(Stroke. 1995;26:755-760.)
© 1995 American Heart Association, Inc.
Articles |
The Shifting Stroke Belt
Changes in the Geographic Pattern of Stroke Mortality in the United States, 1962 to 1988
From the Cardiovascular Health Studies Branch (M.L.C., R.F.A.) and the Statistics Branch (R.A.P.), Division of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Control and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Ga; and the Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill (S.W., M.K.).
Correspondence to Michele L. Casper, PhD, Cardiovascular Health Studies Branch, Division of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Control and Health Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS K47, Atlanta, GA 30333.
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
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Background and Purpose The factors that contribute to the Stroke Belt—a concentration of high stroke mortality rates in the southeastern United States—remain unidentified. Previous hypotheses that focused on physical properties of the area have not been confirmed. This study describes changes in the locations of areas with the highest rates of stroke mortality and the implications for new hypotheses regarding the Stroke Belt.
Methods We calculated annual, age-adjusted stroke mortality rates for black women, black men, white women, and white men for the years 1962 to 1988 using a three-piece log-linear regression model. Maps were produced with the state economic area (SEA) as the unit of analysis. The baseline Stroke Belt was defined as the area with the largest concentration of high-quintile SEAs in 1962.
Results The concentration of high-rate SEAs tended to shift away from the Piedmont region of the Southeast and toward the Mississippi River valley. For example, whereas among black women in 1962, 72% of SEAs in the baseline Stroke Belt were in the highest quintile, by 1988 this percentage had dropped to 48%. Similar patterns were observed for the other race/sex groups.
Conclusions Temporal changes in the location of areas with the highest stroke mortality rates suggest that new hypotheses for understanding the geographic pattern of stroke mortality should consider temporal trends in a variety of medical, socioeconomic, and behavioral factors.
Key Words: cerebrovascular disorders • epidemiology • geography • mortality
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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For the past several decades, researchers have puzzled over the concentration of high stroke mortality rates in the southeastern United States, a pattern often referred to as the Stroke Belt. This pattern was first reported by Borhani1 for the years 1949 to 1951 and 1959 to 1961 for white men and women, with the state as the unit of analysis. Since then, the Stroke Belt has been observed with the use of a variety of geographic units, race/sex groups, and time periods and for stroke hospitalizations in addition to mortality (Table 1
).2 3 4 5 6 7 8 9 10 11 12 13
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The factors that contribute to the existence of the Stroke Belt remain unidentified. No evidence of a systematic geographic bias in the accuracy of death certificate data has been observed.14 15 Other hypotheses that have not been confirmed examine the physical properties of the Southeast9 (ie, soil deficiency in trace elements such as selenium, softness of the water, climate) and are based on the belief that the Stroke Belt is a fixed geographic entity. The inability of these hypotheses to account for the Stroke Belt phenomenon suggests the need for a new direction of inquiry.
The results from a previous study suggest that the location of areas with the highest rates of stroke mortality for white men and women has changed over time.2 If the location of the high-rate areas has continued to change and the shifting pattern is observed for additional sociodemographic groups, then new hypotheses that examine characteristics that are subject to change over time should be pursued in place of those that have focused on the relatively stable physical properties of the Southeast.
We examined the trends in the geographic pattern of stroke mortality among black men and women and white men and women during the period 1962 to 1988. These data provide important clues for developing new hypotheses that may lead to a better understanding of the Stroke Belt phenomenon and ultimately contribute to prevention of stroke, which is still the third leading cause of death in the United States.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The number of deaths for which stroke was listed as the underlying cause of death was obtained from the National Center for Health Statistics (NCHS) for the years 1962 through 1988. Codes for stroke in the International Classification of Diseases 7th (1962 to 1967), 8th (1968 to 1978), and 9th (1979 to 1988) revisions (codes 330 to 334, 430 to 438, and 430 to 438, respectively) have comparability ratios close to unity; therefore, geographic patterns and the rate of decline in stroke mortality can be compared over the three decades. We obtained population data from the United States Environmental Protection Agency intercensal estimates for 1960 to 1969, the Bureau of the Census for 1970 to 1979, and Demo-Detail16 (a demographic consulting firm) for 1980 to 1990. We calculated directly age-adjusted stroke mortality rates for persons aged 35 to 74 years by race/sex group (black women, black men, white women, and white men). The 1970 US population was used as the standard.
