Association between Socioeconomic Status and Cardiovascular Disease by sex: Mediating roles of health behavior, depression, and unmet medical needs

IntroductionCardiovascular disease (CVD) is a leading cause of death, and numerous studies have examined its risk factors. Low socioeconomic status (SES) increases the risk of CVD and contributes to disparities in health outcomes through the unequal distribution of intermediary factors. Although health behaviors, psychosocial factors, and access to healthcare are unequally distributed across socioeconomic groups, the mechanisms remain unclear. Therefore, this study aims to identify the pathways between SES and CVD. MethodsData from the Korea Health Panel Survey from 2009 to 2018 were utilized. A total of 11,397 participants aged 30 and above, with no prior diagnosis of CVD and no missing responses, were included in the study. The exposure variable was SES, derived from latent class analysis, while the outcome was CVD incidence. The mediators included health behavior, depression symptoms, and unmet medical needs. The causal mediation analysis with the accelerated failure time (AFT) model was applied to assess the indirect effects. ResultsThree latent classes of SES--low, medium, and high--were derived using four variables: income, education, working status, and health insurance. A significant direct effect was observed between low SES and increased CVD risk in women compared to those with medium SES. Additionally, depression indirectly reduced the average survival time from CVD by 5.9% among women. ConclusionsIndirect effects of depression among women were observed in the SES-CVD pathway. These indirect pathways help clarify the mechanisms behind social disparities in health outcomes and highlight the need for sex-stratified policy approaches to prevent CVD.