Association between socioeconomic status and cardiovascular disease by sex: Mediating roles of psychological and behavioral factors

Previous research shows that low socioeconomic status (SES) increases the risk of cardiovascular disease (CVD) and contributes to health disparities through the unequal distribution of intermediary factors. This study aims to examine mediation effects of psychological and health behavior factors in the SES–CVD pathway. Also, given the limitations of using a single SES indicator, we aimed to address these gaps by employing latent class analysis to construct a composite measure of SES. Our study analyzed data from the Korea Health Panel Survey, collected between 2009 and 2018. A total of 11,265 participants aged 30 and above, with no prior diagnosis of CVD and no missing responses, were included in the study. SES was derived using latent class analysis based on four variables: income, education, working status, and health insurance, conducted separately by sex. Causal mediation analysis was used to examine the pathway between SES and CVD by sex. Three SES classes were identified separately for men and women. Among men, low SES accounted for 12.7% (n = 639), medium SES for 63.1% (n = 3,177), and high SES for 24.2% (n = 1,218); among women, low SES accounted for 17.3% (n = 1,075), medium SES for 71.8% (n = 4,471), and high SES for 11.0% (n = 685). Among women, low SES was associated with a 18% shorter average survival time until CVD compared to medium SES. This association was partially mediated by depressed mood, accounting for 6.7% of the total effect, and by perceived anxiety/depression, accounting for 8.2%. Our findings indicate that psychological factors partially mediate the association between low SES and CVD among women, highlighting sex‑specific pathways in socioeconomic health disparities and underscoring the importance of incorporating mental health considerations into cardiovascular prevention strategies.