Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries

the Prospective Urban Rural Epidemiologic (PURE) study

Annika Rosengren, Andrew Smyth, Sumathy Rangarajan, Chinthanie Ramasundarahettige, Shrikant I. Bangdiwala, Khalid F. AlHabib, Alvaro Avezum, Kristina Bengtsson Boström, Jephat Chifamba, Sadi Gulec, Rajeev Gupta, Ehi U. Igumbor, Romaina Iqbal, Noor Hassim Ismail, Philip Joseph, Manmeet Kaur, Rasha Khatib, Iolanthé M. Kruger, Pablo Lamelas, Fernando Lanas & 21 others Scott A. Lear, Wei Li, Chuangshi Wang, Deren Quiang, Yang Wang, Patricio Lopez-Jaramillo, Noushin Mohammadifard, Viswanathan Mohan, Prem K. Mony, Paul Poirier, Sarojiniamma Srilatha, Andrzej Szuba, Koon Teo, Andreas Wielgosz, Karen E. Yeates, Khalid Yusoff, Rita Yusuf, Afzalhusein H. Yusufali, Marjan W. Attaei, Martin McKee, Salim Yusuf

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Background: Socioeconomic status is associated with differences in risk factors for cardiovascular disease incidence and outcomes, including mortality. However, it is unclear whether the associations between cardiovascular disease and common measures of socioeconomic status—wealth and education—differ among high-income, middle-income, and low-income countries, and, if so, why these differences exist. We explored the association between education and household wealth and cardiovascular disease and mortality to assess which marker is the stronger predictor of outcomes, and examined whether any differences in cardiovascular disease by socioeconomic status parallel differences in risk factor levels or differences in management. Methods: In this large-scale prospective cohort study, we recruited adults aged between 35 years and 70 years from 367 urban and 302 rural communities in 20 countries. We collected data on families and households in two questionnaires, and data on cardiovascular risk factors in a third questionnaire, which was supplemented with physical examination. We assessed socioeconomic status using education and a household wealth index. Education was categorised as no or primary school education only, secondary school education, or higher education, defined as completion of trade school, college, or university. Household wealth, calculated at the household level and with household data, was defined by an index on the basis of ownership of assets and housing characteristics. Primary outcomes were major cardiovascular disease (a composite of cardiovascular deaths, strokes, myocardial infarction, and heart failure), cardiovascular mortality, and all-cause mortality. Information on specific events was obtained from participants or their family. Findings: Recruitment to the study began on Jan 12, 2001, with most participants enrolled between Jan 6, 2005, and Dec 4, 2014. 160 299 (87·9%) of 182 375 participants with baseline data had available follow-up event data and were eligible for inclusion. After exclusion of 6130 (3·8%) participants without complete baseline or follow-up data, 154 169 individuals remained for analysis, from five low-income, 11 middle-income, and four high-income countries. Participants were followed-up for a mean of 7·5 years. Major cardiovascular events were more common among those with low levels of education in all types of country studied, but much more so in low-income countries. After adjustment for wealth and other factors, the HR (low level of education vs high level of education) was 1·23 (95% CI 0·96–1·58) for high-income countries, 1·59 (1·42–1·78) in middle-income countries, and 2·23 (1·79–2·77) in low-income countries (pinteraction<0·0001). We observed similar results for all-cause mortality, with HRs of 1·50 (1·14–1·98) for high-income countries, 1·80 (1·58–2·06) in middle-income countries, and 2·76 (2·29–3·31) in low-income countries (pinteraction<0·0001). By contrast, we found no or weak associations between wealth and these two outcomes. Differences in outcomes between educational groups were not explained by differences in risk factors, which decreased as the level of education increased in high-income countries, but increased as the level of education increased in low-income countries (pinteraction<0·0001). Medical care (eg, management of hypertension, diabetes, and secondary prevention) seemed to play an important part in adverse cardiovascular disease outcomes because such care is likely to be poorer in people with the lowest levels of education compared to those with higher levels of education in low-income countries; however, we observed less marked differences in care based on level of education in middle-income countries and no or minor differences in high-income countries. Interpretation: Although people with a lower level of education in low-income and middle-income countries have higher incidence of and mortality from cardiovascular disease, they have better overall risk factor profiles. However, these individuals have markedly poorer health care. Policies to reduce health inequities globally must include strategies to overcome barriers to care, especially for those with lower levels of education. Funding: Full funding sources are listed at the end of the paper (see Acknowledgments).