The principles for the categorization of race and ethnicity used by the Bureau of the Census and the NCHS are specified by the Office of Management and Budget.17 The categories were developed to standardize data collection and publication among federal agencies and are explicitly not based on scientific or anthropological considerations. Instead, the categories of race used in this study can be considered to reflect the "intersection of biological, cultural, socioeconomic, political and legal determinants, as well as racism."18
We used the state economic area (SEA) as the unit of analysis. An SEA is defined as either a single metropolitan county or a group of nonmetropolitan counties that have similar social and economic characteristics. The Bureau of the Census designates SEAs based on population size and economic activities of the counties.19
Given the differences in residential patterns between blacks and whites in the United States, there are many SEAs that have no black residents and many SEAs for which the black population is too small to produce stable rates of stroke mortality. To reduce the extremes of variability due to the instability of rates in the smallest populations, rates for black men and black women were calculated for only those SEAs where the population of blacks aged 35 to 84 years was greater than or equal to the smallest 1970 population of whites for the same age group (ie, n=9448). The group aged 35 to 84 years was used for determining the minimum population size because the initial study included groups aged 35 to 74 years and 75 to 84 years. However, the group aged 75 to 84 years was later excluded from the study because of concerns about the accuracy of stroke diagnoses on the death certificate and the meaning of the underlying cause of death for older persons. Stroke mortality rates for black men and black women are presented for the 162 SEAs that met the population size criterion, and the rates for white men and white women are presented for all 507 SEAs of the continental United States.
Annual stroke mortality rates for many SEAs are not stable enough for mapping. An earlier study reduced this instability by calculating average stroke mortality rates for 7-year periods.2 Although this method stabilizes the rates, it may mask variation in the rates over time. Therefore, as an alternative method to reduce the instability, we estimated the annual stroke mortality rates using a piecewise log-linear regression model. National stroke mortality trends for all race and sex groups were observed to be approximately linear within three time periods: 1962 to 1972, 1973 to 1978, and 1979 to 1988. Trends were examined for selected SEAs, and with few exceptions the trends were also linear within the same time periods. The following three-piece log-linear regression model was used to smooth the mortality data for each SEA by race/sex group:
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where Y is year from 0 to 26 (year-62); P1 is 1 if year is 0 through 10, otherwise 0; P2 is 1 if year is 11 through 16, otherwise 0; and P3 is 1 if year is 17 through 26, otherwise 0. To produce a smoothed mortality trend for each SEA over the entire period, the parameters were estimated under the constraints that the linear segments meet at the join points 1972.5 (Y=10.5) and 1978.5 (Y=16.5).
Maps of estimated, age-adjusted stroke mortality rates for 1962, 1975, and 1988 were constructed with the use of the smoothed rates. For each year and race/sex group, SEAs were categorized into deciles and mapped with the following shading scheme: the lowest decile is the lightest shade of gray, the 2nd decile is a slightly darker gray, the middle 6 deciles are medium gray, the 9th decile is dark gray, and the 10th decile is black. On the maps for blacks, the white areas represent the SEAs that did not have large enough black populations to be included in the study.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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For black women, the geographic pattern of stroke mortality from 1962 through 1988 is shown in Fig 1
. In 1962 and 1975
the SEAs in the top two deciles of the distribution of stroke mortality
were concentrated almost exclusively within the southeastern coastal
states. By 1988 the high-decile SEAs were no longer located in the
coastal plain or Piedmont regions of Georgia. Instead, new high-decile
SEAs were observed in the western part of South Carolina and further
westward in Arkansas. As a result, there was no longer a contiguous
concentration of high-rate SEAs along the southeastern coast of the
United States.
