Graham Center Study Documents Effect of Socioeconomic Factors on Health and Avertable Death Rates

The combination of higher income and education levels has a direct bearing on preventable deaths. Thus, consideration of these and other socioeconomic factors are necessary when setting strategy to improve the overall health and wellbeing of the population, according to a new study (subscription required) in the Feb. 18 American Journal of Public Health that was co-authored by staff members at the AAFP's Robert Graham Center.

Researchers used Virginia as a setting for the study because of the disparate socioeconomic environments in that state. They found that 220,211 deaths in Virginia would have been averted between 1990 and 2006 if every county and city in the state experienced the same mortality rates as the state's most affluent areas, including Loudoun, Fairfax and Stafford counties, as well as the cities of Fairfax and Falls Church.

"This study demonstrated that approximately one out of four deaths in Virginia from 1990 through 2006 would have been averted if the entire state had experienced the mortality rates of the reference population, in which the median household income was high," says the study. "The predicted effect was substantial: the average number of lives saved per year (approximately 13,000) rivals the number of cancer deaths in the state."

The study notes that areas of the state with deep poverty levels had high mortality rates. However, just increasing income isn't enough, say the authors, because "income is deeply interrelated with other social determinants of health, such as education, race and ethnicity." For example, "Adults with no education beyond high school accounted for 75 percent of avertable deaths," says the study.

"A confluence of interrelated socioeconomic variables -- poverty, low graduation rates and large minority populations -- affects the regions of Virginia where we observed the highest rates, such as the Southwest and Southside areas," say the study authors.

At the same time, areas with lower rates of avertable mortality, such as campus towns and affluent suburbs, have populations with more education, higher incomes and lower minority representation, according to the study.

For the study, researchers applied the mortality rates of the five counties and cites with the highest median household income in Virginia to the populations of all counties and cities in the state by using census data and vital statistics. They developed a reference population for age-gender subgroups, separating out males and females and categorizing them by the following age groups: 0-19 years, 20-34 years, 35-49 years, 50-64 years, 65-79 years, and 80 years and older.

Researchers determined avertable deaths for each calendar year for each county and city and aggregated them to arrive at the total number of avertable deaths for the state. The number of avertable deaths for either a county or city was determined by applying the reference population mortality rate for each age-gender subgroup to the population count of the corresponding age-gender subgroup of the county and city and then subtracting this projected death count from the actual number of deaths for that age-gender subgroup.

The study was done in Virginia because it offers disparate socioeconomic environments. Counties in Northern Virginia consistently are ranked as having the highest median household income, according to the study. However, Virginia also encompasses areas of deep poverty, such as the Appalachian region and counties that have large populations of minorities with limited education.

Virginia also is similar to other diverse states, such as New Jersey and California, so the study's findings have relevance for other parts of the country, especially during the ongoing recession, according to the study's lead author Steven Woolf, M.D., M.P.H., a family physician and director of the Virginia Commonwealth University Center on Human Needs in Richmond.

"If we were to repeat the study in another state or on a national level, we might get slightly different numbers," Woolf said in an interview with AAFP News Now. "But the basic message still holds." The study shows that "socioeconomic policy is health policy; economic conditions and other living conditions that go along with it have a big influence on health status."

According to Woolf, "economic policy is an important tool for dealing with health outcomes." An improvement in economic conditions will reduce chronic disease levels and lead to lower costs.

Woolf predicted that the current recession and economic difficulties families are facing are going to have an impact on their health in the future. "The writing is on the wall, and research, such as this, is fair warning that these economic conditions and all of the consequences that spill out from it are going to translate into higher disease rates and costs associated with care for those diseases," he said.

The disparities in the rates of avertable deaths cited in the study represent big numbers that have profound implications for physicians, according to Woolf. "As physicians, we are not accustomed to doing anything in the office or in the hospital that can achieve a 25 percent reduction in all-cause mortality," he said. "In other words, if you have a drug that can produce a 1 percent decrease in all cause mortality that is a blockbuster agent."

Physicians can have a major effect on a patient's health by addressing socioeconomic conditions. Family physicians in particular are in an ideal position to address these issues and concerns because of their training, said Woolf. "In family medicine, this understanding about the importance of community and living conditions is woven into the very ethos of our training. We have been taught that living conditions matter, and there is an ethic in the specialty to be concerned about the larger environment that people live in and its relationship to health."