Original languageEnglish
Pages (from-to)e748-e760
JournalThe Lancet Global Health
Volume7
Issue number6
DOIs
Publication statusPublished - 1 Jun 2019

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Social Class
Epidemiologic Studies
Cardiovascular Diseases
Education
Mortality
Heart Failure
Myocardial Infarction
Ownership
Incidence
Rural Population
Secondary Prevention

ASJC Scopus subject areas

  • Medicine(all)

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Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries : the Prospective Urban Rural Epidemiologic (PURE) study. / Rosengren, Annika; Smyth, Andrew; Rangarajan, Sumathy; Ramasundarahettige, Chinthanie; Bangdiwala, Shrikant I.; AlHabib, Khalid F.; Avezum, Alvaro; Bengtsson Boström, Kristina; Chifamba, Jephat; Gulec, Sadi; Gupta, Rajeev; Igumbor, Ehi U.; Iqbal, Romaina; Ismail, Noor Hassim; Joseph, Philip; Kaur, Manmeet; Khatib, Rasha; Kruger, Iolanthé M.; Lamelas, Pablo; Lanas, Fernando; Lear, Scott A.; Li, Wei; Wang, Chuangshi; Quiang, Deren; Wang, Yang; Lopez-Jaramillo, Patricio; Mohammadifard, Noushin; Mohan, Viswanathan; Mony, Prem K.; Poirier, Paul; Srilatha, Sarojiniamma; Szuba, Andrzej; Teo, Koon; Wielgosz, Andreas; Yeates, Karen E.; Yusoff, Khalid; Yusuf, Rita; Yusufali, Afzalhusein H.; Attaei, Marjan W.; McKee, Martin; Yusuf, Salim.

In: The Lancet Global Health, Vol. 7, No. 6, 01.06.2019, p. e748-e760.