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For white men, the shift in the Stroke Belt was even more distinct (Fig 2). In 1962 almost all of the SEAs in Georgia, South
Carolina, North Carolina, and much of Alabama were in the 9th and 10th
deciles of stroke mortality. In contrast, the largest concentration of
SEAs in the lowest deciles were in the western United States. In 1975
the east-west gradient was still very strong; however, the
concentration of high-decile SEAs along the coastal states was less
pronounced, and new high-decile SEAs were observed in the Mississippi
and Ohio River valleys. By 1988 the concentration of high-decile SEAs
in North Carolina, South Carolina, Georgia, and Alabama had
disintegrated considerably, and the concentration of high-decile SEAs
further inland had grown considerably.
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Maps for black men and white women are not presented because of space limitations. The pattern for black men was very similar to that for black women. The pattern for white women was similar to that for white men but somewhat less distinct. In 1962 the concentration of high-decile SEAs along the southeastern coastal plain was narrower for white women than white men, and several high-decile SEAs were located in Minnesota, Wisconsin, and Michigan. In 1975 the concentration of high-decile SEAs in the southeastern coastal plains was broader than in 1962. By 1988 the pattern was more dispersed; high-decile areas were located along the Mississippi and Ohio River valleys and in Nevada.
Data that quantify the temporal changes in the geographic concentration
of SEAs with high stroke mortality rates are presented in Table 2. We defined the area with the largest concentration of
high-quintile SEAs in 1962 (based on visual inspection of the maps) as
the baseline Stroke Belt. This area comprises the 29 SEAs that
constitute South Carolina, Georgia, and Alabama. The percentages of
SEAs in the baseline Stroke Belt that ranked within the highest
quintile of stroke mortality rates are presented for selected years
by race/sex group (Table 2). The quintile rankings are based on the
full distribution of race- and sex-specific rates among all SEAs in the
United States for each year. Over time, the percentage of baseline
Stroke Belt SEAs that were in the highest quintile declined
substantially for each race/sex group. The largest decline—from
82.8% in 1962 to 48.3% in 1988—was observed for white men. The
declines were also substantial for black women and black men. The
smallest amount of change in the concentration of high-quintile SEAs
occurred among white women.
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The observed decline in the percentage of baseline Stroke Belt SEAs
that remained in the highest quintile of stroke mortality rates
indicates a shift in the geographic boundaries of the Stroke Belt but
does not provide information regarding the percentage of the population
that is affected by the changing geographic boundaries. During the
study period, the percentage of the US population within the baseline
Stroke Belt and in the highest-quintile SEAs declined (Table 3). For example, in 1962, 38.5% of black women in the
baseline Stroke Belt lived in high-quintile SEAs, but by 1988 the
percentage had decreased to 23.7%. Thus, both the population burden
and the geographic boundaries of the Stroke Belt shifted over time.
Similar patterns were observed for black men and white men, but for
white women the percentage rose slightly over time.
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The shifting geographic concentration of SEAs with high stroke
mortality rates occurred within the context of declining stroke
mortality rates (Table 4). Black women experienced the
largest percent decline in stroke mortality from 1962 to 1972. During
the period of accelerated declines, 1973 to 1978, the largest decline
was still experienced among black women, although the rate of decline
among white men was very similar. During the period of decelerated
declines, 1979 to 1988, white men experienced the fastest decline in
stroke mortality. The greatest deceleration in declining rates, from
1973-1978 to 1979-1988, occurred among black women. All SEAs
experienced declines in stroke mortality, as evidenced by the downward
shift in the range of stroke mortality rates during the period 1962 to
1988 (Table 5).
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Despite the declines in stroke mortality, however, there was still substantial disparity in the level of stroke mortality among the SEAs. In 1988 the stroke mortality rates in the 95th percentile were approximately two times higher than the rates in the 5th percentile.
