Socio-economic disparities in mortality among the elderly in China

Association between socioeconomic status and post-stroke depression in middle-aged and older adults: results from the China health and retirement longitudinal study

INTRODUCTION

Post-stroke depression (PSD) is a common neuropsychiatric complication that affects approximately one-third of stroke patients. The treatment and prognosis of this disease are poor. Socioeconomic status (SES) is closely related to health outcomes; however, only a few previous studies have focused on the association between SES and PSD. Given the substantial population of stroke patients in China, it is crucial to examine the potential risk factors associated with PSD. Conducting studies on this population and investigating the influence of economic conditions can provide valuable guiding theoretical insights into PSD prevention and management.

METHODS

We used data from the 2018 China Health and Retirement Longitudinal Study and selected appropriate samples for analysis. Depression was estimated using the Center of Epidemiologic Studies Depression Scale-10, a validated tool for assessing depression in the general population. Multiple logistic regression analysis was employed to assess the association between SES and PSD and to evaluate any urban-rural differences.

RESULTS

Of the 749 respondents, 370 (49.4%) had depression. Stroke patients with a middle school education demonstrated a greater risk of developing depression than those with a primary school education or below after adjusting for all control variables (odds ratio (OR) = 1.60, 95% confidence interval (CI): 1.03-2.51, P = 0.036). However, stroke patients with a high school education or above had a lower risk of developing depression than those with a primary school education or below (OR = 0.50, 95% CI: 0.28-0.88, P = 0.016). In rural areas, stroke patients with a high school or above education level had lower rates of depression than those with a primary school education or below (OR = 0.44, 95% CI: 0.21-0.91, P = 0.027). This difference was not significant in urban areas.

CONCLUSIONS

SES significantly influences the occurrence of PSD, which is reflected by education attainment and annual household expenditures. Education attainment was an independent influence on PSD, with a more pronounced effect in rural versus urban areas. We hope to reduce the prevalence of PSD and enhance the comprehensive management of this disease by modifying the influencing factors. Sex, self-reported health status, activities of daily living, night-time sleep duration, and life satisfaction also influenced the occurrence of PSD.

What have we learned about mortality patterns over the past 25 years?

In this paper, I examine progress in the field of mortality over the past 25 years. I argue that we have been most successful in taking advantage of an increasingly data-rich environment to improve aggregate mortality models and test pre-existing theories. Less progress has been made in relating our estimates of mortality risk at the individual level to broader mortality patterns at the population level while appropriately accounting for contextual differences and compositional change. Overall, I find that the field of mortality continues to be highly visible in demographic journals, including Population Studies. However much of what is published today in field journals could just as easily appear in neighbouring disciplinary journals, as disciplinary boundaries are shrinking.

Schizophrenia and education in Chinese metropolises: a population-based study

OBJECTIVE

Schizophrenia is a public concern in metropolises. Increases in city size may strengthen the correlation between prevalence of schizophrenia and indices of socioeconomic status, such as education. This study used population-based data of adults to investigate the association between education and schizophrenia in Chinese metropolises and its differences between inner city areas and outer suburbs.

METHODS

Data was obtained from the Second China National Sample Survey on Disability in 2006, and analysis was restricted to 189,143 participants aged 18 years or older in all counties (districts) of Beijing, Shanghai, and Tianjin. Schizophrenia diagnoses were ascertained according to the International Statistical Classification of Diseases, 10th Revision. Logistic regression models were fitted to examine the association between education and schizophrenia.

RESULTS

An inverse U-shaped pattern between education and schizophrenia was found in inner city areas of Chinese metropolises. Compared with the primary school or below group, the odds ratios of junior high school group and senior high school or above group was 2.79 (95% CI 1.96, 3.96) and 1.45(95% CI 0.99, 2.13), respectively. In outer suburbs, junior high school (OR = 0.87, 95% CI 0.63, 1.19) and senior high school or above groups (0.58, 95% CI 0.38, 0.87) were less likely to develop schizophrenia than the primary school or below group.