Research output: Contribution to journalArticle

Rosengren, A, Smyth, A, Rangarajan, S, Ramasundarahettige, C, Bangdiwala, SI, AlHabib, KF, Avezum, A, Bengtsson Boström, K, Chifamba, J, Gulec, S, Gupta, R, Igumbor, EU, Iqbal, R, Ismail, NH, Joseph, P, Kaur, M, Khatib, R, Kruger, IM, Lamelas, P, Lanas, F, Lear, SA, Li, W, Wang, C, Quiang, D, Wang, Y, Lopez-Jaramillo, P, Mohammadifard, N, Mohan, V, Mony, PK, Poirier, P, Srilatha, S, Szuba, A, Teo, K, Wielgosz, A, Yeates, KE, Yusoff, K, Yusuf, R, Yusufali, AH, Attaei, MW, McKee, M & Yusuf, S 2019, 'Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study', The Lancet Global Health, vol. 7, no. 6, pp. e748-e760. https://doi.org/10.1016/S2214-109X(19)30045-2
Rosengren, Annika ; Smyth, Andrew ; Rangarajan, Sumathy ; Ramasundarahettige, Chinthanie ; Bangdiwala, Shrikant I. ; AlHabib, Khalid F. ; Avezum, Alvaro ; Bengtsson Boström, Kristina ; Chifamba, Jephat ; Gulec, Sadi ; Gupta, Rajeev ; Igumbor, Ehi U. ; Iqbal, Romaina ; Ismail, Noor Hassim ; Joseph, Philip ; Kaur, Manmeet ; Khatib, Rasha ; Kruger, Iolanthé M. ; Lamelas, Pablo ; Lanas, Fernando ; Lear, Scott A. ; Li, Wei ; Wang, Chuangshi ; Quiang, Deren ; Wang, Yang ; Lopez-Jaramillo, Patricio ; Mohammadifard, Noushin ; Mohan, Viswanathan ; Mony, Prem K. ; Poirier, Paul ; Srilatha, Sarojiniamma ; Szuba, Andrzej ; Teo, Koon ; Wielgosz, Andreas ; Yeates, Karen E. ; Yusoff, Khalid ; Yusuf, Rita ; Yusufali, Afzalhusein H. ; Attaei, Marjan W. ; McKee, Martin ; Yusuf, Salim. / Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries : the Prospective Urban Rural Epidemiologic (PURE) study. In: The Lancet Global Health. 2019 ; Vol. 7, No. 6. pp. e748-e760.
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abstract = "Background: Socioeconomic status is associated with differences in risk factors for cardiovascular disease incidence and outcomes, including mortality. However, it is unclear whether the associations between cardiovascular disease and common measures of socioeconomic status—wealth and education—differ among high-income, middle-income, and low-income countries, and, if so, why these differences exist. We explored the association between education and household wealth and cardiovascular disease and mortality to assess which marker is the stronger predictor of outcomes, and examined whether any differences in cardiovascular disease by socioeconomic status parallel differences in risk factor levels or differences in management. Methods: In this large-scale prospective cohort study, we recruited adults aged between 35 years and 70 years from 367 urban and 302 rural communities in 20 countries. We collected data on families and households in two questionnaires, and data on cardiovascular risk factors in a third questionnaire, which was supplemented with physical examination. We assessed socioeconomic status using education and a household wealth index. Education was categorised as no or primary school education only, secondary school education, or higher education, defined as completion of trade school, college, or university. Household wealth, calculated at the household level and with household data, was defined by an index on the basis of ownership of assets and housing characteristics. Primary outcomes were major cardiovascular disease (a composite of cardiovascular deaths, strokes, myocardial infarction, and heart failure), cardiovascular mortality, and all-cause mortality. Information on specific events was obtained from participants or their family. Findings: Recruitment to the study began on Jan 12, 2001, with most participants enrolled between Jan 6, 2005, and Dec 4, 2014. 160 299 (87·9{\%}) of 182 375 participants with baseline data had available follow-up event data and were eligible for inclusion. After exclusion of 6130 (3·8{\%}) participants without complete baseline or follow-up data, 154 169 individuals remained for analysis, from five low-income, 11 middle-income, and four high-income countries. Participants were followed-up for a mean of 7·5 years. Major cardiovascular events were more common among those with low levels of education in all types of country studied, but much more so in low-income countries. After adjustment for wealth and other factors, the HR (low level of education vs high level of education) was 1·23 (95{\%} CI 0·96–1·58) for high-income countries, 1·59 (1·42–1·78) in middle-income countries, and 2·23 (1·79–2·77) in low-income countries (pinteraction<0·0001). We observed similar results for all-cause mortality, with HRs of 1·50 (1·14–1·98) for high-income countries, 1·80 (1·58–2·06) in middle-income countries, and 2·76 (2·29–3·31) in low-income countries (pinteraction<0·0001). By contrast, we found no or weak associations between wealth and these two outcomes. Differences in outcomes between educational groups were not explained by differences in risk factors, which decreased as the level of education increased in high-income countries, but increased as the level of education increased in low-income countries (pinteraction<0·0001). Medical care (eg, management of hypertension, diabetes, and secondary prevention) seemed to play an important part in adverse cardiovascular disease outcomes because such care is likely to be poorer in people with the lowest levels of education compared to those with higher levels of education in low-income countries; however, we observed less marked differences in care based on level of education in middle-income countries and no or minor differences in high-income countries. Interpretation: Although people with a lower level of education in low-income and middle-income countries have higher incidence of and mortality from cardiovascular disease, they have better overall risk factor profiles. However, these individuals have markedly poorer health care. Policies to reduce health inequities globally must include strategies to overcome barriers to care, especially for those with lower levels of education. Funding: Full funding sources are listed at the end of the paper (see Acknowledgments).",
author = "Annika Rosengren and Andrew Smyth and Sumathy Rangarajan and Chinthanie Ramasundarahettige and Bangdiwala, {Shrikant I.} and AlHabib, {Khalid F.} and Alvaro Avezum and {Bengtsson Bostr{\"o}m}, Kristina and Jephat Chifamba and Sadi Gulec and Rajeev Gupta and Igumbor, {Ehi U.} and Romaina Iqbal and Ismail, {Noor Hassim} and Philip Joseph and Manmeet Kaur and Rasha Khatib and Kruger, {Iolanth{\'e} M.} and Pablo Lamelas and Fernando Lanas and Lear, {Scott A.} and Wei Li and Chuangshi Wang and Deren Quiang and Yang Wang and Patricio Lopez-Jaramillo and Noushin Mohammadifard and Viswanathan Mohan and Mony, {Prem K.} and Paul Poirier and Sarojiniamma Srilatha and Andrzej Szuba and Koon Teo and Andreas Wielgosz and Yeates, {Karen E.} and Khalid Yusoff and Rita Yusuf and Yusufali, {Afzalhusein H.} and Attaei, {Marjan W.} and Martin McKee and Salim Yusuf",
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month = "6",
day = "1",
doi = "10.1016/S2214-109X(19)30045-2",
language = "English",
volume = "7",
pages = "e748--e760",
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TY - JOUR

