Racial/Ethnic Health Disparities in South Carolina and the Role of Rural Locality and Educational Attainment.

ABSTRACT

Background. The prevalence of selected health indicators were compared among the Catawba Indians, African Americans, and whites in South Carolina, considering the possible role of rural locality and education.

Methods. Catawba members were respondents of a 1998 survey (N = 808). Other South Carolina residents were respondents of the 1995-1997 Behavioral Risk Factor Survey (4,150 whites and 1,413 African Americans). Prevalence of cardiovascular disease, diabetes, hypertension, overweight, poor health, smoking, physical activity, and poor diet were compared among the racial/ethnic groups. Logistic regression analyses were conducted within strata of urban/rural locality and education to determine whether these factors were associated with the adverse health indicators.

Results. Both Catawba and African Americans had higher prevalence of diabetes, hypertension, overweight, poor health, physical inactivity, and poor diet than whites. In addition, prevalence of diabetes, poor health, smoking, and poor diet were higher among the Catawba than among African Americans. Restricting the analyses to comparisons within urban/rural locality had little effect, whereas restricting the analyses to comparisons by education level eliminated many of the disparities among those with low education.

Conclusions. Prevalence of chronic disease and adverse health behavior are higher among the Catawba than among other residents of South Carolina, especially compared with white residents.

A KEY GOAL of Healthy People 2010 is the elimination of health disparities that currently exist in the United States by race/ethnicity, rural locality, education/income, sex, disabilities, arid sexual orientation. [1] Compared with non-Hispanic whites, Native Americans and African Americans have higher rates of morbidity and mortality for many chronic conditions. It is known that inequalities in income and education underlie many health disparities. [1] Low educational attainment is associated with increased risk of cardiovascular disease among both men and women in the United States and other industrialized countries. [2-4] Compounding the issue, a disproportionate number of economically disadvantaged people live in rural localities where health is often compromised as compared with more urban areas. [5-7]

South Carolina is a primarily rural state, 32 of its 46 counties being classified as such by the US Census Bureau. [8] More than 1 million residents of the state are African American (approximately 31% of the population). South Carolina is also home of the Catawba Indian Nation (approximately 2,000 members), which consists of a 740 acre reservation near the North Carolina border. Several studies have compared health indicators of African Americans and whites in the same state, yet relatively few published studies have compared the health of Native and non-Native populations within the same state, and none in southeastern states. The limited research that exists indicates that Native Americans have higher rates of disease burden. [9-11] One possible explanation of health disparities between Native and non-Native populations may be the relatively lower educational attainment level of Native Americans and the rural environment in which many of them live. Only 8.9% of Native Americans have a college degree compa red with 20.3% for all races in the United States, [12] and one third live on reservations or historic trust lands. [13]

The purpose of this investigation was to compare the prevalence of self-reported cardiovascular disease (CVD), diabetes, hypertension, overweight, and adverse health behavior (current smoking, physical inactivity, and poor diet) of members of the Catawba Indian Nation with residents of South Carolina, both African American and white. A secondary purpose was to examine the possible role of urban versus rural residence, or low versus high educational attainment, in explaining potential differences in prevalence estimates among the racial/ethnic groups.

METHODS

Catawba Diabetes and Health Survey

The Catawba Diabetes and Health Survey (CDHS) was a population-based survey conducted in the spring of 1998. Eligible participants included Catawba tribal members, aged 18 years and older, living in South Carolina and six nearby counties of North Carolina (N = 1,012). The six counties in North Carolina are those eligible for health care services provided by the Catawba Indian Nation in accordance with the federal settlement agreement of 1993. Urban and rural status was assigned by ZIP code. Individuals were excluded from the list of eligible participants if they were institutionalized (n = 10) or deemed unable to comprehend the survey (n = 2). Individuals who no longer lived in the study area (n = 45) or were deceased (n = 3) were identified and removed from the list, leaving a final sampling frame of 952 individuals.

The study protocol was approved by the Ethics Committee of the University of South Carolina's School of Public Health and by the Catawba Indian Nation Executive Committee. Individuals were asked to provide verbal consent before participating in the study. Of the 952 eligible participants, 808 agreed to participate (84.7% response rate), including 155 surveys completed by surrogate responders. The main reason for nonresponse was "unable to locate" (n = 116). Study protocol dictated that surrogate responders were not asked questions pertaining to perceived health or health-related behavior; hence, the sample size for related analyses included 650 with complete data.

