Male and Female Adult Population Health Status in China: A Cross-Sectional National Survey

China's population of 1.3 billion accounts for 20% of the world population, making it the most populated country in the world. With rapid economic growth and globalization, Chinese people's lifestyle has been changing dramatically towards being more physically inactive, eating more fast food, and being overall more stressed compared their old lifestyle. Because of the rapid change in lifestyle, population health is quickly shifting from a high mortality rate due to infectious and domestic diseases, related to 'poverty' before implementation of 'open door policy' in 1980, to a currently greater life expectancy and higher prevalence of chronic and non-communicable diseases brought on by 'affluence' [1].

In the last five decades, the Chinese population has become healthier as measured by decreased mortality rate and increased life expectancy. For example, infant mortality has decreased from 80.8/1000 live births in 1958 to 21.5/1000 live births in 2004 [2], maternal mortality has declined from 88.9/100000 live births in 1990 to 48.3/100000 live births in 2004, and life expectancy has increased from 57.0 years in 1957 to 71.8 years in 2004 [3]. The most recent data showed that heart disease, cancer and stroke are the major causes of death, accounting for 65% of all deaths and infectious disease has become the least important cause of death, only accounting for 3% of all deaths in Chinese population aged 40 or above [4].

Life expectancy is an internationally used health measure because many countries, including China, periodically calculated it using vital data. However, such measure mirrors mortality, and particularly infant mortality, but is insensitive to nonfatal and psychosocial conditions that contribute indirectly to death. Hence, it is imperative to assess population health using indicators that reflect contemporary health issues. This study aimed to describe the male and female adult Chinese population health status in multiple dimensions, including well-being, morbidity, quality of life, and health behaviors of smoking, alcohol consumption and physical activity, using data from the most recent National Health Services Survey from the Chinese government. Our descriptive study on Chinese population health status has application for international organizations because China's large population will influence global health status. Our study provided important information for generating research questions for future studies.

This study highlighted the Chinese adult population health status as the following: 1) only a small proportion of Chinese adults perceived their health as being poor; 2) chronic diseases were high, particularly hypertension, heart disease, chronic pulmonary disease and diabetes; 3) one third of Chinese had a functional problem; 4) prevalence of emotional and/or mental health problems surpassed prevalence of physical functional problems; 5) smoking and alcohol abuse was very common in men; 6) most of the Chinese surveyed were physical inactive and 7) male health status was better than female health status.

Non-communicable, rather than communicable, diseases are the major burden in China and the burden has dramatically increased in the last decade as that in some developing countries [8–10]. Compared to the self-reported health conditions in 1993 [2], our analysis of 2003 national survey data showed that prevalence of hypertension and stroke had doubled and prevalence of diabetes had tripled while the prevalence of pulmonary disease and infectious disease had declined by half. In reality, the prevalence of chronic diseases should be higher than our reports because of unawareness of their presence. For example, we reported prevalence of 3.6% for hypertension and 0.8% for diabetes. Based on previous report of unawareness rate of 55.3% for hypertension [11] and 66.6% for diabetes in China [12], the prevalence should be 8.1% for hypertension and 2.4% for diabetes.

In contrast with the social-economic gradient in health commonly found in the literature [13–16], the wealthier urban population in China is not found to be healthier than the rural population in terms of physician diagnosed chronic disease. Our findings are consistent with a previous report in China [17]. That study measured glucose tolerance among 42,751 residents who were randomly selected from 11 provinces in China, and reported diabetes prevalence rates of 5.8% in municipal areas, 2.9% in high income rural areas and 1.8% in low income rural areas [17].

There are several possible explanations for the above findings. First, the rural population had lower incidence of chronic disease compared with the urban population. The urban population, who has benefited most from China's economic development, has experienced a dramatic lifestyle change in the past two decades. Compared with before, they are becoming more physically inactive (commuting by cars rather than bicycles), and eating more fast food and high protein/fat food. Prior to the implementation of the "open door policy" in the 1980s, China's population health was characterized with a high prevalence of infectious diseases as a result of poverty. It has now shifted to a high prevalence of chronic and non-communicable diseases, brought on by 'affluence.' Such change is much more dominant in urban than rural populations. Of all daily sources of energy, cereals accounted for 61.4% and meat 10.8% for rural residents, compared with 48.5% and 17.6% respectively for urban residents [18].