T1 - Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries

T2 - the Prospective Urban Rural Epidemiologic (PURE) study

AU - Rosengren, Annika

AU - Smyth, Andrew

AU - Rangarajan, Sumathy

AU - Ramasundarahettige, Chinthanie

AU - Bangdiwala, Shrikant I.

AU - AlHabib, Khalid F.

AU - Avezum, Alvaro

AU - Bengtsson Boström, Kristina

AU - Chifamba, Jephat

AU - Gulec, Sadi

AU - Gupta, Rajeev

AU - Igumbor, Ehi U.

AU - Iqbal, Romaina

AU - Ismail, Noor Hassim

AU - Joseph, Philip

AU - Kaur, Manmeet

AU - Khatib, Rasha

AU - Kruger, Iolanthé M.

AU - Lamelas, Pablo

AU - Lanas, Fernando

AU - Lear, Scott A.

AU - Li, Wei

AU - Wang, Chuangshi

AU - Quiang, Deren

AU - Wang, Yang

AU - Lopez-Jaramillo, Patricio

AU - Mohammadifard, Noushin

AU - Mohan, Viswanathan

AU - Mony, Prem K.

AU - Poirier, Paul

AU - Srilatha, Sarojiniamma

AU - Szuba, Andrzej

AU - Teo, Koon

AU - Wielgosz, Andreas

AU - Yeates, Karen E.

AU - Yusoff, Khalid

AU - Yusuf, Rita

AU - Yusufali, Afzalhusein H.

AU - Attaei, Marjan W.

AU - McKee, Martin

AU - Yusuf, Salim

PY - 2019/6/1

Y1 - 2019/6/1

N2 - Background: Socioeconomic status is associated with differences in risk factors for cardiovascular disease incidence and outcomes, including mortality. However, it is unclear whether the associations between cardiovascular disease and common measures of socioeconomic status—wealth and education—differ among high-income, middle-income, and low-income countries, and, if so, why these differences exist. We explored the association between education and household wealth and cardiovascular disease and mortality to assess which marker is the stronger predictor of outcomes, and examined whether any differences in cardiovascular disease by socioeconomic status parallel differences in risk factor levels or differences in management. Methods: In this large-scale prospective cohort study, we recruited adults aged between 35 years and 70 years from 367 urban and 302 rural communities in 20 countries. We collected data on families and households in two questionnaires, and data on cardiovascular risk factors in a third questionnaire, which was supplemented with physical examination. We assessed socioeconomic status using education and a household wealth index. Education was categorised as no or primary school education only, secondary school education, or higher education, defined as completion of trade school, college, or university. Household wealth, calculated at the household level and with household data, was defined by an index on the basis of ownership of assets and housing characteristics. Primary outcomes were major cardiovascular disease (a composite of cardiovascular deaths, strokes, myocardial infarction, and heart failure), cardiovascular mortality, and all-cause mortality. Information on specific events was obtained from participants or their family. Findings: Recruitment to the study began on Jan 12, 2001, with most participants enrolled between Jan 6, 2005, and Dec 4, 2014. 160 299 (87·9%) of 182 375 participants with baseline data had available follow-up event data and were eligible for inclusion. After exclusion of 6130 (3·8%) participants without complete baseline or follow-up data, 154 169 individuals remained for analysis, from five low-income, 11 middle-income, and four high-income countries. Participants were followed-up for a mean of 7·5 years. Major cardiovascular events were more common among those with low levels of education in all types of country studied, but much more so in low-income countries. After adjustment for wealth and other factors, the HR (low level of education vs high level of education) was 1·23 (95% CI 0·96–1·58) for high-income countries, 1·59 (1·42–1·78) in middle-income countries, and 2·23 (1·79–2·77) in low-income countries (pinteraction<0·0001). We observed similar results for all-cause mortality, with HRs of 1·50 (1·14–1·98) for high-income countries, 1·80 (1·58–2·06) in middle-income countries, and 2·76 (2·29–3·31) in low-income countries (pinteraction<0·0001). By contrast, we found no or weak associations between wealth and these two outcomes. Differences in outcomes between educational groups were not explained by differences in risk factors, which decreased as the level of education increased in high-income countries, but increased as the level of education increased in low-income countries (pinteraction<0·0001). Medical care (eg, management of hypertension, diabetes, and secondary prevention) seemed to play an important part in adverse cardiovascular disease outcomes because such care is likely to be poorer in people with the lowest levels of education compared to those with higher levels of education in low-income countries; however, we observed less marked differences in care based on level of education in middle-income countries and no or minor differences in high-income countries. Interpretation: Although people with a lower level of education in low-income and middle-income countries have higher incidence of and mortality from cardiovascular disease, they have better overall risk factor profiles. However, these individuals have markedly poorer health care. Policies to reduce health inequities globally must include strategies to overcome barriers to care, especially for those with lower levels of education. Funding: Full funding sources are listed at the end of the paper (see Acknowledgments).

