Modifiable risk factors and overall cardiovascular mortality: Moderation of urbanization.

Abstract

Background: Modifiable risk factors are associated with cardiovascular mortality (CVM) which is a leading form of global mortality. However, diverse nature of urbanization and its objective measurement can modify their relationship. This study aims to investigate the moderating role of urbanization in the relationship of combined exposure (CE) of modifiable risk factors and CVM.Design and Methods: This is the first comprehensive study which considers different forms of urbanization to gauge its manifold impact. Therefore, in addition to existing original quantitative form and traditional two categories of urbanization, a new form consisted of four levels of urbanization was duly introduced. This study used data of 129 countries mainly retrieved from a WHO report, Non-Communicable Diseases Country Profile 2014. Factor scores obtained through confirmatory factor analysis were used to compute the CE. Age-income adjusted regression model for CVM was tested as a baseline with three bootstrap regression models developed for the three forms of urbanization.Results: Results revealed that the CE and CVM baseline relationship was significantly moderated through the original quantitative form of urbanization. Contrarily, the two traditional categories of urbanization could not capture the moderating impact. However, the four levels of urbanization were objectively estimated the urbanization impact and subsequently indicated that the CE was more alarming in causing the CVM in levels 2 and 3 urbanized countries, mainly from low-middle-income countries.Conclusion: This study concluded that the urbanization is a strong moderator and it could be gauged effectively through four levels whereas sufficiency of two traditional categories of urbanization is questionable.Significance for public healthWHO has set global targets for the control of CVDs and CVM, however, the required outcomes are only possible if implemented policies are aligned with customized regional needs. This study guides the health-care providers that urbanization, as a macro-level socio-demographic change, can substantially influence the relationship of modifiable risk factors and CVM if measured objectively. The efficacy of rural-urban dichotomy is questionable and needs precise measurement. The newly proposed effective classification of urbanization can act as risk strata which will improve the CVDs and CVM risk estimates. This will subsequently lead towards developing customized population-based strategies aimed at controlling the surge of CVM and its possible causes. This study advocates the public health-care providers that the rapid urbanization is a real challenge especially for low-middle-income countries which needs due diligence and a viable solution.