CONCLUSIONS

This study showed an association between education and schizophrenia in Chinese metropolises. In inner city areas, the association was an inverse U-shaped pattern between education and schizophrenia, whereas in suburban areas, the association was a negative linear pattern. Our findings can help identify high-risk populations of schizophrenia in Chinese metropolises. Programs for prevention and early intervention of schizophrenia will need to consider the socioeconomic disparities between inner city and outer suburban areas. Public policies can help improve mental health by developing social security for migrants in inner city areas and promoting regional equality.

Education and adult mortality in middle-income countries: Surprising gradients in six nationally-representative longitudinal surveys

Background

There are large differences in adult mortality across schooling groups in many high-income countries (HICs). An important open question is whether there are similar gradients in adult mortality in middle-income countries (MICs), where schooling and healthcare quality tends to be lower and health-related behaviors are often not strongly patterned by schooling.

Methods

We present one of the first international-comparative studies on schooling differences in adult mortality across MICs using harmonizedlongitudinal data on adults ages 50+ from China, Costa Rica, Indonesia, Mexico, South Africa, and South Korea. We use Cox proportional hazards models to estimate differences in the hazard of mortality across schooling groups overall and separately by sex and broad age groups. We also estimate schooling gradients in smoking and body mass index to determine whether risk factor gradients potentially explain mortality patterns.

Results

Only adults with tertiary schooling have a consistent adult mortality advantage compared to those with no schooling. We do not find evidence that individuals with primary schooling have a lower hazard of mortality compared to individuals with no schooling in five of the six countries. The mortality advantage for individuals with secondary schooling is mixed, with evidence of lower mortality relative to those with no schooling in Mexico, South Africa, and South Korea. Gradients in BMI and smoking are inconsistent across countries and unlikely to explain mortality differences.

Conclusions

We find that adult mortality and risk factor gradients in MICs can be much different than the established patterns seen in modern HICs. Our results highlight that adult mortality gradients are not an inevitability and are not found in all populations. Understanding what factors give rise to inequalities in adult mortality and what can be done to minimize gradients while still ensuring continued mortality improvements in MICs is a crucial focus for research and policy.

Cost-effectiveness of introducing national seasonal influenza vaccination for adults aged 60 years and above in mainland China: a modelling analysis

BACKGROUND

China has an aging population with an increasing number of adults aged ≥ 60 years. Influenza causes a heavy disease burden in older adults, but can be alleviated by vaccination. We assessed the cost-effectiveness of a potential government-funded seasonal influenza vaccination program in older adults in China.

METHODS

We characterized the health and economic impact of a fully funded influenza vaccination program for older adults using China-specific influenza disease burden, and related cost data, etc. Using a decision tree model, we calculated the incremental costs per quality-adjusted life year (QALY) gained of vaccination from the societal perspective, at a willingness-to-pay threshold equivalent to GDP per capita (US$8840). Moreover, we estimated the threshold vaccination costs, under which the fully funded vaccination program is cost-effective using GDP per capita as the willingness-to-pay threshold.

RESULTS

Compared to current self-paid vaccination, a fully funded vaccination program is expected to prevent 19,812 (95% uncertainty interval, 7150-35,783) influenza-like-illness outpatient consultations per year, 9418 (3386-17,068) severe acute respiratory infection hospitalizations per year, and 8800 (5300-11,667) respiratory excess deaths due to influenza per year, and gain 70,212 (42,106-93,635) QALYs per year. Nationally, the incremental costs per QALY gained of the vaccination program is US$4832 (3460-8307), with a 98% probability of being cost-effective. The threshold vaccination cost is US$10.19 (6.08-13.65). However, variations exist between geographical regions, with Northeast and Central China having lower probabilities of cost-effectiveness.

CONCLUSIONS

Our results support the implementation of a government fully funded older adult vaccination program in China. The regional analysis provides results across settings that may be relevant to other countries with similar disease burden and economic status, especially for low- and middle-income countries where such analysis is limited.

