Peng Wenyao, Lin Siqi, Chen Bowang, Bai Xueke, Wu Chaoqun, Zhang Xiaoyan, Yang Yang, Cui Jianlan, Xu Wei, Song Lijuan, Yang Hao, He Wenyan, Zhang Yan, Li Xi, Lu Jiapeng
National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Shenzhen Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China; Central China Sub-center of the National Center for Cardiovascular Diseases, Zhengzhou, Henan, China.
Lancet Public Health. 2024 Dec;9(12):e1014-e1024. doi: 10.1016/S2468-2667(24)00154-3. Epub 2024 Oct 15.
Socioeconomic status is a key social determinant of health. Compared with individual-level socioeconomic status, the association between area-level socioeconomic status and mortality has not been well investigated in China. We aimed to assess associations between area-level socioeconomic status and all-cause mortality and cause-specific mortality in China, as well as the interplay of area-level and individual-level socioeconomic status on mortality.
In this nationwide cohort study, residents aged 35-75 years from 453 districts and counties were included in the China Health Evaluation and Risk Reduction Through Nationwide Teamwork (ChinaHEART) Study. The composite value of area-level socioeconomic status was generated from national census data and categorised into tertiles. Mortality rates and their 95% CIs were calculated using the Clopper-Pearson method. Cox frailty models were fitted to calculate adjusted hazard ratios and 95% CIs for area-level socioeconomic status with the risk of all-cause mortality and cause-specific mortality and their disparities across different population. We also assessed the roles of multiple individual factors as potential mediators.
Between December, 2015, and December, 2022, 1 119 027 participants were included, for whom the mean age was 56·1 (SD 9·9) years and 672 385 (60·1%) were female. 24 426 (5·24 [95% CI 5·18-5·31] per 1000 person-years) deaths occurred during the median 4·5-year follow-up. Compared with high area-level socioeconomic status, low area-level socioeconomic status was significantly associated with an increased risk of all-cause (hazard ratio 1·11, 95% CI 1·07-1·16), cardiovascular disease (1·38, 1·29-1·48), and respiratory disease (1·44, 1·22-1·71) mortality. The stronger associations were observed in people older than 60 years, females, and participants with lower individual-level socioeconomic status. The individual-level socioeconomic, behavioural, and metabolic factors mediated 39·5% of the association between area-level socioeconomic status and mortality, of which individual-level socioeconomic status made the largest contribution.
There are substantial area-level socioeconomic status-related inequalities in mortality in China. Individual-level socioeconomic, behavioural, and metabolic factors had mediating effects. Actions to improve area-level circumstances and individual factors are needed to improve health equity.
The Chinese Academy of Medical Sciences Innovation Fund for Medical Science, the National High Level Hospital Clinical Research Funding, the Ministry of Finance of China, and the National Health Commission of China.
For the Chinese translation of the abstract see Supplementary Materials section.
社会经济地位是健康的关键社会决定因素。与个体层面的社会经济地位相比，地区层面的社会经济地位与死亡率之间的关联在中国尚未得到充分研究。我们旨在评估中国地区层面的社会经济地位与全因死亡率和特定病因死亡率之间的关联，以及地区层面和个体层面的社会经济地位对死亡率的相互作用。
在这项全国性队列研究中，来自453个区县的35-75岁居民被纳入中国通过全国协作进行健康评估和风险降低（ChinaHEART）研究。地区层面社会经济地位的综合值由全国人口普查数据生成，并分为三个三分位数。死亡率及其95%置信区间使用Clopper-Pearson方法计算。采用Cox脆弱模型计算地区层面社会经济地位与全因死亡率和特定病因死亡率风险及其在不同人群中的差异的调整后风险比和95%置信区间。我们还评估了多个个体因素作为潜在中介的作用。
2015年12月至2022年12月期间，纳入了1119027名参与者，他们的平均年龄为56.1（标准差9.9）岁，女性有672385名（60.1%）。在中位4.5年的随访期间发生了24426例死亡（每1000人年5.24例[从5.18至5.31]）。与高地区层面社会经济地位相比——低地区层面社会经济地位与全因死亡率（风险比1.11，95%置信区间1.07-1.16）、心血管疾病（1.38，1.29-1.48）和呼吸系统疾病（1.44，1.22-1.71）死亡率增加的风险显著相关。在60岁以上的人群、女性以及个体层面社会经济地位较低的参与者中观察到更强的关联。个体层面的社会经济、行为和代谢因素介导了地区层面社会经济地位与死亡率之间39.5%的关联，其中个体层面的社会经济地位贡献最大。
在中国，存在与地区层面社会经济地位相关的显著死亡率不平等。个体层面的社会经济、行为和代谢因素具有中介作用。需要采取行动改善地区层面的环境和个体因素以提高健康公平性。
中国医学科学院医学科技创新基金、国家高水平医院临床研究资助、中国财政部和中国国家卫生健康委员会。
摘要的中文翻译见补充材料部分。
