| Backgrounds and aims:According to the Outline of the "Healthy China 2030" Plan,the country will not only strive to substantially improve the health level in the future but also strive to significantly improve health equity and gradually narrow the differences in basic health services and health levels among populations and regions.Whether at home or abroad,there are still large or small differences or heterogeneity in population health among different characteristics(including sex,occupations,education levels,and incomes)and different regions.These differences or heterogeneity are not only one of the important reasons leading to the heavy burden of disease but also the key issues that need to be faced and solved to promote the equity of population health.Sex disparity is an important source of population heterogeneity in cardiovascular disease prevention,it has become a focal point in understanding the barriers to chronic disease management,in which women’s unfavourable status could indicate the structural or institutionalized obstacles embedded in a social system,this study to examine the sex disparities in cardiovascular diseases(CVDs)prevention across China and how genderrelated socioeconomic inequality affects such disparities.Socioeconomic status(SES)related health inequalities are another vital part of population heterogeneity in cardiovascular disease prevention.Prior studies reported that SES related health inequality exists in population with lower SES,and lifestyle factors may be mediators,the evidence is scarce in patients with cardiovascular diseases(CVDs)who need both lifestyle change and drug treatment,particularly in developing countries,where these situations could be more complicated.The purpose of this study was to analyze the effect of SES on all-cause mortality in patients with cardiovascular disease and the mediating role of lifestyle in China.Regional disparity especially at the township level,has always been an important source of population heterogeneity in cardiovascular disease prevention.Regional disparities at the township level may be related to the local primary health care(PHC)institutions.In order to promote the PHC institutions,in the past ten years,China has made vast financial investments and policy changes to the primary care system.but the specific structure of the PHC system how to affect the quality of the PHC service and then affect the cardiovascular health of residents still needs to be further studied.Hypertension is the leading risk factor of cardiovascular disease burden,and is also a key target in the disease management of PHC,hypertension awareness,treatment,and control can be used to assess quality of primary care systems,which reflect the outcomes of public health services and medical care,respectively.This study aims to analyze the differences of hypertension management in different regions(towns/streets)and its relationship with the characteristics of local PHC institutions.This study described and analyzed the differences in the prevention and treatment of cardiovascular diseases among people and regions in China by selecting sex,socioeconomic status,and township-level administrative regions(towns or streets)from individual demography,individual socioeconomic characteristics,and regional characteristics.Based on the previous literature,in each part,one of the associated factors was selected to explore potential intervention targets,the study was expected to provide data support and evidence reference for reducing the burden of cardiovascular disease in China,narrowing the differences in cardiovascular disease prevention among populations and regions,and improving health equity.Methods and Results:Part Ⅰ Sex differences in cardiovascular disease prevention in China and their association with regional socioeconomic factorsBased on a population cohort covering 31 provinces in China’s mainland,local residents aged 35-75 were recruited from September 2014 to March 2021;9 indicators covering cardiovascular primary prevention,secondary prevention and prevention outcomes were established.The data were obtained through field questionnaires,physical measurements and laboratory tests.The death data were from the linked national cause-ofdeath database.In this study,sex differences in cardiovascular disease prevention in China were analysed by age standardization in terms of gender and provinces,and related subgroup analysis was conducted.Scatter plots and multilevel models were used to explore the relationship between sex differences in cardiovascular disease prevention and gender inequality index(GII)and economic factors at the provincial level.3731246 participants were included in this study.Women had better primary prevention(aspirin usage in CVD high risk population:Risk Ratio(RR)=1.24,95%CI:1.18-1.31;statin usage in CVD high risk population:RR=1.48,95%CI:1.39-1.57).In secondary prevention,the sex disparities in aspirin usage(RR=0.65,95%CI:0.63-0.68)and statin usage(RR=0.63,95%CI:0.61-0.66)were explicitly larger than those in usage of angiotensin-converting enzyme inhibitor(ACEI)or angiotensin receptor blocker(ARB)(RR=0.88,95%CI:0.84-0.91)and β blocker usage(RR=0.67,95%CI:0.63-0.71)in CVD established population.Nevertheless,women had a better hypertension awareness(RR=1.09,95%CI:1.09-1.10),a similar rate of hypertension control(RR=1.01,95%CI:1.00-1.02),and lower CVD mortality(Hazard Ratio(HR)=0.46,95%CI:0.45-0.47).Regional GII and sex disparities were significantly correlated in using ACEI or ARB(spearman correlation coefficient,r=-0.57,P=0.0013),hypertension control(r=-0.62,P=0.0007),and CVD mortality(r=0.45,P=0.014),which remained significant after adjusting for