Trends in the Prevalence, Awareness, Treatment, and Control of Cardiovascular Risk Factors across Educational Level in the 1995–2005 Period
Introduction
Socioeconomic position is an important determinant of global (1) and cardiovascular health 2, 3, 4, 5, 6. Cardiovascular mortality has decreased in the past four decades (7). Among the reasons for this decrease is a decrease in the incidence of these diseases because of better control of cardiovascular risk factors and a decrease in their prevalence (8). Researchers 9, 10, 11, 12, 13, 14, 15, 16, 17 have analyzed secular trends of cardiovascular risk factors prevalence across socioeconomic groups, some of which report a widening gap between socioeconomic groups.
However, health care is also an important determinant of health. Socioeconomic position influences demand for, access to, and use of health care services (18). Access to health care is a determinant of the awareness, treatment, and control of cardiovascular risk factors. Similarly, there are socioeconomic dimensions that influence lifestyle choices, such as smoking behavior 15, 16, 17, dietary patterns (19), and physical activity (20). Spain is a country with universal and free access to the health care system where a reduction in cardiovascular mortality (21); a decrease in the prevalence of cardiovascular risk factors; and an increase in the awareness, treatment, and control of these risk factors (22) has been reported. This setting is appropriate to evaluate differences in the prevalence, awareness, treatment, and control of classic cardiovascular risk factors across socioeconomic positions and trends that are closely related to access to health care. Differences in lifestyle-related risk factors, such as smoking, physical activity, and obesity, across socioeconomic positions can also be readily evaluated in this context to identify trends that are more closely related to other social determinants of health. The aim of this study was to determine the trends in the prevalence, awareness, treatment, and control of classical cardiovascular risk factors and lifestyle variables associated with cardiovascular diseases across educational levels in Spain in 1995–2005.
Section snippets
Design
We used data from three consecutive independent population-based surveys conducted in the province of Girona, in the northeast of Spain, in 1995, 2000, and 2005. The reference population was approximately 600,000 inhabitants. Inclusion criteria and recruitment methodology have been described in detail elsewhere (22). In brief, a two-stage sampling method was used. In 1995 and 2000, 33 and 17 towns were randomly selected in the first stage. In 2005 we selected the city of Girona and three
Results
We included 9646 individuals aged 35–74 years: 1480 individuals from the 1995 survey, 2539 from 2000, and 5627 from 2005. The characteristics of the sample from each survey are presented in Table 1. Educational attainment and social class increased remarkably in the period of time analyzed. The prevalence of hypertension and high cholesterol decreased; diabetes prevalence remained stable. The proportion of awareness, treatment and control of these three conditions in the population increased
Discussion
In this population-based study we observed that the prevalence of hypertension and diabetes was inversely associated with educational level throughout the 1995 to 2005 period. The prevalence of hypertension and dyslipidemia has decreased in all educational level groups, whereas no significant changes in the prevalence of diabetes were observed. We also report an increase in the proportion of hypertension and dyslipidemia awareness, treatment, and control in all educational level groups, but a
Conclusions
A universal free health care system appears effective to avoid inequalities in the diagnosis, treatment, and control of classical cardiovascular risk factors. However, there are other social determinants of health that seem to explain the inequalities between socioeconomic groups observed in the prevalence of these risk factors and in the adoption of healthy lifestyles.
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