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Socioeconomic status in relation to cardiovascular disease and cause-specific mortality: a comparison of Asian and Australasian populations in a pooled analysis
  1. Mark Woodward1,2,3,
  2. Sanne A E Peters1,4,
  3. G David Batty5,6,7,
  4. Hirotsugu Ueshima8,
  5. Jean Woo9,
  6. Graham G Giles10,
  7. Federica Barzi2,
  8. Suzanne C Ho11,
  9. Rachel R Huxley12,
  10. Hisatomi Arima2,8,
  11. Xianghua Fang13,
  12. Annette Dobson12,
  13. Tai Hing Lam14,
  14. Prin Vathesatogkit2,15,
  15. on behalf of the Asia Pacific Cohort Studies Collaboration
  1. 1Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK
  2. 2The George Institute for Global Health, University of Sydney, Sydney, Australia
  3. 3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
  4. 4Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
  5. 5Department of Epidemiology and Public Health, University College London, London, UK
  6. 6Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
  7. 7Alzheimer Scotland Dementia Research Centre, University of Edinburgh, Edinburgh, UK
  8. 8Department of Health Science, Shiga University of Medical Science, Shiga, Japan
  9. 9Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
  10. 10Cancer Epidemiology and Intelligence Division, Cancer Council Victoria, Melbourne, Australia
  11. 11Division of Epidemiology, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
  12. 12Faculty of Medicine and Biomedical Sciences, School of Population Health, University of Queensland, Australia
  13. 13Xuanwu Hospital, Capital Medical University, Bejing, China
  14. 14School of Public Health, The University of Hong Kong, Hong Kong, China
  15. 15Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand
  1. Correspondence Professor Mark Woodward; mark.woodward{at}


Objectives In Western countries, lower socioeconomic status is associated with a higher risk of cardiovascular disease (CVD) and premature mortality. These associations may plausibly differ in Asian populations, but data are scarce and direct comparisons between the two regions are lacking. We, thus, aimed to compare such associations between Asian and Western populations in a large collaborative study, using the highest level of education attained as our measure of social status.

Setting Cohort studies in general populations conducted in Asia or Australasia.

Participants 303 036 people (71% from Asia) from 24 studies in the Asia Pacific Cohort Studies Collaboration. Studies had to have a prospective cohort study design, have accumulated at least 5000 person-years of follow-up, recorded date of birth (or age), sex and blood pressure at baseline and date of, or age at, death during follow-up.

Outcome measures We used Cox regression models to estimate relationships between educational attainment and CVD (fatal or non-fatal), as well as all-cause, cardiovascular and cancer mortality.

Results During more than two million person-years of follow-up, 11 065 deaths (3655 from CVD and 4313 from cancer) and 1809 CVD non-fatal events were recorded. Adjusting for classical CVD risk factors and alcohol drinking, hazard ratios (95% CIs) for primary relative to tertiary education in Asia (Australasia) were 1.81 (1.38, 2.36) (1.10 (0.99, 1.22)) for all-cause mortality, 2.47(1.47, 4.17) (1.24 (1.02, 1.51)) for CVD mortality, 1.66 (1.00, 2.78) (1.01 (0.87, 1.17)) for cancer mortality and 2.09 (1.34, 3.26) (1.23 (1.04, 1.46)) for all CVD.

Conclusions Lower educational attainment is associated with a higher risk of CVD or premature mortality in Asia, to a degree exceeding that in the Western populations of Australasia.


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