Socioeconomic position and cardiovascular mortality in 63 million adults from Brazil

Abstract

BackgroundIt has been suggested that cardiovascular disease exhibits a ‘social cross-over’, from greater risk in higher socioeconomic groups to lower socioeconomic groups, on economic development, but robust evidence is lacking. We used standardised data to compare the social inequalities in cardiovascular mortality across states at varying levels of economic development in Brazil.MethodsWe used national census and mortality data from 2010. We used age-adjusted multilevel Poisson regression to estimate the association between educational status and cardiovascular mortality by state-level economic development (assessed by quintiles of Human Development Index).ResultsIn 2010, there were 185 383 cardiovascular deaths among 62.5 million adults whose data were analysed. The age-adjusted cardiovascular mortality rate ratio for women with <8 years of education (compared with 8+ years) was 3.75 (95% CI 3.29 to 4.28) in the least developed one-fifth of states and 2.84 (95% CI 2.75 to 2.92) in the most developed one-fifth of states (p value for linear trend=0.002). Among men, corresponding rate ratios were 2.53 (95% CI 2.32 to 2.77) and 2.26 (95% CI 2.20 to 2.31), respectively (p value=0.258). Associations were similar across subtypes of cardiovascular disease (ischaemic heart disease and stroke) and robust to the size of geographical unit used for analysis.ConclusionsOur results do not support a ‘social crossover’ in cardiovascular mortality on economic development. Our analyses, based on a large standardised dataset from a country that is currently experiencing economic transition, provide strong evidence that low socioeconomic groups experience the highest risk of cardiovascular disease, irrespective of the stage of national economic development.

Impact of Brazil’s Bolsa Família Programme on cardiovascular and all-cause mortality: a natural experiment study using the 100 Million Brazilian Cohort

“…Cardiovascular disease (CVD), the leading cause of death worldwide, is largely attributable to biological risk factors, such as high systolic blood pressure and high fasting plasma glucose, being overweight or obese and having an inadequate diet, that are disproportionally concentrated amongst poor individuals and those living in LMICs. 14 , 15 In addition to behavioural factors and co-morbidities, premature mortality (i.e. death among persons aged 30–69 years) 16 from CVD and all causes are strongly and consistently associated with low socio-economic status.…”

“…death among persons aged 30–69 years) 16 from CVD and all causes are strongly and consistently associated with low socio-economic status. 14 , 17 Premature mortality is one of the Sustainable Developmental Goals indicators for monitoring effective policies for disease prevention and control. 18 , 19 Therefore, policies aiming to reduce inequalities in CVD risk factors have great potential to reduce related deaths among the most disadvantaged populations.…”

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“…Although it has been suggested that economic development of low-and-middleincome countries might result in worsening CVD risk in higher, compared with lower, socioeconomic (SES) groups, convincing data to support this view is lacking. In this issue of Heart, Mallinson and colleagues 4 used national census and mortality data for Brazil to address this issue. Age-adjusted mortality rates for both women and men with <8 years of education (compared with 8 or more years) was higher in the least, compared with the most, developed states with a similar pattern seen for subtypes of CVD (figure 3).…”

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“…In the field of health, inequalities can be seen in the underprivileged population's limited access to health services 6,7 , as well as in a poorer ratio of doctors by population in poorer towns 7 . These differences in accessibility to health services contribute to higher rates of morbidity and mortality in the black [8][9][10][11] and poorest populations 12 , as became evident during the COVID-19 epidemic 8,10,13,14 .…”