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Original research
Socioeconomic position and cardiovascular mortality in 63 million adults from Brazil
  1. Poppy Alice Carson Mallinson1,
  2. Shammi Luhar1,2,
  3. Elizabeth Williamson1,
  4. Mauricio L Barreto3,4,
  5. Sanjay Kinra1
  1. 1Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
  2. 2Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
  3. 3Centre for Data and Knowledge Integration for Health (CIDACS), Fiocruz Bahia, Salvador, Bahia, Brazil
  4. 4Institute of Collective Health, Federal University of Bahia, Salvador, Bahia, Brazil
  1. Correspondence to Poppy Alice Carson Mallinson, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; poppy.mallinson1{at}


Background It has been suggested that cardiovascular disease exhibits a ‘social cross-over’, from greater risk in higher socioeconomic groups to lower socioeconomic groups, on economic development, but robust evidence is lacking. We used standardised data to compare the social inequalities in cardiovascular mortality across states at varying levels of economic development in Brazil.

Methods We used national census and mortality data from 2010. We used age-adjusted multilevel Poisson regression to estimate the association between educational status and cardiovascular mortality by state-level economic development (assessed by quintiles of Human Development Index).

Results In 2010, there were 185 383 cardiovascular deaths among 62.5 million adults whose data were analysed. The age-adjusted cardiovascular mortality rate ratio for women with <8 years of education (compared with 8+ years) was 3.75 (95% CI 3.29 to 4.28) in the least developed one-fifth of states and 2.84 (95% CI 2.75 to 2.92) in the most developed one-fifth of states (p value for linear trend=0.002). Among men, corresponding rate ratios were 2.53 (95% CI 2.32 to 2.77) and 2.26 (95% CI 2.20 to 2.31), respectively (p value=0.258). Associations were similar across subtypes of cardiovascular disease (ischaemic heart disease and stroke) and robust to the size of geographical unit used for analysis.

Conclusions Our results do not support a ‘social crossover’ in cardiovascular mortality on economic development. Our analyses, based on a large standardised dataset from a country that is currently experiencing economic transition, provide strong evidence that low socioeconomic groups experience the highest risk of cardiovascular disease, irrespective of the stage of national economic development.

  • coronary artery disease
  • epidemiology
  • global health
  • stroke
  • cardiac risk factors and prevention

Statistics from


  • Contributors PACM and SK conceived the study. PACM conducted data management and analyses, and wrote the first draft. EW provided statistical support. SL, EW, MLB and SK reviewed and commented on all drafts of the manuscript.

  • Funding This work was funded by Medical Research Council UK (grant number: MR/N013638/1) through a studentship to PACM.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data used in this study are made available online by the Brazilian Government. Mortality data were obtained from Ministry of Health’s DATASUS website (, census data for denominators were obtained from the Instituto Brasileiro de Geografia e Estatística website ( and Human Development Index data were obtained from the Atlas do Desenvolvimento Humano no Brasil website (

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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