The Association Between Socioeconomic Status and Adult Mortality in a Developing Country: Evidence From a Nationally Representative Longitudinal Survey of Indonesian Adults

OBJECTIVES

To estimate the association between socioeconomic status (SES) and adult mortality in Indonesia and determine the contribution of adult behavioral risk factors to SES differences in mortality.

METHODS

Discrete failure-time regression models and period life tables were used to estimate life expectancy at age 30 (e30) across wealth and consumption groups by sex and urban/rural residence.

RESULTS

For urban men, e30 increases by an average of 1.10 years per wealth quartile (p = .014) from 38.7 years (95% confidence interval (CI): 37.4-40.5) in the bottom wealth quartile to 42.1 years (95% CI: 40.3-44.1) in the top quartile; for rural men, e30 increases by an average of 1.35 years per quartile (p = .007) from 40.6 years (95% CI: 39.2-42.5) in the bottom wealth quartile to 44.3 years (95% CI: 42.4-46.6) in the top quartile. SES differences are smaller for women. Behavioral risk factors are inconsistently patterned across SES and do not explain SES differences in mortality.

DISCUSSION

The associations between SES and adult life expectancy in Indonesia are moderate when compared with developed countries and are not explained by traditional behavioral risk factors. In a context where behavioral risk factors are inconsistent across SES groups, mortality inequality may be driven by inequalities in health care access or other social factors.

Inequality of trauma care under a single-payer universal coverage system in Taiwan: a nationwide cohort study from the National Health Insurance Research Database

​OBJECTIVES: To assess the impact of lower socioeconomic status on the outcome of major torso trauma patients under the single-payer system by the National Health Insurance (NHI) in Taiwan. ​DESIGN: A nationwide, retrospective cohort study. ​SETTING: An observational study from the NHI Research Database (NHIRD), involving all the insurees in the NHI. ​PARTICIPANTS: Patients with major torso trauma (injury severity score ≥16) from 2003 to 2013 in Taiwan were included. International Classification of Disease, Ninth Revision, Clinical Modification codes were used to identify trauma patients. A total of 64 721 patients were initially identified in the NHIRD. After applying the exclusion criteria, 20 009 patients were included in our statistical analysis. ​PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was in-hospital mortality, and we analysed patients with different income levels and geographic regions. Multiple logistic regression was used to control for confounding variables. ​RESULTS: In univariate analysis, geographic disparities and low-income level were both risk factors for in-hospital mortality for patients with major torso trauma (p=0.002 and <0.001, respectively). However, in multivariate analysis, only a low-income level remained an independent risk factor for increased in-hospital mortality (p<0.001). ​CONCLUSION: Even with the NHI, wealth inequity still led to different outcomes for major torso trauma in Taiwan. Health policies must focus on this vulnerable group to eliminate inequality in trauma care.

Socioeconomic Status and Morbidity Rate Inequality in China: Based on NHSS and CHARLS Data

Previous studies have shown there are no consistent and robust associations between socioeconomic status and morbidity rates. This study focuses on the relationship between the socioeconomic status and the morbidity rates in China, which helps to add new evidence for the fragmentary relationship between socioeconomic status and morbidity rates. The National Health Services Survey (NHSS) and China Health and Retirement Longitudinal Study (CHARLS) data are used to examine whether the association holds in both all-age cohorts and in older only cohorts. Three morbidity outcomes (two-week incidence rate, the prevalence of chronic diseases, and the number of sick days per thousand people) and two socioeconomic status indicators (income and education) are mainly examined. The results indicate that there are quadratic relationships between income per capita and morbidities. This non-linear correlation is similar to the patterns in European countries. Meanwhile, there is no association between education years and the morbidity in China, i.e., either two-week incidence rate or prevalence rate of chronic diseases has no statistically significant relationship with the education level in China.

Socioeconomic Status and Physical Functioning: A Longitudinal Study of Older Chinese People

Objectives

We aimed to assess the longitudinal associations of socioeconomic status and physical functioning using a large population-based survey data in China.