The second possible explanation is that compared with the urban population, the rural population had a higher mortality rate (6.1/1000 versus 5.6/1000) [19], with a shorter duration from disease occurrence to death, and thus a lower life expectancy (69.5 versus 75.2 years) [20, 21]. It was reported that the rural population had higher rates of heart disease and stroke specific mortality than the urban population (330.7 versus 279.5/100,000 person-years for heart disease and 304.1 versus 256.1/100,000 person-years for stroke) [4]. The higher mortality rate is related to lower insurance coverage and lower ability to afford treatment among rural population compared with their counterparts in urban areas [22, 23]. China's current healthcare system relies heavily on a non-regulated market to reduce government health expenditure and allows public hospitals to determine the price of services within a certain range [24]. The rural population utilized physicians more than the urban population (52.0% versus 43.0%), but utilized hospitals far less (7.6% versus 11.1%, p < 0.001) when they were ill [25]. More people in rural than in urban areas opted for no treatment when suffering from an illness and were more likely to die earlier.

The third possible explanation is that rural populations were more likely than the urban population to be unaware of the presence of chronic disease. China's national physical measurement study [12] reported that the unawareness of diabetes was 71% and 62% for rural and urban populations, respectively.

Quality of life has been less studied in China although it is an important parameter of population health status. The reason may be due to unawareness of its importance and unavailability of well-developed and validated instruments in the Chinese language. A few previous reports on quality of life either in English or Chinese [26–28] focused on general populations in small geographic areas or patients receiving certain healthcare services. Our study findings of about 30% population with functional problems could not be compared to previous Chinese studies. Compared to a Canadian report [29], our study indicated that Chinese in mainland China had 5% more physical problems but 5% fewer emotional functional problems than Chinese in Canada. However, we have noticed that differences between these two studies in social demographic characteristics and cultural influence were not adjusted.

Health promotion for better nutrition, tobacco and alcohol reduction, increase in exercise, and hypertension control is critical for avoiding population health declining and promote quality of life. Smoking and alcohol abuse was very common in male population, particularly those in the middle age group, but was rare among females. This is related to the Chinese culture, which accepts male smoking and drinking but not female [30]. China's recent health promotion activities have achieved a decline in the male smoking rate from 70% in 1996 to 52% in 2003 [31]. However, many people are still unaware of the dangers in smoking; the proportion who were unaware of smoking's dangers was over 60% in some provinces and higher in rural than urban area [31]. Physical inactivity was common for both men and women. Interestingly, Chinese seniors were more active than the younger populations.

Hypertension is an important risk factor for many chronic diseases, particularly for stroke, heart disease and chronic renal disease. He and colleagues [4] found that hypertension contributed 11.7% to total mortality, smoking 7.9% and physical inactivity 6.8%, resulting in a total of 28.4% (when combined) to mortality in the Chinese adult population. However, these factors were very poorly controlled. About 30% of hypertensive patients took antihypertensive medication with 8.1% achieved blood pressure control [11], and 27.2% of diabetics took medication with 9.7% controlled diabetes [12]. The huge gap between presence, awareness, treatment and control of hypertension strongly indicates imperative needs for a national education program that targets the public, clinicians and decision makers to eliminate the gap. Reforming the healthcare system towards the universal insurance coverage is also essential to remove financial barrier to access the system.

There are four major limitations in the study. First limitation was that validity of self-report health condition was suboptimal. Our prevalence of chronic disease was likely underestimated as stated above. Second limitation was that we did not conduct risk factorial analysis for health status due to the nature of the cross sectional survey. Third limitation is that we did not assess child health status. The reason for that is the survey did not include children under age 15. Fourth limitation is that we only analyzed three major risk factors but were unable to assess other important risk factors of diet and obesity.

Our analysis demonstrated that males had better health status than females in terms of presence of self-perceived poor wellbeing, illness, chronic disease, and poor quality of life. However, smoking and frequent drinking of alcohol was more prevalent among males than that among females. Our results also indicated that prevalence of chronic illnesses was higher among the urban residents, as compared with rural residents among males and females. Along with reduction of the risk factors to chronic disease, promotion of emotional and mental health should be considered to increase quality of life. Further research on measuring mental health is imperative. Without intervening preventable risk factors for chronic diseases (i.e. reducing hypertension, smoking, alcohol abuse, and physical inactivity), the Chinese population health status will deteriorate even faster as the population ages rapidly due to one-child per family policy in the last thirty years.