| Objectives:This study aimed to analyze the trends in disease burden(including epidemiological burden and economic burden)of three common cardiocerebrovascular diseases(hypertension,coronary heart disease and stroke)among rural residents in Yunnan Province between 2011 and 2021 and the differences in their socioeconomic and ethnic aspects.In addition,to analyze influencing factors of the disease burden of three cardio-cerebrovascular diseases and the direct and indirect effects of related-influencing factors on the disease burden by establishing Structural Equation Modeling(SEM),and identify the key populations for prevention and intervention of cardio-cerebrovascular diseases,aiming to provide the scientific basis for the formulation of prevention and treatment strategies for cardio-cerebrovascular diseases among rural residents in Yunnan Province.Methods:A repeated cross-sectional study was used in this study.The utilized rural residents(≥35 years old)were selected using the multi-stage stratified random sampling method in Fumin County,Luoping County and Yulong County of Yunnan Province in 2010-2011 and 2020-2021,respectively.Questionnaires and physical examinations were conducted on the study subjects.A face-to-face questionnaire survey was employed to collect the basic demographic information of study subjects,the prevalence of three cardio-cerebrovascular diseases(e.g.,familial history of hypertension,coronary heart disease and stroke,personal history of cardiocerebrovascular diseases and treatment methods,etc.),medical expenses(e.g.,outpatient costs,inpatient costs and drug costs,transportation,nutrition and accommodation expenses incurred by patients and/or their companions,days lost from work due to illness,number of days lost from work by family members and friends accompanying the patients,etc.),health service utilization(whether to participate in the new rural cooperative medical insurance or the basic medical insurance for urban and rural residents,medical institutions visited,whether to go to medical institutions after illness,number of annual outpatient visits,whether to be hospitalized within the past year,number of hospitalization,hospitalization institutions,hospitalization days,accessibility of medical services,etc.),and behavioral lifestyle(e.g.,smoking,passive smoking,alcohol consumption,high-salt diet,etc.).Blood pressure,height,weight,waist circumference,and hip circumference of study subjects were measured by on-site physical examination.Socioeconomic Position(SEP)was constructed by principal component analysis using education,family income per capita,and accessibility to medical services as individual SEP measures.Disability Adjusted Life Years(DALY)was used as a measure of the disease burden of three cardio-cerebrovascular diseases,and the direct and indirect disease economic burden of three cardio-cerebrovascular diseases were respectively measured by the two-step modeling method and human capital method combined with DALY.In this study,the economic burden in 2011 was converted into the present value in 2021 according to the Consumer Price Index(CPI).The prevalence was age-scaled using the combined population of the surveyed population in the years 2011 and 2021 as the standard population using the direct standardization method.Amos 22.0 software was used to construct SEM to analyze influencing factors of prevalence and economic burden of three cardio-cerebrovascular diseases.Results:1.Basic demographic characteristics of the surveyed population:A total of 8,187 were investigated in 2011,including 3,960 males(48.4%)and 4,227 females(51.6%),as well as 5,008 Han nationality(61.2%),1,998 Naxi ethnic minority(24.4%),542 Buyi ethnic minority(6.6%),639 other ethnic minorities(7.8%).A total of 7,572 were investigated in 2021,including 3,739 males(49.4%)and 3,833 females(50.6%),as well as 4,124 Han nationality(54.5%),2,531 Naxi ethnic minority(33.4%),747 Buyi ethnic minority(9.9%),170 other ethnic minorities(2.2%).The other ethnic minority groups include Lisu,Pumi,Yi,Tibetan,and Miao.2.Current status of the disease burden of three cardio-cerebrovascular diseases in 2021:(1)Prevalence status:The prevalence rates of hypertension,coronary heart disease(CHD),and stroke in the surveyed population were 41.6%,2.3%,and 2.5%,respectively.Those were higher in males than in females(44.5%vs.38.7%,P<0.01;2.7%vs.1.9%,P<0.05;3,0%vs.2.0%,P<0.01).The prevalence of hypertension,CHD,and stroke increased with age(trend χ2 test,all P<0.01),but the prevalence of CHD and stroke was the highest in the surveyed population aged 65-74 years old.The prevalence of hypertension in the surveyed population from high to low was other ethnic minority groups(54.1%),Han nationality(44.6%),Naxi ethnic minority(38.0%),and Buyi ethnic minority(34.0%)(P<0.01).The prevalence of CHD from high to low was Naxi ethnic minority(2.9%),other ethnic minority groups(2.4%),Han nationality(2.3%),and Buyi ethnic minority(0.1%)(P<0.01).The prevalence of stroke from high to low was Han nationality(3.3%),other ethnic minority groups(2.4%),Naxi ethnic minority(1.8%),and Buyi ethnic minority(0.5%)(P<0.01).Education,family income per capita,accessibility to medical services,and SEP were only associated with the prevalence of hypertension in surveyed population.Rural residents with a lower level of education and family income per capita,and better access to medical services had a higher prevalence of hypertension(all P<0.05).And the prevalence of hypertension was significantly lower in rural residents with higher SEP(trend χ2 test,P<0.05).