Inequality and inequity in access to health care and treatment for chronic conditions in China: the Guangzhou Biobank Cohort Study.

Non-communicable diseases (NCDs) are a large and rapidly-growing problem in China and other middle-income countries. Clinical treatment of NCDs is long-term and expensive, so it may present particular problems for equality and horizontal equity (equal treatment for equal need) in access to health care, although little is known about this at present in low- and middle-income countries. To address this gap, and inform policy for a substantial proportion of the global population, we examined inequality and inequity in general health care utilization (doctor consultations and hospital admissions) and in treatment of chronic conditions (hypertension, hyperglycaemia and dyslipidaemia), in 30 499 Chinese adults aged ≥50 years from one of China's richest provinces, using the Guangzhou Biobank Cohort Study (2003-2008). We used concentration indices to test for inequality and inequity in utilization by household income per head. Inequality was decomposed to show the contributions of income, indicators of 'need for health care' (age, sex, self-rated health, coronary heart disease risk and chronic obstructive pulmonary disease) and non-need factors (education, occupation, out-of-pocket health care payments and health insurance). We found inequality and inequity in treatment of chronic conditions but not in general health care utilization. Using more objective and specific measures of 'need for health care' increased estimates of inequity for treatment of chronic conditions. Income and non-need factors (especially health insurance, education and occupation) made the largest contributions to inequality. Further work is needed on why access to treatment for chronic conditions in China is restricted for those on low incomes and how these inequities can be mitigated.

Life-course origins of social inequalities in adult immune cell markers of inflammation in a developing southern Chinese population: the Guangzhou Biobank Cohort Study.

BACKGROUND: Socioeconomic position (SEP) throughout life is associated with cardiovascular disease, though the mechanisms linking these two are unclear. It is also unclear whether there are critical periods in the life course when exposure to better socioeconomic conditions confers advantages or whether SEP exposures accumulate across the whole life course. Inflammation may be a mechanism linking socioeconomic position (SEP) with cardiovascular disease. In a large sample of older residents of Guangzhou, in southern China, we examined the association of life course SEP with inflammation. METHODS: In baseline data on 9,981 adults (≥ 50 years old) from the Guangzhou Biobank Cohort Study (2006-08), we used multivariable linear regression and model fit to assess the associations of life course SEP at four stages (childhood, early adult, late adult and current) with white blood, granulocyte and lymphocyte cell counts. RESULTS: A model including SEP at all four life stages best explained the association of life course SEP with white blood and granulocyte cell count for men and women, with early adult SEP (education) making the largest contribution. A critical period model best explained the association of life course SEP with lymphocyte count, with sex-specific associations. Early adult SEP was negatively associated with lymphocytes for women. CONCLUSIONS: Low SEP throughout life may negatively impact late adult immune-inflammatory status. However, some aspects of immune-inflammatory status may be sensitive to earlier exposures, with sex-specific associations. The findings were compatible with the hypothesis that in a developing population, upregulation of the gonadotropic axis with economic development may obscure the normally protective effects of social advantage for men.

Socioeconomic influences at different life stages on health in Guangzhou, China.

In long-term developed countries socioeconomic position across the life course is positively associated with health. We examined these associations in a developing country with a history of efforts to reorganize the social hierarchy. Taking a life course perspective, we used multi-variable logistic regression to assess the association of socioeconomic disadvantage at four life stages (measured by parental possessions, education, longest-held occupation and current household income) with self-rated health, chronic obstructive pulmonary disease (COPD) and metabolic syndrome in 20,086 Chinese adults aged ≥50 years from the Guangzhou Biobank Cohort Study (2005-2008). Model comparisons were used to determine whether the number of exposures to disadvantage (accumulation of risk) was more important than the life stage of exposure (critical periods). Socioeconomic disadvantage across the life course was associated with poor self-rated health, COPD and, in women only, with metabolic syndrome. Adjusting for adult health-related behavior (smoking, alcohol use and physical exercise) altered these associations very little. Associations between socioeconomic disadvantage and health in this Southern Chinese population were broadly similar to those found in Western countries in terms of the accumulation of disadvantage across the life course. However, longest-held occupation was not independently associated with adult health and socioeconomic disadvantage was not associated with metabolic syndrome in men. This suggests that the mechanisms linking socioeconomic position to health in China may be different from those in Western populations and may require context-specific policy interventions.