象很大，而且没有任何缩小的迹象。社会和经济改革肯定有助于改变这种状况。与此同时，公共卫生系统还应改进处理慢性病和伤害危险因素的方式，使死亡率最高的群体获得更大的利益。请通过此摘要的在线版本访问这些网站：http://dx.doi.org/10.1371/journal.pmed.0030260。 Gregory Pappas 在本期 PLoS Medicine 上发表的一篇观点文章（DOI：10.1371/journal.pmed.0030357）讨论了这项研究的方法和结果。美国医学生协会讨论了“什么是健康差异？”这一问题。在其网站上 美国国立卫生研究院的“减少并最终消除健康差异的战略研究计划”可以在 NIH 网站上看到 疾病控制和预防中心的少数族裔健康办公室有一个名为“消除种族和民族健康差异”的网页 罗伯特伍德约翰逊基金会也处理了美国的健康不平等问题
The gap between the highest and lowest life expectancies for race-county combinations in the United States is over 35 y. We divided the race-county combinations of the US population into eight distinct groups, referred to as the “eight Americas,” to explore the causes of the disparities that can inform specific public health intervention policies and programs. The eight Americas were defined based on race, location of the county of residence, population density, race-specific county-level per capita income, and cumulative homicide rate. Data sources for population and mortality figures were the Bureau of the Census and the National Center for Health Statistics. We estimated life expectancy, the risk of mortality from specific diseases, health insurance, and health-care utilization for the eight Americas. The life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was 20.7 y in 2001. Within the sexes, the life expectancy gap between the best-off and the worst-off groups was 15.4 y for males (Asians versus high-risk urban blacks) and 12.8 y for females (Asians versus low-income southern rural blacks). Mortality disparities among the eight Americas were largest for young (15–44 y) and middle-aged (45–59 y) adults, especially for men. The disparities were caused primarily by a number of chronic diseases and injuries with well-established risk factors. Between 1982 and 2001, the ordering of life expectancy among the eight Americas and the absolute difference between the advantaged and disadvantaged groups remained largely unchanged. Self-reported health plan coverage was lowest for western Native Americans and low-income southern rural blacks. Crude self-reported health-care utilization, however, was slightly higher for the more disadvantaged populations. Disparities in mortality across the eight Americas, each consisting of millions or tens of millions of Americans, are enormous by all international standards. The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries. US mortality rates were calculated according to "race-county" units and divided into the "eight Americas", across which there are enormous disparities in life expectancy. It has been recognized for a long time that the number of years that people in the United States can expect to live (“life expectancy”) varies enormously. For example, white Americans tend to live longer than black Americans, and life expectancy is much greater in some of the roughly 3,000 counties of the US than it is in others. However, there is a lack of information and understanding on how big a part is played in “health inequalities” by specific diseases and injuries, by risk factors (such as tobacco, alcohol, and obesity), and by variations in access to effective health care. The researchers wanted to find a way of dividing the people of the US into groups based on a small number of characteristics—such as location of county of residence, race, and income—that would help demonstrate the most important factors accounting for differences in life expectancy. The researchers used figures from the US Census Bureau and the National Center for Health Statistics to calculate mortality (death) rates for the years 1982–2001. They took note of the county of residence and of the race of all the people who died during that period of time. This enabled them to calculate the mortality rates for all 8,221 “race-county units” (all of the individuals of a given race in a given county). They experimented with different ways of combining the race-counties into a small and manageable number of groups. They eventually settled on the idea of there being “eight Americas,” defined on the basis of race-county, population density, income, and homicide rate. Each group contains millions or tens of millions of people. For each of the eight groups the researchers estimated life expectancy, the risk of mortality from specific diseases, the proportion of people who had health insurance, and people's routine encounters with health-care services. (The researchers also created maps of life expectancies for the US counties.) They describe their eight Americas as follows: Asians, northland low-income rural whites, Middle America, low-income whites in Appalachia and the Mississippi Valley, western Native Americans, black Middle America, low-income southern rural blacks, and high-risk urban blacks. Many striking differences in life expectancy were found between the eight groups. For example, in 2001, the life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was nearly 21 years. Within the sexes, the life expectancy gap between the best-off and the worst-off groups was 15.4 years for males (Asians versus high-risk urban blacks) and 12.8 years for females (Asians versus low-income rural blacks in the South). The causes of death that were mainly responsible for these variations were various chronic diseases and injury. The gaps between best-off and worst-off were similar in 2001 to what they were in 1987. Health inequalities in the US are large and are showing no sign of reducing. Social and economic reforms would certainly help change the situation. At the same time, the public health system should also improve the way in which it deals with risk factors for chronic diseases and injuries so that groups with the highest death rates receive larger benefits. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030260. A Perspective article by Gregory Pappas in this issue of PLoS Medicine (DOI: 10.1371/journal.pmed.0030357) discusses the methods of this piece of research and the findings The American Medical Students' Association deals with the question “What are Health Disparities?” on its web site The National Institutes of Health's “Strategic Research Plan to Reduce and Ultimately Eliminate Health Disparities” may be seen at the NIH web site The Office of Minority Health at the Centers for Disease Control and Prevention has a Web page called “Eliminating Racial and Ethnic Health Disparities” The issue of health inequalities in the US has also been dealt with by the Robert Wood Johnson Foundation
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