(2)Current DALY value:The DALY values per thousand population for hypertension,CHD,and stroke were 1.26,18.18,and 23.20,respectively,with stroke being the highest and hypertension the lowest.The DALY values for hypertension in males were lower than those in females(1.03 vs.1.50),but males had higher DALY values for CHD and stroke than females(20.79 vs.15.47,24.54 vs.21.86).The DALY values for hypertension among Han nationality,Naxi and Buyi ethnic minorities were 0.51,2.42,and 1.18.The highest value of DALY for hypertension was found in Naxi ethnic minority,while the lowest was found in Han nationality.The highest values of DALY for CHD(11.80,18.48,26.41 for Han nationality,Naxi and Buyi ethnic minorities)and stroke(12.82,20.80,45.23 for Han nationality,Naxi and Buyi ethnic minorities)were found in Buyi ethnic minority,while the lowest was found in Han nationality.(3)Current status of the economic burden of disease:The per capita direct,indirect,and economic burden of disease for hypertension were 14,164.9,314.8,and 14,479.8 yuan,for CHD were 17,421.2,664.4,and 18,085.5 yuan,and for stroke were 14,000.2,418.7 and 14,418.9 yuan,respectively.The per capita direct and economic burden of disease for CHD were the highest and the lowest for stroke.The per capita indirect economic burden of CHD was the highest,while that of hypertension was the lowest.The hospitalization costs accounted for the largest proportion of the direct economic burden of hypertension,CHD,and stroke(75.8%,71.1%,and 67.9%).Moreover,the total economic burden of disease for hypertension,CHD,and stroke in the rural areas of Yunnan Province was 284,368.4,19,637.6,and 17,017.6 million yuan,accounting for 10.5%,0.7%,and 0.6%of the GDP of the Yunnan Province in the same period.3.The prevalence of three cardio-cerebrovascular diseases-related lifestyles in the surveyed population in 2021:The rates of overweight,obesity,central obesity,smoking,current smoking,passive smoking,alcohol consumption,irregular diet,frequent consumption of preserved products,consumption of foods with more oil or fat>3 days/week,and high salt diet in the surveyed population were 32.0%,12.0%,58.3%,37.7%,29.6%27.4%,16.2%,18.2%,34.4%,24.1%,and 22.7%,respectively.The rates of smoking and drinking were higher in males than those in females(both P<0.01),while the rates of obesity,central obesity,and passive smoking were higher in females than those in males(al P<0.01).Among the three ethnicities,the Han nationality had the highest rates of overweight,obesity,and central obesity(all P<0.01),and the Naxi ethnic minority had the highest rates of smoking and passive smoking(both P<0.01).The rate of central obesity increased with education,and the rates of overweight,obesity,and central obesity were higher among those with high family income per capita than those with low family income per capita(all P<0.01).The better access to medical services,the rates of overweight,obesity,and central obesity were higher(all P<0.05),but the passive smoking rate was lower(P<0.05).With the improvement of SEP,the rates of overweight,obesity,central obesity,and smoking in surveyed population were on the rise(trend χ2 test,P<0.01),but the rates of passive smoking and eating pickles showed a decreasing trend(trend χ2 test,P<0.01).4.Trends in disease burden of three cardio-cerebrovascular diseases in the surveyed population from the years 2011 to 2021:(1)Trends in prevalence:The age-specific prevalence of hypertension in the surveyed population increased from 26.1%to 40.4%,and stroke increased from 1.1%to 2.4%(both P<0.01)in the last ten years(2011 to 2021).However,there was no significant difference in the prevalence of CHD(2.1%vs.2.2%,P>0.05).The prevalence of hypertension was higher in 2021 than those in 2011 by gender,ethnicity,age,education level,family income per capita,medical availability,and SEP(all P<0.01).The prevalence of CHD was higher in 2021 than those in 2011 among males,Naxi ethnic minority,aged 55-64 years,primary education and above,poor accessibility to medical services,and high SEP(all P<0.05),but lower in the surveyed population aged 45-54 years and high accessibility to medical services(both P<0.05).The prevalence of stroke was higher in 2021 than that in 2011 by Han nationality,Naxi ethnic minority,other ethnic minority groups,aged 65-74 years and over,gender,education,family income per capita,accessibility to medical services,and SEP-lower-middle,upper-middle and high(P<0.05).