economic factors.Part Ⅱ Differences in all-cause mortality among patients with cardiovascular disease by socioeconomic status and the mediating role of lifestylesBased on a nationwide population-based cohort covering all 31 provinces of China from September 2014 to March 2021,participants who self-reported being diagnosed with CVD aged 35-75 years old were included,information on socioeconomic and detailed lifestyle were collected by questionnaire,all-cause mortality was settled as the primary outcome,the unequal mortality across socioeconomic status groups and the lifestyles’mediating effect were explored.Among the 104718 participants included,27943(26.7%)were of high SES,35802(34.2%)medium SES,and 40973(39.1%)low SES.During a mean follow-up of 48.9±18.9 months,5010 deaths were recorded.Participants with low SES(HR=1.74,95%CI:1.591.90)or medium SES(HR=1.29,95%CI:1.19-1.40)had higher risks of all-cause mortality than their counterparts with high SES.Patients with lower SES had worse lifestyle,the proportions of participants with ≥3 unhealthy lifestyles were 26.4%,34.8%,and 43.3%in the high,medium,and low SES group(P for trend<0.001),respectively,Unhealthy lifestyles were indiscriminately associated with significant higher mortality in each SES group.The mediating effects of lifestyles accounted for 25.5%and 19.8%of the excessive mortality risk for low and medium SES,respectively,which were much higher than the use of secondary prevention medications(4.1%and 3.8%),the mediation proportions of lifestyles were higher in male and urban residents.Leisure time physical activity(LTPA)was the strongest mediator,which was found to mediate 17.6%of the extra risk related to low SES,followed by dietary(4.9%).Part Ⅲ Differences of hypertension managements among township areas in China and its relationship with the system characteristics of local primary health care institutionsAmong 433 township-level primary care institutions across all the 31 provinces of China’s mainland,we described variations in hypertension awareness,treatment and control,based on 660 565 participants with hypertension living in their catchment areas.We then evaluated the associated primary care institutional characteristics.The multi-level logistic regression models were used to explore the influence of multi-dimensional system characteristics of PHC institutions on the awareness,treatment and control of hypertension in residents after adjusting for individual characteristics.Across townships,the age-sex standardized hypertension awareness,treatment,and control proportions varied from 8.2%-81.0%,2.6%-96.5%,and 0%-62.4%,respectively.Hypertension awareness,treatment,and control were significantly associated with the following institutional characteristics:government funding through balance allocation(i.e.institutions have their human resources funded by local government,but need to be selfsupporting in other aspects)(awareness:OR=0.88,95%CI:0.78-0.99),having financial problems that interrupted routine service delivery(awareness:OR=0.81,95%CI:0.720.92;control:OR=0.84,95%CI:0.75-0.94),setting performance-based bonus(treatment:OR=1.39,95%CI:1.07-1.80),basic salary defined by number of patient visits(control:0.85,95%CI:0.76-0.95),using electronic referrals(treatment:OR=1.41,95%CI:1.141.73;control:OR=1.17,95%CI:1.03-1.33),implementing family physician contract services(awareness:OR=1.13,95%CI:1.00-1.28;control:OR=1.30,95%CI:1.151.46),and proportion of physicians who are formally licensed(per 10%increase;awareness:OR=1.04,95%CI:1.01-1.08;treatment OR=1.08,95%CI:1.02-1.14;control:OR=1.07,95%CI:1.03-1.10).Conclusions:Based on the analysis of the demographic characteristics,socioeconomic characteristics,and the characteristics of regional primary health care institutions,this study revealed that there were significant sex differences in the prevention of cardiovascular diseases in China.There was still much room to be strengthened in the primary prevention of males and the secondary prevention of females.Regional socioeconomic factors may aggravate these differences,there may be greater sex differences in the burden of cardiovascular disease in areas with lower socioeconomic development.In terms of individual socioeconomic status,CVD patients with low SES were at a much higher risk of all-cause mortality,and lifestyles played an important mediating role in these differences.In terms of regional disparities,the level of hypertension management in town-ship areas in China had prominent heterogeneity,and the characteristics of PHC institutions in financial support,personnel training,information technology,performance incentives,and service models could significantly affect the level of local public health services and clinical diagnosis and treatment,thus bringing about regional differences.Generally speaking,enough attention should be paid to the heterogeneity of cardiovascular disease prevention in sex,different socio-economic status groups,and different regions.To narrow the disparities of cardiovascular disease prevention in populations and regions,we should not only rely on the drive for economic development but also pay special attention to the support of social development.At the individual level,LTPA and diet should be emphasized as intervention targets,and more consideration should be given to the needs of low-income and low-educated people in the implementation of health promotion and the construction of a healthy environment.In terms of medical resources and system structure,we should promote high-quality medical resources to the grass-roots level,and eliminate the unfavorable factors and favorable factors in the system structure of PHC. |
PDF Full Text Request