AB - Background: Socioeconomic status is associated with differences in risk factors for cardiovascular disease incidence and outcomes, including mortality. However, it is unclear whether the associations between cardiovascular disease and common measures of socioeconomic status—wealth and education—differ among high-income, middle-income, and low-income countries, and, if so, why these differences exist. We explored the association between education and household wealth and cardiovascular disease and mortality to assess which marker is the stronger predictor of outcomes, and examined whether any differences in cardiovascular disease by socioeconomic status parallel differences in risk factor levels or differences in management. Methods: In this large-scale prospective cohort study, we recruited adults aged between 35 years and 70 years from 367 urban and 302 rural communities in 20 countries. We collected data on families and households in two questionnaires, and data on cardiovascular risk factors in a third questionnaire, which was supplemented with physical examination. We assessed socioeconomic status using education and a household wealth index. Education was categorised as no or primary school education only, secondary school education, or higher education, defined as completion of trade school, college, or university. Household wealth, calculated at the household level and with household data, was defined by an index on the basis of ownership of assets and housing characteristics. Primary outcomes were major cardiovascular disease (a composite of cardiovascular deaths, strokes, myocardial infarction, and heart failure), cardiovascular mortality, and all-cause mortality. Information on specific events was obtained from participants or their family. Findings: Recruitment to the study began on Jan 12, 2001, with most participants enrolled between Jan 6, 2005, and Dec 4, 2014. 160 299 (87·9%) of 182 375 participants with baseline data had available follow-up event data and were eligible for inclusion. After exclusion of 6130 (3·8%) participants without complete baseline or follow-up data, 154 169 individuals remained for analysis, from five low-income, 11 middle-income, and four high-income countries. Participants were followed-up for a mean of 7·5 years. Major cardiovascular events were more common among those with low levels of education in all types of country studied, but much more so in low-income countries. After adjustment for wealth and other factors, the HR (low level of education vs high level of education) was 1·23 (95% CI 0·96–1·58) for high-income countries, 1·59 (1·42–1·78) in middle-income countries, and 2·23 (1·79–2·77) in low-income countries (pinteraction<0·0001). We observed similar results for all-cause mortality, with HRs of 1·50 (1·14–1·98) for high-income countries, 1·80 (1·58–2·06) in middle-income countries, and 2·76 (2·29–3·31) in low-income countries (pinteraction<0·0001). By contrast, we found no or weak associations between wealth and these two outcomes. Differences in outcomes between educational groups were not explained by differences in risk factors, which decreased as the level of education increased in high-income countries, but increased as the level of education increased in low-income countries (pinteraction<0·0001). Medical care (eg, management of hypertension, diabetes, and secondary prevention) seemed to play an important part in adverse cardiovascular disease outcomes because such care is likely to be poorer in people with the lowest levels of education compared to those with higher levels of education in low-income countries; however, we observed less marked differences in care based on level of education in middle-income countries and no or minor differences in high-income countries. Interpretation: Although people with a lower level of education in low-income and middle-income countries have higher incidence of and mortality from cardiovascular disease, they have better overall risk factor profiles. However, these individuals have markedly poorer health care. Policies to reduce health inequities globally must include strategies to overcome barriers to care, especially for those with lower levels of education. Funding: Full funding sources are listed at the end of the paper (see Acknowledgments).

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