The CDHS instrument was designed to assess demographic variables and self-report of heart attack, stroke, diabetes, hypertension, height and weight, and perceived health status, as well as health-related behavior, including cigarette smoking, physical activity or inactivity, and dietary behavior of fruit and vegetable consumption. All surveys were conducted by a telephone (n = 642) or an in-person interview (n = 166) by a trained, elder member of the Catawba Indian Nation. Survey data were monitored weekly, and clarifications or corrections were made as needed.

South Carolina Behavioral Risk Factor Surveillance System 

For this report, data were pooled from the 1995-1997 South Carolina BRESS (SC-BRFSS) to obtain an adequate sample size (N = 5,796) for subgroup comparison with the Catawba sample. The BRESS uses random-digit dialing techniques to provide state-specific estimates of health behavior related to leading causes of death in the United States. [14] The SC-BRFSS is conducted each year by the South Carolina Department of Health and Environmental Control in cooperation with the Centers for Disease Control and Prevention. The same disease and health-related behavior items were assessed in the CDHS as the SC-BRFSS. These variables, which will be defined later, included heart attack, stroke, diabetes, hypertension, height and weight, perceived health status, smoking, physical activity, and frequency of fruit and vegetable consumption.

The BRFSS data were weighted to represent the age, sex, and race-specific characteristics of the state. Respondents were adults, aged 18 years and older, from randomly selected households in South Carolina. Urban or rural status was defined at the county level. Respondents from counties in which at least 50% of the population resided in towns or cities with at least 25,000 persons were classified as urban as defined by the US Census Bureau. Fourteen counties were defined as urban according to the 1990 Census in South Carolina. [5] The remaining 32 counties were classified as rural. Approximately 30% of the respondents who reported their race/ethnicity were 570 African Americans in rural counties and 839 in urban counties.

Study Variable Definitions

Self-report of CVD was defined by an affirmative response to one or both questions regarding past occurrence of heart attack or stroke. Self-report of diabetes (excluding cases of gestational diabetes) was assessed by the question, "Has a doctor or nurse ever said that you have diabetes?" Self-report of hypertension was assessed by the question, "Has a doctor or nurse ever said that you have high blood pressure?" Overweight was calculated from self-reported height and weight. A body mass index (BMI) of [greater than or equal to]25 kg/[m.sup.2] was classified as overweight. [15] Perceived health status was assessed by the question, "In general, would you say your health is excellent, very good, good, fair, or poor?" Fair and poor responses were pooled to define perceived poor health.

Smoking status for the CDHS was assessed by two questions: (1) "Have you smoked 100 cigarettes in your life?" (2) "Do you smoke now?" An affirmative response to both was classified as a current smoker. For the SC-BRFSS, current smoking was defined as having smoked 100 cigarettes in one's lifetime and smoking on all days or most days in the past 30 days. Physical activity was assessed with two questions for the CDHS. (1) "How often do you participate in vigorous activity?" Answer choices included rarely or never, 1 to 3 times per month, one time per week, 2 to 4 times per week, or 5 or more times per week. Rarely to never participating in vigorous activity on this scale has been shown to be correlated with increased incidence of type 2 diabetes. [16] (2) "How many minutes per day do you spend engaged in moderate activity?" Answer choices included less than 15 minutes, 15 to 30 minutes, 30 to 60 minutes, 1 to 4 hours, or more than 4 hours per day. Rarely or never participating in vigorous activity and particip ating in less than 30 minutes per day of moderate activity was classified as physical inactivity for the CDHS. Physical inactivity for the SC-BRFSS was defined as not having participated in any moderate or vigorous leisure time physical activity in the past 2 weeks. Fruit and vegetable consumption for both surveys was assessed with six similar survey items addressing intake of fruits, fruit juices, and vegetables, [17] and these survey items have been used successfully in other community-level dietary assessments. [18] Number of servings of fruits and vegetables per day was calculated, and reported consumption of less than five servings per day was defined as poor diet or not meeting fruit and vegetable recommendation.

