The role of cardiovascular risk factors on educational and regional inequalities in mortality in Spain 2016-2022: An analysis using multiple causes of death

Background: Cardiovascular (CVD) mortality is a key component of life expectancy dynamics. CVD mortality is influenced by well-established risk factors and inequalities across and within sub-populations exist. This paper assesses the role of risk factors on educational and regional inequalities in CVD and all-cause mortality in Spain and its regions (2016-2022). Methods: Using multiple cause-of-death mortality data, we examine two indicators of CVD mortality: 1) Deaths with CVDs as the underlying cause (CVD mortality); and 2) deaths with CVDs as the underlying cause and a mention in the death certificate of any of the following risk factors: diabetes, chronic kidney disease, obesity, lipidemias and hypertension (CVD mortality with risk factors). We use Poisson models to estimate Relative Index of Inequalities (RII) and counterfactual scenarios to estimate potential gains in life expectancy at age 35 resulting from eliminating educational and regional inequalities in risk factors associated with CVDs. Results: CVD deaths with any mentions of risk factors contributed to approximately one-third of CVD deaths and were strongly associated with CVD mortality and CVD mortality inequalities, especially among females. Eliminating inequalities in risk factors associated with CVDs would yield gains in life expectancy (for Spain: 0.19 years among females, 0.14 years among males), with regional variation. These gains were higher than expected compared to its relative weight on CVD and all-cause mortality. Conclusions: Our results suggest that targeting well-established risk factors is an effective strategy for regional health policies, to improve overall life expectancy and CVD mortality and to reduce socioeconomic inequalities.