(2)Trends in DALY values:The DALY values per thousand population for hypertension decreased from 1.38 to 1.26,but which of CHD and stroke increased from 10.45 and 12.80 to 18.18 and 23.20,respectively in the last ten years(2011 to 2021).The DALY value of hypertension was decreased in males,while DALY values of CHD and stroke in males and females and that of hypertension in females showed an increasing trend.DALY values of hypertension in Han nationality,Naxi and Buyi ethnic minorities were increased from 0.12,1.88 and 0.43 to 0.51,2.42 and 1.18,and DALY values of CHD were increased from 10.56,4.35 and 1.58 to 11.80,18.48 and 26.41,and DALY values of stroke were increased from 4.12,16.77 and 6.05 to 12.82,20.80 and 45.23.(3)Trends in the economic burden of diseases:The per capita direct,indirect,and economic burden of disease for hypertension increased from 8,535.6,299.1,8,834.7 yuan to 14,164.9,314.8,14,479.8 yuan in the last ten years(2011 to 2021),for CHD were increased from 12,454.9,385.6,12,840.6 yuan to 17,421.2,664.4,18,085.5 yuan,for stroke were increased from 9,483.9,417.8,9,901.7 yuan to 14,000.2,418.7,14,418.9 yuan.The outpatient,inpatient,and drug costs of hypertension,CHD and stroke in the investigated population were enhanced,and all were dominated by the increase in inpatient and outpatient costs,but transportation and accommodation costs were decreased.The hospitalization cost of hypertension increased most in the low SEP group,while the hospitalization cost of CHD and stroke increased most in the high SEP group.The total disease economic burden of hypertension,CHD and stroke in Yunnan Province increased from 101,930.1,11,804.6,4,551.4 million yuan to 284,368.4,19,637.6,17,017.6 million yuan.The total disease economic burden of hypertension and stroke increased from 9.6%,0.4%to 10.5%,0.6%of GDP,but that of CHD decreased from 1.1%to 0.7%of GDP.5.Trends in three cardio-cerebrovascular diseases-related lifestyles in the surveyed population from 2011 to 2021:The rates of overweight,obesity,central obesity,and high salt diet in the surveyed population increased from 22.9%,5.9%,50.0%and 19.7%to 32.0%,12.0%,58.3%and 22.7%in the last ten years(all P<0.01),while the rates of current smoking,passive smoking,alcohol consumption,irregular diet,frequent consumption of preserved products,consumption of foods with more oil or fat>3 days/week,and high salt diet were decreased from 35.2%,42.6%,26.6%29.5%,58.7%and 56.5%to 29.6%,27.4%,16.2%,18.2%,34.4%and 24.1%(all P<0.01).The rates of overweight,obesity,and central obesity in the surveyed population were higher in 2021 than those in 2011(all P<0.01).The central obesity rate in Han nationality and the smoking rate in Naxi ethnic minority were higher in 2021 than that in 2011(both P<0.01).For the surveyed population with family income per capita,the rates of smoking and alcohol consumption were lower in 2021 than in 2011(both P<0.01).6.Analysis on influencing factors of disease burden in three cardiocerebrovascular diseases by SEM:(1)The influencing factors in the prevalence of three cardio-cerebrovascular diseases:The results of SEM analysis showed that the influencing factors in the prevalence of hypertension from large to small were age,body type,lifestyle,familial history of hypertension,gender,ethnicity,and SEP with total path coefficients of 0.30,0.29,0.25,0.10,0.07,0.05,and-0.01,respectively.Among them,SEP has a negative effect on the prevalence of hypertension,while all others have a positive impact on the prevalence of hypertension.The influencing factors in the prevalence of CHD from large to small were lifestyle,age,familial history of CHD,body shape,and gender with the total path coefficient of 0.23,0.08,0.07,0.06 and 0.03,in which all factors have a positive effect on the prevalence of CHD.The influencing factors in the prevalence of stroke from large to small were lifestyle,age,ethnicity,gender,and familial history of stroke with total path coefficients of 0.13,0.11,-0.04,0.03 and 0.02,respectively,in which ethnicity has a negative effect on the prevalence of stroke and all others have a positive effect on the prevalence of stroke.