Educational attainment was used as a surrogate for socioeconomic status (SES). Educational attainment has been shown to be a reasonable and reliable indicator of SES. [4,19] Having less than a high school education was defined as "low education," and high school or greater education was defined as "high education" for these analyses.

Statistical Analyses

Estimated prevalence for CVD, diabetes, hypertension, overweight, perceived poor health status, and three health behaviors were calculated for the Catawba using direct age-adjustment with the 1998 South Carolina estimated census as the standard population. The proportion of SC-BRFSS respondents classified as having a chronic disease or adverse health-related behavior was estimated using SUDAAN (Research Triangle Park, NC) to account for the complex sampling design of the BRFSS. The SC-BRFSS data were weighted to the age-distribution of the South Carolina population each year of administration; hence, the data were not further age-adjusted.

Pearson chi-square analyses were used to detect significant differences in proportions among the Catawba, African Americans, and whites overall in South Carolina. Subgroup analyses were repeated among the three racial/ethnic groups restricting the comparisons by urban locality or rural locality, and then by low education (less than high school) or high education. Finally, logistic regression models, adjusted for age, were used to test whether urban/rural locality or educational attainment was associated with CVD, diabetes, hypertension, overweight, perceived poor health status, or any of the related health behaviors within each of the three racial/ethnic groups.

RESULTS

Demographic characteristics of the 1998 CDHS and the 1995-1997 SC-BRFSS respondents are shown in Table 1. The Catawba were younger than either African Americans or whites; a greater percentage of the Catawba were men, did not finish high school, and lived rurally. Table 1 also shows the estimated prevalence of self-reported CVD, diabetes, hypertension, overweight, and health behavior among Catawba, African American and white South Carolina residents. Catawba reported higher prevalence of diabetes (13.3%), perceived poor health status (28.3%), and poor diet (98.3%) than either African Americans or whites (P [less than] .01). African Americans reported the highest prevalence of hypertension (33.8%) and overweight (66.5%) (though estimates did not differ significantly from those of the Catawba) and the lowest prevalence of current tobacco use (20.0%) (P [less than] .01 for both Catawba and whites). Whites reported lower prevalence of diabetes, hypertension, overweight, perceived poor heath status, physical inac tivity, and poor diet than either Catawba or African Americans (P [less than] .01).

Table 2 shows the estimated prevalence of self-reported CVD, diabetes, hypertension, overweight, and adverse health behavior separately for urban and rural Catawba, African Americans, and whites. Restricting the analyses to rural counties, it is estimated that the African Americans have the lowest prevalence of CVD (4.6%) and current tobacco use (17.4%), yet the highest prevalence of overweight (71.3%) (P [less than] .01 for both Catawba and white comparisons). The whites living in rural counties reported the lowest prevalence of perceived poor health status (18.0%) and poor diet (72.4%) (P [less than] .01 for both Catawba and African American comparisons). When analyses are restricted to urban counties, the Catawba reported the highest prevalence of diabetes (19.6%), perceived poor health status (34.6%), and poor diet (96.4%) (P[less than] .01 for both African American and white comparisons). Several more significant differences exist, with the whites having the lowest prevalence estimates of adverse health indicators in both urban and rural counties.

Table 2 also shows age-adjusted odds ratios of adverse health indicators for urban/rural status among the Catawba, African American, and white residents of South Carolina. Across the racial/ethnic groups, living in a rural locality appeared to be most detrimental to whites. White residents of rural counties were at increased odds of having hypertension, being overweight, having poor health, and being physically inactive compared with white residents of urban counties. Living rurally increased the odds of being overweight and having a poor diet for African Americans and increased the odds of smoking for the Catawba. Catawba in urban counties, on the other hand, were more likely to report having diabetes than Catawba in rural counties.

Table 3 shows the estimated prevalence of self-reported CVD, diabetes, hypertension, overweight, and adverse health behavior separately by education level (less than high school versus high school or higher) for the Catawba, African Americans, and whites. There were no significant differences across the three racial/ethnic groups for CVD, perceived poor health status, or physical inactivity among those with less than a high school education. The Catawba with less than a high school education had the highest prevalence of smoking (45.8%) and poor diet (98.5%) (P [less than] .01 for African American and white comparisons) and higher prevalence of diabetes compared with whites (13.2%). African Americans with less than a high school education had the highest prevalence of hypertension (51.2%) and the lowest prevalence of current smoking (23.0%) (P [less than] .01 for Catawba and white comparisons). Restricting the analyses to those with at least a high school education reveals that both Catawba and African Americ ans have higher prevalence of adverse health outcome and behavior (other than current smoking) compared with whites.

