Sarah Wamala Inst. För Folkhälsovetenskap, Avd för Preventiv medicin
Karolinska Institutet
Abstract
Socioeconomic Status and Cardiovascular Vulnerability in Women:
Psychosocial, Behavioral, and Biological Mediators
Sarah P. Wamala
Inst. För Folkhälsovetenskap, Avd för Preventiv medicin
Karolinska Institutet
Cardiovascular disease (CVD) is the leading cause of death in both men
and
women in the industrialized world, and represents a major health and
economic burden. CVD is the disease which is invariably more frequent
in
men and women of lower than higher socioeconomic status (SES), than
any
other disease. In spite of the overall decline in CHD rates,
socioeconomic
differences persist, and may even be widening, particularly in women.
Women
are more socioeconomically disadvantaged than men, and the
attributable
fraction of low SES for CVD, may be higher in women than in men.
Unfortunately, relatively little is known about the association
between SES
and CVD in women.
The aims of the thesis included studying the association between SES
and
CVD risk in women, and to estimate the relative contribution of social
and
behavioral factors to the socioeconomic disparities in women's CVD.
In
addition the effects of SES and childhood circumstances on CVD
prognosis,
and the associations between SES and physiological risk factors for
CVD
(obesity, atherogenic lipid profile and hemostatic dysfunction) in
women
were studied.
The data used in this thesis were from the Stockholm Female Coronary
Risk
(FemCorRisk) Study. The FemCorRisk study is a population-based
case-control
study which comprises all women aged 65 years or younger who were
admitted
for an acute event of CHD between 1991 and 1994 in any of the coronary
care
units of all hospitals in the greater Stockholm area. Healthy controls
from
the census register were matched with CHD patients with regard to age
and
catchment area.
The results showed that low SES increases vulnerability to CHD in
women.
Low SES (as measured by low educational attainment and low
occupational
status) had a substantial impact on both cardiovascular risk, and
physiological risk factors for CHD (obesity, atherogenic lipid profile
and
hemostatic dysfunction).
After adjustment for age, women with only mandatory school
education (¾9 years) had a two-fold increased risk for CHD as compared
to
women who had attained college/university. Psychosocial stress,
unhealthy
behaviors and poorer physiological risk factor profiles were the
factors
which explained the association between low education and increased
CHD
risk. Of these factors, psychosocial stress and unhealthy behaviors
were
the most important.
Un/semi-skilled workers had a four-fold increased risk for CHD as
compared
to executives/professionals after adjustment for age. Traditional
cardiovascular risk factors and work-related factors however, did not
"fully" explain why women with lower status jobs had an increased risk
of
CHD.
There was no indication of low SES being associated with a poorer
prognosis
of CHD. Adverse childhood circumstances (as measured by short stature)
on
the other hand, showed a strong negative effect on CHD prognosis.
Low SES was also associated with obesity, atherogenic lipid profile
(mainly
low HDL) and hemostatic dysfunction in the healthy control women.
The results in this thesis underline the importance of low SES in the
etiology of CVD in women. The factors explaining the CVD-SES
association in
women range from adverse childhood circumstances, negative
personality,
poor social relations, unhealthy behaviors, poorer biological risk
factor
profiles, to stressors that operate both at work and at home.
The fact that these findings are based on women living in Sweden
raises a
major concern for re-considering the substantial importance of SES in
the
etiology of CVD. In Sweden there is a tradition of economic policies
which
are geared to reducing the gap between the "better-off" and the
"disadvantaged". These economic policies unfortunately, have not been
successful in reducing the socioeconomic inequalities in health. In
fact,
these inequalities are increasing and widening, especially for women.
More
over, the impact of socioeconomic status on health in women, who
occupy the
most vulnerable socioeconomic positions, has been given relatively
little
attention.
Because of the structural positions that women occupy in society, one
of
the challenges for future preventive efforts is to create favorable
conditions for socioeconomically deprived women. Such efforts should
combine both work and non-work related factors.
I Wamala SP, Mittleman AM, Schenck-Gustafsson K, Orth-Gomér K.
Potential explanations for the educational gradient in coronary heart
disease: A population-based case control study of Swedish women.
American J
Public Health 1999;89(3):315-321.
II Wamala SP, Mittleman AM, Horsten M, Schenck-Gustafsson K,
Orth-Gomér K. Job control and the occupational gradient in coronary
heart
disease risk in women.1999: In review.
III Wamala SP, Mittleman AM, Horsten M, Schenck-Gustafsson K,
Orth-Gomér K. Short stature and prognosis of coronary heart disease in
women. J Internal Medicine 1999;245:(in press).
IV Wamala SP, Wolk A, Orth-Gomér K. Determinants of obesity in
relation to socioeconomic status in middle aged Swedish women.
Preventive Medicine 1997;26:734-44.
V Wamala SP, Wolk A, Schenck-Gustafsson K, Orth-Gomér K.
Socioeconomic status and lipid profile in middle aged women in Sweden.
J
Epidemiology Community Health 1997;51(4):400-407.
Erratum: J Epidemiol Community Health 1998;52:340.
VI Wamala SP, Mittleman AM, Horsten M, Eriksson M, Hamsten A, Silveira
A, Schenck-Gustafsson K, Orth-Gomér K. Socioeconomic status and determinants
of hemostatic function in healthy women. Arteriosclerosis Thrombosis Vascular
Biology 1999; (in press).
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