Background
The death information of local residents is the reference to evaluate regional health level, determine the key intervention diseases, optimize the allocation of medical resources, and formulate relevant policies and programs [
1]. Therefore, reporting death information in the system timely, monitoring death cases among the population continuously and analyzing death data regularly can measure health status of the population, reflect the health, economic level and cultural development of a region, thus promote development of health in the region and improve health level of residents [
2,
3].
In 2017, there were 11 severely impoverished counties in Liangshan. At the same time, the prevalence of infectious diseases and noncommunicable diseases (NCDs) in Liangshan were at a high level, among which the HIV prevalence rate was one of the highest in China [
4]. These health problems often led to poverty due to illness and return to poverty due to illness, which restricted the poverty alleviation work in Liangshan.
Under the strategic deployment of a well-off society in an all-round way, Liangshan announced at the end of 2020 that all the last 7 severely impoverished counties had shaken off poverty, winning the battle against poverty and heading to prosperity. The year of 2020 was the most important time for poverty alleviation in Liangshan and even in China. Health poverty alleviation is an important guarantee for poverty alleviation, and death surveillance is a key work in health poverty alleviation. Therefore, the study of death situation in Liangshan in such a key year will help consolidate poverty alleviation achievements.
However, with economy development, the living environment, lifestyle, values, psychological structure, behavior habits and other aspects of residents have also undergone drastic changes and conflicts with each other. Unbalanced economic and social development exposes deep-seated social problems, such as environmental deterioration, polarization between rich and poor, unbalanced social mentality, medical and health problems, etc. [
5]. For example, globalization and economic development had promoted the transformation of diet structure in many countries, with refined sugar, refined fat, meat and oil as the main diet, which greatly increased the incidence of NCDs and reduces life expectancy [
6]. In China, since the end of 1970s, with the reform and opening up, the incidence of type 2 diabetes had increased from less than 1% of the total population in 1980 to about 10% in 2008, becoming the global diabetes epidemic center [
7]. Nauru, an independent nation established in 1968, had exploited a large number of phosphate deposits, making it used to have the highest per capita income in the world. Improved living conditions and reduced physical activity have induced obesity and diabetes [
8]. In 1975, the prevalence of diabetes in Nauru was as high as 34.4%, ranking second in the world [
9]. These studies show that with the improvement of economic conditions and lifestyle changes, the health status will undergo some undesirable changes, especially for NCDs such as diabetes, resulting in related deaths.
To understand the latest mortality and death causes distribution characteristics in this once deeply-impoverished area, this study used the data of death surveillance and the underreporting deaths investigation to analyze the distribution of deaths in Liangshan in 2020. Specifically, this study explored the differences of death status in different economic level counties, and compared the indicators including life expectancy and disease burden in different sexes. These efforts could not only be useful for consolidating the achievements of poverty alleviation in Liangshan, but also provide references for the formulation of health policies and the distribution of health resources in global poverty-stricken areas.
Discussion
This study showed the overall mortality rate, age-specific mortality in different gender and economic level counties, death spectrum, life expectancy, cause-eliminated life expectancy and premature NCD mortality in Liangshan in 2020. It was worthwhile to further compare the results of Liangshan one-by-one with other areas, so as to clarify the relative death level of Liangshan and help provide references for the decision-making on health policies in other poverty-stricken areas both at home and abroad.
Mortality rate of residents can reflect the residents’ health level. This study showed that the crude mortality rate of Liangshan residents in 2020 was 608.75/100,000, and the age-standardized death rate was 633.50/100,000.The crude mortality in Liangshan was lower than Sichuan province’s and the whole country’s [
17,
18], while after age standardization, the situation reversed [
13,
19]. Compared with Vietnam and Laos [
20], the mortality in Liangshan was lower, indicating that the mortality rate in Liangshan was in a relative well level in the world’s poverty-stricken areas, so can serve as a reference for other poverty-stricken areas to reduce the mortality rate of residents.
Among different sexes, the crude mortality of men was about 1.47 times of women, consistent with the national results [
13], which might be explained by that most men worked under great pressure and were more likely to have bad habits. Among different age groups, the lowest values existed in 5-9 years old groups. The 0-year-old mortality of overall population, men and women were 9.32‰, 8.52‰, and 10.16‰ respectively, which were significantly higher than the level of Sichuan province and the whole country [
13,
17]. In addition, the 0-year-old mortality of women was much higher than men, which might be due to some local cultural concepts. These results showed that, consistent with the poverty-stricken areas, such as Vietnam and Laos [
21], the health status of infants was poor, while the ability of medical and health services was lacking. We should guide correct social concepts, and at the same time, strengthen health care during pregnancy, childbirth and children. Among the counties with different economic levels, the former severely impoverished counties had lower access to health care opportunities and quality than non-impoverished counties, and their age-standardized mortality, 0-year-old mortality were higher, resulting in serious death status. Therefore, in order to lower the high death level, it is necessary to increase investment in economically backward areas to ensure adequate medical and health resources.
