Environmental drivers of CVD DALYs: 20-year macro-level evidence from China's administrative data

Cardiovascular diseases (CVD) account for 40% of deaths in China, with increasing prevalence associated with rapid urbanization and aging populations. Current research lacks comprehensive analysis of macro-scale environment-socioeconomic interactions. This study establishes a framework analyzing five environmental determinants of CVD disability-adjusted life years (DALYs): air quality (M₁), green space accessibility (M₂), public service facilities (M₃), natural conservation status (M₄), and transportation infrastructure (M₅). Using 2000-2019 national and provincial data, we applied partial least squares structural equation modeling (PLS-SEM) to quantify direct/mediated effects, complemented by spatial heatmaps. Results reveal: (1) urbanization indirectly reduces CVD burden through improved transportation infrastructure (β = - 1.396, p < 0.1); (2) natural reserves provide the strongest protection (β = - 1.235, p < 0.01) with time-lagged effects; (3) significant synergy between green spaces and public services (r = 0.69); (4) high-risk provinces (e.g., Yunnan, Fujian) require geographically tailored strategies. The results can provide evidence-based planning strategies for CVD-mitigating urban development.