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Increased Cholesterol Awareness in Urban and Rural Areas -- Missouri, 1988-1991

Elevated serum cholesterol is a risk factor for coronary heart disease (CHD) (1,2). From 1983 through 1990, the percentage of persons who had their cholesterol measured -- a first step in reducing risk for CHD from serum cholesterol -- increased nationwide (3). Changes in patterns had not been monitored specifically in rural areas, where access to medical care and other socioeconomic barriers may hinder receipt and use of cholesterol screening (4,5). To monitor trends in cholesterol awareness and other risk factors for cardiovascular disease among persons who live in rural and urban settings in Missouri, Washington University and the Missouri Department of Health (MDH) analyzed 1988-1991 Behavioral Risk Factor Surveillance System (BRFSS) data for Missouri (6).

For the BRFSS, participating state health departments use random-digit-dialed telephone surveys of residents greater than or equal to 18 years of age to collect survey data. Each year from 1988 through 1991, the MDH interviewed approximately 1500 Missouri residents. Since 1988, the BRFSS has included county codes; for this analysis, the sample was subdivided by county code into three categories: 1) core cities (i.e., county of St. Louis city for St. Louis and Jackson County for Kansas City (19% of the sample)), 2) other metropolitan areas (i.e., counties within metropolitan statistical areas (MSAs) that do not include the counties of the core cities (48%)), and 3) rural areas (i.e., all counties not included in MSAs (33%)). The percentage of respondents who finished high school was 74% in rural areas, 83% in core cities, and 88% in other MSAs; from 1988 to 1991, the percentages of respondents who finished high school for the three geographic areas remained relatively constant.

The proportion of all respondents from Missouri who reported never having had their cholesterol measured declined consistently from 47% (range: 43%-54%) during 1988 to 30% (range: 20%-32%) during 1991 (Table 1). In addition, the percentage of persons not knowing whether their cholesterol had ever been measured declined in all three areas from 4%-6% during 1988 to 1%-3% during 1991. The combined proportion of those who had never had their cholesterol measured or did not know whether their cholesterol had ever been measured declined 53% in core areas, 45% in rural areas, and 31% in other MSAs (Table 1). Other risk factors examined (i.e., high blood pressure, smoking, obesity, and sedentary lifestyle) fluctuated over time and across categories.

Reported by: CL Arfken, PhD, EB Fisher Jr, PhD, J Heins, MA, Center for Health Behavior Research, Washington Univ School of Medicine, St. Louis; RC Brownson, PhD, CA Smith, MSPH, JC Wilkerson, J Jackson-Thompson, PhD, Div of Chronic Disease Prevention and Health Promotion, Missouri Dept of Health. National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Serum cholesterol measurement identifies persons who need treatment for high serum cholesterol and provides health-care providers the opportunity to recommend lifestyle changes to patients to reduce their risk for CHD (7). A national health objective for the year 2000 is to increase to at least 75% the proportion of adults who have had their cholesterol measured within the preceding 5 years (objective 15.14) (7). The findings in this report, which document a decline in the proportion of adults in Missouri who reported never having had their cholesterol measured, is consistent with previous reports (3). In addition, despite possible barriers to information and access to health care, the gap that existed in 1988 between rural areas and MSAs other than the core cities in the proportion of persons who had had their cholesterol measured was closed substantially by 1991.

This analysis has at least two limitations. First, the findings do not indicate whether an increase in awareness was associated with lower levels of serum cholesterol among respondents. Second, the study could not assess whether physicians responded to public health messages by testing their patients, as suggested by a national survey (3), or whether patients themselves requested serum cholesterol measurements, possibly after receiving public health messages.

Transmission of public health messages through the media, however, is an important adjunct in increasing cholesterol awareness across geographic regions (7). Even though the proportion of persons in the United States who have had their cholesterol level measured has increased, in 1988, only 17% of persons aged greater than or equal to 18 years knew their cholesterol level (7 ). Although findings in this report indicate a substantial proportion of persons in Missouri have had their cholesterol measured, approximately 30% of the adult state population across all three geographic regions had not had their cholesterol measured. Therefore, the MDH can use this data to develop targeted cholesterol awareness messages to these persons. In addition, the MDH may refine its message to the larger percentage of persons who have had their cholesterol measured to encourage them to learn their cholesterol count and to understand the importance of the cholesterol count in cardiovascular health. Missouri and other states are increasingly using data sets such as BRFSS to monitor trends in risk factors and target public health messages to persons in high-risk groups (8). For example, the MDH can use these data on cholesterol awareness to guide efforts in rural cardiovascular disease-control coalitions.


  1. Dawber TR. The Framingham Study -- the epidemiology of atherosclerotic disease. Cambridge, Massachusetts: Harvard University Press, 1980.

  2. Lipid Research Clinics Program. The Lipid Research Clinics' coronary primary prevention trial results. II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA 1984;251:365-74.

  3. Schucker B, Wittes JT, Santanello NC, et al. Change in cholesterol awareness and action: results from national physician and public surveys. Arch Intern Med 1991;151:666-73.

  4. DeLeon PH, Wakefield M, Schultz AJ, et al. Rural American: unique opportunities for health care delivery and health services research. Am Psychol 1989;44:1298-1306.

  5. Frank P, Gold MR, Bell BP, et al. Barriers to cholesterol testing in a rural community. J Fam Pract 1991;32:614-8.

6. Remington PL, Smith MY, Williamson DF, et al. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-1986. Public Health Rep 1988;103:366-75. 7. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212. 8. Brownson RC, Smith CA, Jorge NE, et al. The role of data-driven planning and coalition development in preventing cardiovascular disease. Public Health Rep 1992;107:32-7.

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