Changes in health-related quality of life and inequality in China: evidence from a nationwide repeated cross-sectional survey (2021–2023)

Abstract

Background: Health improvement is a multidimensional process requiring attention to both health levels and equity. This study examined nationwide trends in both the levels and equality of health-related quality of life (HRQoL) of Chinese residents during the COVID-19 pandemic (2021–2023). Methods: Data were extracted from the Psychology and Behavior Investigation of Chinese Residents (PBICR) survey: 9,963 participants in 2021, 28,280 in 2022, and 45,003 in 2023. HRQoL was assessed using the EQ-5D-5 L. Changes in the weighted average EQ-5D-5L utility index (UI) and visual analogue scale (VAS) scores were assessed. OLS regression models were used to verify the changes in UI and VAS scores over time, controlling variations in other variables. The Erreygers Index (EI) was calculated to measure inequality in UI and VAS scores. RIF-EI-OLS models were employed to decompose contributors to EI scores. Results: There was a slight decline in HRQoL over the study period, with 2021 showing the highest weighted average UI score (0.9363 ± 0.1389), compared to 0.9332 (SD = 0.1524) in 2022 (β=-0.0081, P < 0.0001) and 0.9244 (SD = 0.1546) in 2023 (β=-0.0143, P < 0.0001). The EI value for UI in 2021 was 0.0703, showing a decreasing trend to 0.0635 in 2022 (β=-0.0105, P < 0.001), with no further significant change in 2023. Regional disparities in both UI and EI were evident. Higher socioeconomic status (e.g., income, education) was associated with higher UI and lower EI scores. Chronic conditions were associated with lower UI scores, while co-morbidity was associated with higher EI scores. Higher UI and lower EI scores were also associated with higher health literacy and a better family environment. The predictors of VAS were similar to those for UI. The EI value for VAS showed an increasing trend. Conclusions: From 2021 to 2023, residents in mainland China experienced a slight decline in HRQoL, accompanied by a lowered UI inequality but higher VAS inequality in 2022 and 2023. These may reflect how life and health change under the specific context of the COVID-19 pandemic.