Table 3 also shows age-adjusted odds ratios of adverse health indicators for high/low education levels among the Catawba, African American, and white residents of South Carolina. Across the three racial/ethnic groups, having less than a high school education was associated with increased odds of reporting perceived poor health status (OR = 2.6 to 3.9). Low education was also associated with smoking for Catawba and whites (OR = 3.8 and 2.3, respectively) and physical inactivity for African Americans (OR = 1.52). There were no other significant associations with education for the Catawba or African Americans. Yet, among white residents, having less than a high school education was also associated with CVD (OR = 2.0), hypertension (OR = 1.6), and poor diet (OR = 1.6)

DISCUSSION

Health disparities are evident in South Carolina by race/ethnicity. Both Catawba Indians and African Americans have a higher prevalence of adverse health outcome and adverse health-related behavior than whites. Interestingly, the Catawba also have a higher prevalence of adverse health indicators (diabetes, perceived poor health, smoking, and poor diet) than African Americans.

Other studies have shown that Native Americans tend to have disproportionate health problems compared with non-Natives in the same state, though none have compared with African Americans. In the state of New York (exclusive of New York City), the Seneca Indians had higher standardized mortality ratios (SMR) than the rest of the population. [9] Rates of death among the Seneca were significantly higher than those in the New York population for deaths due to diabetes (SMR = 404), atherosclerosis (SMR = 298), and many other conditions? Mortality data from the Strong Heart Study indicate that when compared with the rate among the population of the state in which the participants lived (Oklahoma, Arizona, North Dakota, and South Dakota), average annual, all-cause mortality rates were generally higher among the Native Americans. [10] Four tribes in Washington state collaborated with the Indian Health Service area office and the Centers for Disease Control and Prevention to conduct the BRFSS survey among a random sa mple of Native Americans. [11] The Native Americans reported current smoking at a higher rate than the non-Natives (45.0% of men and 54.2% of women compared with 33.3% and 29.7%, respectively); and a greater percentage was determined to be overweight as defined by a BMI [greater than or equal to]27.3 kg/[m.sup.2] for women and [greater than or equal to]27.8 kg/[m.sup.2] for men (45.0% of men and 43.4% of women compared with 21.9% and 29.1%, respectively). [11] Similar studies had not been conducted among Native American and non-Native American populations in the Southeast.

It might be expected that low educational attainment would explain differences in prevalence estimates among the racial/ethnic groups in South Carolina. This hypothesis was only partially supported by these results; it appears that race/ethnicity has a differential effect within education level. African American residents with low educational attainment have higher prevalence of self-reported hypertension than the Catawba (51.2%). The Catawba have the highest prevalence of smoking (45.8%) and poor diet (98.5%) and a higher prevalence of diabetes (13.2%) than whites only. Most of the other significant racial/ethnic differences were eliminated by restricting the analyses to adults with less than a high school education. On the other hand, differences remain among the high education group, especially in comparison to whites with at least a high school education.

It appears that education level and urban/rural locality have the largest impact among the white residents of the state and not among the Catawba or the African Americans. Other studies have shown that low education and low SES are associated with increased rates of obesity [20] and physical inactivity. [21] It was recently shown that low SES was associated with physical inactivity, smoking, and hypertension in a predominantly African American, poor urban community. [22] Men and women with low educational attainment were 10 times more likely to have 3 or more cardiovascular risk factors than those with a higher education level. [22] Other research supports a differential effect of the SES on mortality; Hayward et al [23] found the SES gradient in mortality to be greater among urban residents than rural residents and longevity to be associated with high SES in urban areas.

