Mediating role of health behaviors in income-related health inequalities: evidence from socioeconomically deprived rural areas of China.

Introduction: Existing evidence from high-income countries suggests that higher income is associated with better health outcomes through health-promoting behaviors. However, limited evidence exists regarding income-related health inequalities mediated by health behaviors in low- and middle-income countries. This study focuses on socioeconomically deprived rural areas of China and examines how health behaviors contribute to the association between income and health.

Methods: In 2023, a cross-sectional study comprising 6,674 participants was conducted in rural Shandong, China, using a stratified cluster random sampling method. Income was measured using annual per capita net household income. Health behaviors included smoking, overdrinking, teeth brushing, fruit and vegetable consumption, and physical activity. Health status was assessed using the self-rated health (SRH) scale, the activities of daily living (ADLs) scale and EuroQol-5 Dimension (EQ5D). The ordinary least squares (OLS) method was adopted to examine the associations among income, health behaviors and health status after controlling for confounding factors. The non-parametric bootstrapping method was employed to further explore the mediating role of health behaviors in income-related health inequalities.

Results: Income was positively associated with SRH, ADLs, EQ5D, and three positive behaviors including teeth brushing, fruit consumption, and physical activity, but was also positively correlated with overdrinking. Mediation analysis revealed that health behaviors mediated 35.05% (SRH), 67.90% (ADLs), and 72.08% (EQ5D) of the association between income and health status.

Conclusion: This study has shown income-related inequalities in both health and health behaviors in socioeconomically deprived rural areas of China. The health behaviors mediated the association between income and health status.