Regional Inequality, Healthcare Capacity, and Cardiovascular Disease in Türkiye: A Multilevel Study

Abstract Background Cardiovascular disease (CVD) is the leading cause of death in Türkiye. While individual risk factors are well known, the role of regional socioeconomic disparities and healthcare capacity in CVD incidence remains unclear. This study examined the influence of these regional factors-independent of personal risk-on six-year CVD incidence using a multilevel approach. Methods We analyzed data from the 2011 Türkiye Chronic Diseases and Risk Factors Survey, excluding those with prior CVD. A cohort of 16,137 adults was followed until 2017. Participants, nested within 12 NUTS-1 regions, were linked to regional indicators of unemployment, income inequality, hospital/bed density, and population per family physician. A random-intercept multilevel logistic regression was used to estimate associations between regional factors and CVD incidence, adjusting for individual-level sociodemographic, behavioral, and clinical risks. Analyses were conducted in R (v4.3.2). Results Among 10,653 participants, 4.9% developed CVD over six years. Higher risk was associated with older age (OR 3.06, 95% CI 2.72-3.43), elevated systolic blood pressure (OR 1.23, 95% CI 1.13-1.34 per 10 mmHg), current smoking (OR 1.35, 95% CI 1.06-1.72), impaired fasting glucose (OR 1.30, 95% CI 1.05-1.59), and urban residence (OR 1.29, 95% CI 1.05-1.59). At the regional level, greater income inequality increased CVD risk (OR 1.28, 95% CI 1.13-1.45 per 0.01 Gini), while more hospital beds were protective (OR 0.79, 95% CI 0.67-0.92 per 10 beds/10,000). Unemployment rates and hospital counts showed no significant associations. After full adjustment, regional clustering was minimal (ICC<0.1%). Conclusions Higher regional income inequality independently elevated CVD incidence, whereas greater hospital bed availability was protective. Reducing socioeconomic disparities and expanding inpatient resources-along with improved management of individual risk factors-may help mitigate Türkiye's cardiovascular disease burden. Key messages • Higher regional income inequality raises cardiovascular risk; policies that narrow income gaps could prevent many cases. • Reducing regional disparities in healthcare capacity could meaningfully lower Türkiye’s CVD burden.