In the present study, it does not appear that education, as a marker for SES, explains adverse health indicators among the Catawba or the African Americans as well as it does for the whites. Based on a review of the literature, it appears that "Racism is an added burden for non-dominant populations."[24] Community-level factors that may be related to racism, rather than individual-level factors, may help to explain the high prevalence of diabetes, overweight, and related risk factors among the Catawba and African Americans. Using data from the Atherosclerosis Risk in Communities Study, Diez-Roux et al [25] found that living in deprived neighborhoods was associated with increased prevalence of coronary artery disease and its risk factors. Indeed, 74.3% of Catawba households surveyed in a previous questionnaire in 1996 were defined as low income (iez, income below 50% of median in the county where the reservation is located) [26] Access to health care or quality of care has also been posed as an explanatory fac tor in the health disparities between rich and poor or among racial and ethnic groups. [27-29] Yet, a recent review article cites several contrary findings, such as the fact that in United Kingdom, where there is universal access to care, SES is still an important predictor of health. [90]

At least two limitations to this study should be mentioned. Rural status for the Catawba respondents was assigned by ZIP code, while rural status for the BRFSS respondents was assigned at the county level, leaving open the potential for misclassification of individuals living in more urban areas of rural counties. Second, the measurement of SES and sociocultural or demographic factors was restricted to educational attainment level assessed only by self-report. Many other markers can define related characteristics, but these were not assessed in the CDHS. However, education is easy to ascertain and has the advantage of being a stable measure, [3,4] and it has been shown to be a reasonable indicator of SES. [19] Unlike income as a proxy for SES, education is not likely to be affected by disease or poor health in an adult population. [31] The percentage of SXBRFSS respondents with less than a high school education may be underestimated because of response bias in telephone survey methodology. The Catawba surve y was administered primarily via telephone, but some in-person interviews were conducted among those without a telephone. It is documented that Native Americans without telephones are more likely to be of lower SES and higher risk of disease than those with telephones. [32] Similar individuals were potentially missed in the rest of South Carolina by the BRFSS.

In summary, the prevalence estimates of diabetes, perceived poor health, and poor diet are higher among Catawba adults than residents of South Carolina, both African American and white. Differences are more numerous and more pronounced between Catawba and white residents than between Catawba and African Americans. Neither the rural setting in which participants lived nor their educational attainment appeared to fully explain the difference in prevalence estimates between the Catawba and the non-Catawba populations. Further studies are needed to elucidate the etiologic factors that may originate in social or cultural realms underlying the health disparities of the Catawba and the African Americans in South Carolina, without overlooking the effects of discrimination in the state.

Acknowledgments. We thank the Catawba Indian Nation Executive Committee for their support of this project, and the people of the Nation for voluntarily participating in the survey. The Executive Committee unanimously consented to the publication of these data. Special recognition goes to Florence H. Wade for conducting the interviews.