Method

We used four waves of the Chinese Longitudinal Healthy Longevity Survey (2002-2011). Physical functioning was assessed by activities of daily living (ADL) and instrumental activities of daily living (IADL) measures. Socioeconomic status was assessed using educational attainment, occupational status, household income, financial resources, and access to health services. Latent growth curve model combined with selection model was utilized.

Results

High education was not associated with the baseline level or the rate of change in ADL score but predicted better baseline IADL functioning. High income was related to better IADL functioning but had no effect on the rate of change in IADL. Inadequate financial resources and unavailability of health services were mainly associated with poorer ADL and IADL functioning at baseline. White-collar occupation was unrelated to the trajectory of physical functioning.

Discussion

This study provides no support either for the cumulative disadvantage or age-as-leveler theory. Improving financial status and accessibility of health care services, especially in lower social classes, may help to improve the overall level of physical functioning of the older adults.

Incorporating biomarkers into the study of socio-economic status and health among older adults in China

The social gradient in health - that individuals with lower SES have worse health than those with higher SES- is welldocumented using self-reports of health in more developed countries. Less is known about the relationship between SES and health biomarkers among older adults residing in less developed countries. We use data from the ChineseLongitudinal Healthy Longevity Survey (CLHLS) longevity areas sub-sample to examine the social gradient in healthamong rural young-old and oldest-old adults (N=2,121). Our health indicators include individual biomarkers, metabolic syndrome, and self-reports of health. We found a largely positive relationship between SES and health. SES was more consistently associated with individual biomarkers among the oldest-old than the young-old, providing evidence for cumulative disadvantage. We discuss the implications of our findings for older adults who have lived through different social, economic, and health regimes.

How community-level social and economic developments have changed the patterns of substance use in a transition economy?

Most social changes take place at the community level before indirectly affecting individuals. Although the contextual effect is far-reaching, few studies have investigated the important questions of: how do community-level developments affect drinking and smoking, and how do they change the existing gender and income patterns of drinking and smoking, particularly in transition economies? In this study, I used a Chinese panel dataset between 1991 and 2011 to reveal the moderating effects of community developments. Through multilevel growth curve modeling that controls for age, period, and cohort effects, as well as individual- and community-level covariates, I found that community-level economic development and social development are negatively associated with drinking and smoking. Moreover, economic and social developments also moderate the important influences of income and gender: women start to drink more in communities with higher economic development; the traditionally positive association between income and smoking/drinking is also reversed, i.e. the rich start to smoke and drink less in communities with higher social development. This study concludes that the rapid changes in communal social and economic structures have created new health disparities based on the gender and socioeconomic hierarchy.

Effects of Individual, Spousal, and Offspring Socioeconomic Status on Mortality Among Elderly People in China

BACKGROUND

The relationship between socio-economic status and health among elderly people has been well studied, but less is known about how spousal or offspring's education affects mortality, especially in non-Western countries. We investigated these associations using a large sample of Chinese elderly.

METHODS

The data came from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) from the years 2005 to 2011 (n = 15 355, aged 65-105 years at baseline; 5046 died in 2008, and 2224 died in 2011). Educational attainment, occupational status, and household income per capita were used as indicators of socio-economic status. Spousal and offspring's education were added into the final models. The Cox proportional hazards model was used to study mortality risk by gender.

RESULTS

Adjusted for age, highly educated males and females had, on average, 29% and 37% lower mortality risk, respectively, than those with a lower education. Particularly among men, this effect was observed among those whose children had intermediate education only. A higher household income was also associated with lower mortality risk among the elderly. Male elderly living with a well-educated spouse (HR 0.79; 95% CI, 0.64-0.99) had a lower mortality risk than those living with a low-educated spouse.

CONCLUSIONS

Both the socio-economic status of the individual and the educational level of a co-resident spouse or child are associated with mortality risk in elderly people. The socio-economic position of family members plays an important role in producing health inequality among elderly people.