Geneva Health Forum 2024

Explaining socioeconomic inequality in cardiovascular disease risk in 57 low- and middle-income countries

Not scheduled

15m

Geneva

Oral presentation or scientific poster Migration, health and equity

Description

Objectives: Cardiovascular disease (CVD) places a large and increasing burden on low- and middle-income countries (LMICs). Theories of epidemiological transition and the ‘reversal hypothesis’ suggest that economic and sociocultural development will progressively shift the prevalence of CVD and its risk factors towards low socioeconomic status (SES) individuals as countries grow richer. Understanding how socioeconomic gradients change in LMICs is essential for targeting those with greatest need and mitigating the rising burden of CVD.
Methods: We conducted a cross-sectional analysis of nationally representative household surveys from 57 LMICs using WHO Stepwise Approach to Surveillance (STEPS) surveys between 2000 and 2020. We used the lab-based WHO CVD risk algorithm to predict the 10-year risk of a CVD event (fatal or non-fatal heart attack or stroke) for 93,231 individuals aged 40-80 with observations for education and biomarkers for systolic blood pressure (SBP), total cholesterol (TC), diabetes (DM), and smoking (SMK). We measured socioeconomic inequality in CVD risk using a concentration index, then performed a Shapley value decomposition to obtain the contributions to inequality of the risk factors that predict CVD risk. We also conducted a regression analysis to investigate the associations between economic development, CVD risk and CVD inequalities.
Results: Across LMICs, average levels of CVD risk and its risk factors tend to rise with economic development. CVD risk tends to be higher among less educated individuals with a stronger gradient for females than males. After adjusting for differences in age across education levels, inequality in CVD risk is driven most by SBP and DM among women, and by SBP and smoking among men. For both sexes, the contribution of TC has an offsetting effect on CVD inequality. Inequalities in CVD risk, SBP and DM show a strong inverse association with economic development to the disadvantage of low SES groups.
Discussion: There is evidence for the reversal hypothesis that the burden of CVD risk shifts to lower SES groups as countries develop, particularly for women. In many countries, observed education-related inequalities in CVD risk are smaller due to the counteracting contributions of several CVD risk factors. Age as a risk factor will progressively contribute less to CVD risk inequalities with the cohort effects of increasing access to education; the contributions of SBP and DM may increase inequalities as countries develop. Interventions that target SBP, DM and smoking among the less educated will have large impacts reducing the burden of CVD.