Racial differences in the range of stroke mortality rates among the
SEAs persisted throughout the study period (Table 5
). The rates were so
much higher for black women compared with white women that the
distributions between the 5th and 95th percentiles did not overlap for
the years 1962, 1965, 1975, 1985, and 1988. For men, the distributions
overlapped somewhat during the earlier years, but in 1985 and 1988 the
lowest rates for black men were greater than the highest rates for
white men.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The area generally referred to as the Stroke Belt is not a fixed geographic entity. Although the east-west mortality gradient was maintained over the three decades for each of the four race/sex groups in this study, within the South there was substantial change in the geographic pattern of SEAs with high rates of stroke mortality. Whereas in 1962 the SEAs with the highest rates of stroke mortality were concentrated primarily in the Piedmont and coastal regions of South Carolina, Georgia, and Alabama, by 1988 clusters of SEAs with high rates were located along the Mississippi and Ohio River valleys. Further evidence of the shifting Stroke Belt was observed in the declining percentages of baseline Stroke Belt SEAs that ranked within the highest quintile of stroke mortality rates. Previous studies of the Stroke Belt, with the exception of one study,2 were not able to detect this shift in the Stroke Belt for one of two reasons. Either the geographic unit that was used was too large (eg, a state) and masked the changes occurring among the smaller geographic units,1 6 7 11 13 or a long enough time period was not included to observe changes in a chronic disease such as stroke.3 4 5 8 9 10
The unequal residential distribution of blacks and whites in the United States makes it difficult to compare the geographic variation in stroke mortality between blacks and whites nationwide. However, since the concentration of black women and men is greatest in the southern and northeastern states, it is possible to compare the changing geographic pattern in stroke mortality in these areas.
The observation that the Stroke Belt is shifting suggests a new direction of inquiry into the geographic pattern of high stroke mortality rates in the Southeast. Previous hypotheses that focus on conditions of the physical environment9 (ie, concentration of selenium and other trace elements, softness of the water, climate) seem unlikely given the changing geographic pattern of stroke mortality. Instead it may be more appropriate to identify changes in relevant characteristics of communities that are consistent with the changing geographic variation of stroke mortality. For example, changes in circumstances such as the accuracy of diagnosing and reporting stroke, the level of social and economic conditions, the prevalence of risk factors for stroke, the direction of migration patterns, the availability of prevention activities, and the quality of medical care are among the types of factors that may have contributed to the observed shift in the Stroke Belt. Since these factors are interrelated characteristics of communities, the goal is to understand how these types of characteristics, along with others, may have interacted to result in the changing geographic pattern of stroke mortality.
Accuracy in the reporting of stroke as the cause of death may vary depending on the availability of expensive equipment, as well as the expertise and/or diagnostic preferences of the certifying physician or coroner.20 21 22 Although previous studies have shown no systematic geographic bias in the accuracy of reporting stroke mortality,13 14 the possibility that temporal changes in the certification of stroke mortality may vary geographically has not been examined. Use of new technology for diagnosing stroke is unlikely to have been uniform among the SEAs, but predicting the direction of any bias resulting from differential access is difficult because technical advances increase both the ability to rule out and the ability to confirm the diagnosis of stroke.
Studies of the changing economic conditions in the United States have documented uneven patterns of social and economic development in the southern region.23 24 25 26 27 Historically, the South has been an underdeveloped region. Profits from the raw material and cheap labor in the South were accrued primarily in the Northeast.26 27 During the past several decades, however, economic centers have developed within the South. Instead of the profits leaving the region altogether, some of the profits are now being received in these economic centers while the other, more rural, areas of the South remain underdeveloped.23 24 25 26 Previous studies have indicated that mortality rates for cardiovascular disease are lower in areas with greater access to social and economic resources28 29 30 ; thus, the changing geographic variation in stroke mortality may reflect geographic changes in the concentration of economic resources. The areas within the baseline Stroke Belt area that were in the highest quintile in 1962 but dropped into the lower quintiles over time may be those in which economic conditions improved. Simultaneously, the new areas with the highest stroke mortality rates may be areas that became increasingly economically underdeveloped. The impact of economic development and underdevelopment patterns on stroke mortality may occur through a variety of the mechanisms that are discussed here, such as biomedical and behavioral risk factors, medical and preventive care, and migration patterns.