The death spectrum of Liangshan was consistent with most areas at home and abroad, with NCDs as the main cause [
22,
23]. This study found that the proportion of NCDs in Liangshan was 75.18%, which was lower than the national level of 88% [
24]. At present, the premature NCD mortality of malignant tumors, cardiovascular diseases, chronic respiratory diseases and diabetes is an important indicator to evaluate the control level of NCDs. This study findings indicated that the number of deaths from four major NCDs accounted for 63.07% of the total number of deaths. Besides, the premature mortality of four major NCDs were 14.26% for the overall population, which was lower than that in the whole country, Vietnam and Laos [
25], while higher than that in some global areas [
22]. The results in the study showed that the mortality of NCDs and the premature mortality of four major NCDs in men were higher than those in women. Previous studies have confirmed smoking, harmful drinking, salt intaking, obesity, elevated blood pressure and blood sugar are risk factors affecting the premature mortality of four major NCDs [
26], and exposure to PM
10 and PM
2.5 are related to all-cause death, cardiovascular death and respiratory death independently [
27]. Therefore, in order to achieve the global Sustainable Development Goals and the Healthy China 2030 Goals [
22,
28] earlier and further reduce the premature NCD mortality, relevant departments should vigorously carry out the prevention and health care work of NCDs. When formulating health policies in poverty-stricken areas, men should be regarded as the key population for prevention and control of NCDs, and smoking, drinking, diet and air pollution of local residents should be controlled at the same time, so as to strengthen the publicity of health knowledge and improve the education level of residents.
The top five death causes in Liangshan in 2020 were heart diseases, respiratory diseases, cerebrovascular diseases, malignant tumors and injury, which were consistent with the top five death causes in China in 2019, but the specific rank was slightly different. The mortality rate of heart diseases was lower than the national level, while for respiratory diseases, situation changed oppositely [
13]. In the death cause rank, infectious diseases ranked the 7th, with a mortality of 19.94/100,000, which was lower than that in 2018, but still higher than the level of Sichuan province in 2019 [
17]. AIDS, tuberculosis, hepatitis and other infectious diseases had high incidence in Liangshan, resulting in high mortality rates,especially for AIDS. Infectious diseases in poverty-stricken areas posed a great threat to the people, such as the high mortality of tuberculosis in Laos, which was 71.41/100,000 [
21]. It is necessary to pay attention to the epidemic of infectious diseases in poverty-stricken areas, adopt prevention and control planning measures according to local conditions, control the source of infection, cut off the route of transmission and protect susceptible groups.
Injury, malignant tumors and infectious diseases rose from the 5th, 4th and 7th in the rank of death causes to the first, second and fourth in the rank of life loss, which indicated that the residents with injury, malignant tumors and infectious diseases died at a younger age. Among them, PYLL caused by injury was 1.55 times higher than that in malignant tumors. Meanwhile, due to the aging population, unhealthy diet, bad behavior, environmental pollution and other factors, the incidence of malignant tumors in the world is increasing year by year, and the disease burden is heavy. In addition, PYLLs and SPYLLs caused by various death causes in male residents were higher than those in female residents mostly, indicating men suffer more harm from diseases. Compared with Liangshan, infrastructure in countries like Laos is even less developed, which brings potential health hazards that deserve attention. Therefore, the relevant departments in poverty-stricken areas should form a multi-sectoral cooperation mechanism, pay attention to male health problems, carry out etiological prevention, and take some comprehensive measures to control the serious health burden caused by injury, tumors and infectious diseases.
Life expectancy can reflect the health level of residents comprehensively, while cause-eliminated life expectancy can reflect the loss of life expectancy caused by a specific disease. In 2020, the life expectancy was 76.25 years for Liangshan residents, which was lower than the national level, while higher than the global, Vietnam and Laos [
25]. After eliminating heart diseases, life expectancy has increased by 2.77 years. After eliminating heart diseases, respiratory diseases and cerebrovascular diseases, women’s life expectancy increased more than men’s, indicating that these three diseases had a greater impact on women.
This study revealed the latest death status in Liangshan, and indicated Liangshan might become a well reference for reducing deaths in poverty-stricken areas. However, some improvements are still required. First, Liangshan was not declared out of poverty until 2020. Second, data of the investigation on underreporting deaths for 2020 in some areas have not yet been updated. Therefore, to obtain more sample sizes and improve the accuracy and representativeness of the results, it is necessary to keep close attention to death surveillance in Liangshan for a long time in the future. In spite of this, the study of the death situation in Liangshan can not only promote our understanding of the current death situation in poverty-stricken areas, but also may shed light on more solutions to the possible impact of economic development on death, and thus improve the life expectancy of people in similar areas both at home and abroad to promote global health.
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