References

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TABLE 1.
Demographic Characteristics and Estimated Prevalence Rates a
(per 100) of Chronic Disease and Selected Risk Factors of the Catawba
Indian Nation Compared With Whites and African Americans b in South
Carolina
                                    CDHS Survey
                                      Catawba
                                     (N = 808)
Age (mean [+ or -] SD)           38.1 [+ or -] 15.4
Female (%)                              50.2
Less than high school (%)               40.1
Rural locality b (%)                    86.9
Cardiovascular disease c                 9.2
Diabetes                                13.3
Hypertension                            29.6
Overweight                              63.4
Perceived poor health status            28.3
Current smoker                          30.2
Physically inactive                     42.8
Fruit and vegetable consumption         98.3
  ([less than]5 servings daily)
                                   SC-BRFSS Survey
                                   African American
                                     (N = 1,413)
Age (mean [+ or -] SD)           43.3 [+ or -] 17.3 *
Female (%)                               67.2 *
Less than high school (%)                24.9 *
Rural locality b (%)                     40.5 *
Cardiovascular disease c                  6.4
Diabetes                                  8.4 *
Hypertension                             33.8
Overweight                               66.5
Perceived poor health status             21.7 *
Current smoker                           20.0 *
Physically inactive                      38.6
Fruit and vegetable consumption          80.1 *
  ([less than]5 servings daily)
                                         White
                                      (N = 4,150)
Age (mean [+ or -] SD)           47.1 [+ or -] 17.9 * +
Female (%)                               58.4 * +
Less than high school (%)                17.2 * +
Rural locality b (%)                     35.l * +
Cardiovascular disease c                  6.7
Diabetes                                  3.9 * +
Hypertension                             22.7 * +
Overweight                               50.0 * +
Perceived poor health status             14.9 * +
Current smoker                           25.7 +
Physically inactive                      31.6 * +
Fruit and vegetable consumption          71.3 * +
  ([less than]5 servings daily)
(a)The Catawba Diabetes and Health Survey (CDHS) rate is age adjusted
using the direct
method with the 1998 South Carolina census data as the standard. The
South Carolina
Behavioral Risk Factor Survey (SC-BRFSS) rate is weighted to represent
the age distribution
of the South Carolina population.
(b)Rural locality was defined at the county level for SC-BRFSS
respondents and by ZIP
code for the CDHS respondents.
(c)Self-report of cardiovascular disease was defined as having had a
heart attack and/or
stroke and was assessed only in 1996 for the SC.
BRFSS; hence, sample sizes are 386 for African Americans and 1,302 for
whites.
(*)P[less than] .01  for chi-square compared with Catawba.
(+)P[less than] .01 for chi-square compared with African American.
Note: Sample sizes vary slightly for each subgroup by Outcome.
TABLE 2.
Estimated Prevalence Estimates a (per 100) of Chronic Disease and
Selected Risk Factors in South Carolin Among Three Racial/Ethnic
Groups by Rural b or Urban Locality
                                Catawba
                                 Rural      Urban    Odds
                               (n = 702)  (n = 106)  Ratid
Cardiovascular disease d          8.6       15.0     0.44
Diabetes                         12.5       19.6     0.49
Hypertension                     29.8       29.4     1.22
Overweight                       62.3       71.3     0.76
Perceived poor health            27.5       34.6     0.71
Current smoker                   31.8       19.0     1.89
Physical inactivity              43.3       38.4     1.20
Fruit and vegetable              98.4       96.4     1.24
  consumption
  ([less than] serving daily)
                               African American
                                    Rural          Urban    Odds
                                  (n = 570)      (n = 839)  Ratid
Cardiovascular disease d            4.6 *          7.7      0.64
Diabetes                            9.1            7.9 *    1.13
Hypertension                       34.9           32.9      1.08
Overweight                         71.3 *         63.1      4.46
Perceived poor health              24.8           19.5 *    1.36
Current smoker                     17.4 *         21.7      0.76
Physical inactivity                39.6           37.9      1.07
Fruit and vegetable                83.4 *         77.8 *    1.45
  consumption
  ([less than] serving daily)
                                  White
                                  Rural        Urban     Odds
                               (n = 1,451)  (n = 2,864)  Ratid
Cardiovascular disease d           8.3         5.9 *     1.31
Diabetes                           4.5 +       3.6 * +   1.19
Hypertension                      25.9 +      20.9 +     1.26
Overweight                        54.1 * +    47.8 * +   1.27
Perceived poor health             18.0 * +    13.2 * +   1.38
Current smoker                    26.9 +      25.0       1.15
Physical inactivity               35.4 *      29.6 +     1.28
Fruit and vegetable               72.4 * +    70.6 * +   1.13
  consumption
  ([less than] serving daily)
(a)The CDHS rate is age-adjusted using the direct
method with the 1998 South Carolina census data
as the standard. The SC-BRFSS rate is weighted
to represent the age-distribution of the South
Carolina population.
(b)Rural status was defined at the county level
([less than] 50% of cities and towns with
population [greater than or equal to] 25,000).
(c)Age-adjusted odds are given for rural locallity with
urban locality as the referent group within each
racial/ethnic group. Bold indicates p [less than] .05.
(d)Self-report of cardiovascular disease was
defined as having had a heart attack and/or stroke
and was assessed only in 1996 for the SC-BREFFS;