Geographic variation in the prevalence of risk factors for stroke may also have changed during this time period. Secular trends in the prevalence of cigarette smoking, dietary factors, hypertension, physical inactivity, and other factors are likely to have varied among the SEAs, resulting in a changing geographic pattern of risk factor profiles. Although no data on these factors are available for SEAs, variations in the temporal trends in these factors have been reported for demographic subgroups in the United States.31 32 33 34 35
Emigration from the Stroke Belt area into the western and northern edges of the South, or immigration from regions of the country with low stroke mortality rates into parts of the Stroke Belt, may have contributed to the changes in the geographic distribution of stroke mortality. Migration patterns have the potential to influence rates of stroke mortality by changing risk factor profiles of the communities and/or changing socioeconomic conditions.36 37 38
Changes in medical care and prevention activities may also have differed among the southern SEAs. Such changes could have been related to changes in social and economic conditions and may have been reflected in the prevalence of risk factors for stroke.
There has been a downward shift in the range of stroke mortality rates
among the SEAs over time. By 1988 the highest rate was lower than the
lowest rate observed in 1962 (Table 5). However, despite the declines
in stroke mortality among all SEAs, in 1988 there was still substantial
geographic inequality in the level of stroke mortality. For example, in
1988 the rates in the 95th percentile were approximately two times
higher than those in the 5th percentile. The rate ratios were larger
for blacks than whites, indicating greater geographic variation in the
level of stroke among SEAs for blacks than for whites.
The racial differences in the level and range of stroke mortality rates emphasize the well-documented pattern of excess stroke mortality among blacks compared with whites in the United States.39 40 Racial inequalities in stroke mortality persisted within the context of changing geographic patterns of stroke mortality.
The observation that the Stroke Belt is a changing phenomenon rather than one that is static suggests that new hypotheses should be pursued to understand the geographic pattern of stroke mortality in the United States. New hypotheses should encompass the temporal trends in a variety of medical, socioeconomic, and behavioral conditions that may be occurring differentially within the United States.
Received October 24, 1994; revision received February 14, 1995; accepted February 14, 1995.
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T. O. Obisesan, C. M. Vargas, and R. F. Gillum Geographic Variation in Stroke Risk in the United States : Region, Urbanization, and Hypertension in the Third National Health and Nutrition Examination Survey Stroke, January 1, 2000; 31(1): 19 - 25. [Abstract] [Full Text] [PDF]
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R. F. Gillum Stroke Mortality in Blacks : Disturbing Trends Stroke, August 1, 1999; 30(8): 1711 - 1715. [Abstract] [Full Text] [PDF]
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D. T. Lackland, D. L. Bachman, T. D. Carter, D. L. Barker, S. Timms, and H. Kohli The Geographic Variation in Stroke Incidence in Two Areas of the Southeastern Stroke Belt : The Anderson and Pee Dee Stroke Study Stroke, October 1, 1998; 29(10): 2061 - 2068. [Abstract] [Full Text] [PDF]
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C. I. Kiefe, O. D. Williams, D. E. Bild, C. E. Lewis, J. E. Hilner, and A. Oberman Regional Disparities in the Incidence of Elevated Blood Pressure Among Young Adults : The CARDIA Study Circulation, August 19, 1997; 96(4): 1082 - 1088. [Abstract] [Full Text]
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Z.-S. Huang, T.-L. Chiang, and T.-K. Lee Stroke Prevalence in Taiwan : Findings From the 1994 National Health Interview Survey Stroke, August 1, 1997; 28(8): 1579 - 1584. [Abstract] [Full Text]
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L. W. Pickle, M. Mungiole, and R. F. Gillum Geographic Variation in Stroke Mortality in Blacks and Whites in the United States Stroke, August 1, 1997; 28(8): 1639 - 1647. [Abstract] [Full Text]
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G. Howard, R. Anderson, N. J. Johnson, P. Sorlie, G. Russell, and V. J. Howard Evaluation of Social Status as a Contributing Factor to the Stroke Belt Region of the United States Stroke, May 1, 1997; 28(5): 936 - 940. [Abstract] [Full Text]
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G. Howard and V. J. Howard The End of the Stroke Belt? : It May Be Too Early to Declare Victory! Stroke, July 1, 1995; 26(7): 1150 - 1152. [Full Text]
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