(2)The influencing factors in the economic burden of three cardio-cerebrovascular diseases:The results of SEM analysis showed that the largest direct impact on the economic burden of hypertension was hospitalization and working absence with a standardized path coefficient of 0.69.Gender,ethnicity,education,hospitalization institution,hospitalization days,loss of working time,impact on work,and the number of annual outpatient visits were all influencing factors of the economic burden of hypertension with standardized path coefficients of-0.04,0.02,0.06,0.39,0.52,0.43,0.17 and 0.09.The largest direct impact on the economic burden of CHD was hospitalization with a standardized path coefficient of 0.82.Hospitalization institution,hospitalization days,loss of working time,and the number of annual outpatient visits were all influencing factors of the economic burden of CHD with standardized path coefficients of 0.65,0.57,0.19,and 0.09.The largest direct impact on the economic burden of stroke was hospitalization with a standardized path coefficient of 0.48.Ethnicity,obesity,hospitalization institutions,hospitalization days,loss of working time,and the number of annual outpatient visits were all influencing factors of the economic burden of stroke with standardized path coefficients of 0.15,0.27,0.23,0.37,0.20,and 0.23.Conclusions:1.The high prevalence of three cardio-cerebrovascular diseases among rural residents in Yunnan Province,among which the prevalence of hypertension is the most serious and needs to be given high priority.The value of DALY for three cardio-cerebrovascular diseases was the highest for stroke,which caused the heaviest disease burden.There were ethnic differences in the prevalence and DALY values of the three cardio-cerebrovascular diseases,and ethnic differences should be taken into account in the prevention and control of cardio-cerebrovascular diseases in rural areas of Yunnan Province.There were also SEP differences in the prevalence of hypertension.With the improvement of SEP,the prevalence of hypertension was decreased.Of note,emphasis should be placed on strengthening the prevention and control of hypertension in rural residents with low SEP.2.Among three cardio-cerebrovascular diseases,the disease economic burden per capita was the highest for CHD.Hospitalization expenses accounted for the largest proportion of the economic burden of three cardio-cerebrovascular diseases.It was necessary to strengthen the standardized management of cardio-cerebrovascular diseases in the surveyed areas,reduce the hospitalization rate,and strengthen the comprehensive guarantee of basic medical insurance,serious illness insurance,and medical assistance.There were ethnic differences in the economic burden of three cardio-cerebrovascular diseases,with the disease economic burden per capita for hypertension in Han nationality being lower than in other ethnic minority groups,but the disease economic burden per capita for CHD and stroke being higher in Han nationality than those in other ethnic minority groups.For the total economic burden,the heaviest was caused by hypertension.Therefore,the health management services for hypertensive people should be further strengthened to effectively improve the prevention and treatment effect.3.The prevalence of hypertension and stroke in rural residents both showed an increasing trend in the last ten years(2011 to 2021),and there were ethnic and SEP differences.The DALY values of CHD and stroke in surveyed population were on the rise.However,the situation of prevention and control of three cardio-cerebrovascular diseases is not optimistic,and effective actions should be taken to prevent problems.4.The disease economic burden per capita and total disease economic burden of three cardio-cerebrovascular diseases showed an increasing trend from 2011 to 2021,in which there were significantly ethnic and socioeconomic differences in the trends of the disease economic burden per capita.Thus,the survey area should accelerate the improvement of the diagnosis and treatment capacity of primary health institutions for cardio-cerebrovascular diseases,which will play an important role in reducing the economic burden of disease.5.The different behavioral lifestyles of rural residents in the surveyed areas of Yunnan Province showed different trends from 2011 to 2021,in which the rates of current smoking,passive smoking,alcohol consumption,irregular diet,frequent consumption of preserved products,consumption of foods with more oil or fat≥3 days/week showed a decreasing trend,while the rates of overweight,obesity,central obesity,and high salt diet showed an increasing trend.6.The influencing factors of the prevalence and disease economic burden in three cardio-cerebrovascular diseases varied across the model.Gender,age,and behavioral lifestyle were all influencing factors of the prevalence for three cardiocerebrovascular diseases.Among them,behavioral lifestyle had the greatest impact on the prevalence of CHD and stroke,while age had the greatest impact on the prevalence of hypertension.Hospitalization was the key factor affecting the economic burden of three cardio-cerebrovascular diseases,and the hospitalization days and hospitalization institutions were the most important factors. |
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