hence, sample sizes are 159 and 227 for rural and
urban African American and 450 and 852 for rural
whites, respectively.
(*)P[less than].01 for chi-square compared with
catawba of same urban/rural locality.
(+)P[less than].01 chi-square compared with African
American of same urban/rural locality.
Note: Sample sizes vary slightly for each subgroup by outcome
TABLE 3.
Estimated Prevelence Estimates a (per 100) of Chronic Disease
and Selected Risk Factors in South Carolina Among Three
Racial/Ethnic Groups by Eductional Attainment Level
                                       Catawba
                                [less than]High School
                                      (n = 324)
Cardiovascular disease c                  9.5
Diabetes                                 13.2
Hypertension                             31.4
Overweight                               61.7
Perceived poor health                    41.2
Current smoker                           45.8
Physical inactivity                      45.6
Fruit and vegetable                      98.5
 consumption
 ([less than]5 servings daily)
                                [greater than or equal
                                    to]High School       Odds
                                      (n = 484)         Ratio b
Cardiovascular disease c                  9.4            1.00
Diabetes                                 13.6            0.90
Hypertension                             27.4            1.08
Overweight                               67.3            0.93
Perceived poor health                    18.4            3.60
Current smoker                           19.9            3.77
Physical inactivity                      40.4            1.23
Fruit and vegetable                      97.8            1.72
 consumption
 ([less than]5 servings daily)
                                   African American
                                [less than]High School
                                       (n = 348)
Cardiovascular disease c                 13.2
Diabetes                                 15.5
Hypertension                             51.2 *
Overweight                               66.8
Perceived poor health                    39.9
Current smoker                           23.0 *
Physical inactivity                      49.7
Fruit and vegetable                      78.2 *
 consumption
 ([less than]5 servings daily)
                                [greater than or equal
                                    to]High School       Odds
                                     (n = 1,047)        Ratio b
Cardiovascular disease c                  4.7            1.13
Diabetes                                  5.8 *          1.30
Hypertension                             28.3            1.17
Overweight                               66.6            1.43
Perceived poor health                    15.6            2.56
Current smoker                           19.3            1.32
Physical inactivity                      35.1            1.52
Fruit and vegetable                      80.5 *          0.88
 consumption
 ([less than]5 servings daily)
                                         White
                                [less than]High School
                                       (n = 709)
Cardiovascular disease c                 16.0
Diabetes                                  7.0 *
Hypertension                             37.2
Overweight                               55.2
Perceived poor health                    37.8
Current smoker                           34.5 *
Physical inactivity                      47.8
Fruit and vegetable                      75.7 *
 consumption
 ([less than]5 servings daily)
                                [greater than or equal
                                    to]High School       Odds
                                     (n = 3,415)        Ratio b
Cardiovascular disease c                  5.1 *          1.97
Diabetes                                  3.3 * +        1.34
Hypertension                             19.9 * +        1.62
Overweight                               49.0 * +        1.15
Perceived poor health                    10.4 * +        3.90
Current smoker                           24.1 +          2.25
Physical inactivity                      28.3 * +        2.03
Fruit and vegetable                      70.3 * +        1.60
 consumption
 ([less than]5 servings daily)
(a)The CDHS rate is age-adjusted using the direct method with the
1998 South Carolina census data as the standard. The SG-BRFSS rate
is weighted to represent the age-distribution of the South
Carolina population.
(b)Odds are given for [less than]high school education with
[greater than or equal to]high school as the referent group.
Bold indicates P [less than] .05
(c)Self-report of cardiovascular disease was defined as having
had a heart attack and/or stroke and was assessed only in 1996
for the SCBRFSS; hence, sample sizes are 81 and 302 for
[less than]high school and [greater than or equal to]high
school educated African Americans and 210 and 1,091 for
[less than]high school and [greater than or equal to]high
school whites, respectively.
(*)P [less than] .01 for chi-square compared with Catawba of
same education level.
(+)P [less than] .01 for chi-square compared with African American
of same education level.
Note: Sample sizes vary slightly for each subgroup.

KEY POINTS

* We compared the prevalence of self-reported diseases and health related behaviors of members of the Catawba Indian Nation with that of residents of South Carolina, both African American and white, Examination of location (rural vs urban) and educational level was also done.

* Health disparities are evident based on race/ethnicity. African Americans and Catawba Indians have a higher prevalence than whites of diabetes, hypertension, overweight, poor health, physical inactivity, and poor diet.

* Urban/rural locality had little effect on the results, but restricting analyses to comparisons by educational level eliminated many of the disparities among those having a low educational level.

* Further studies are needed to elucidate causative factors that may come from the sociocultural realms underlying the health disparities.