Advancements in healthcare services have rapidly improved people’s health. However, these improvements are not uniform across all population groups. According to the characteristics of residential areas, physical environment, social and psychological environment, and health behavioral traits, health disparities continue to persist. The reason for this is that an individual’s health is influenced not only by their demographic characteristics but also by the material, social, psychological, and health behavioral characteristics of the community (Schwan, 2021). Social, economic, and political contexts shape an individual’s socioeconomic position in terms of income, education, occupation, and location. These factors influence exposure and vulnerability to health interventions such as health behaviors, material environment, and sociopsychological aspects. Thus, the unequal distribution of social and regional resources creates health inequalities, significantly impacting individual health levels (Peacock et al., 2014).

“Improving health equity” is a primary objective of South Korea’s fourth Comprehensive National Health Promotion Plan is considered important as it encompasses the objective of “extending healthy life expectancy.” Therefore, securing health equity is the core goal of South Korea’s health policy. To reduce health disparities, active interventions are necessary in the healthcare sector, as well as in the political, economic, and social domains that influence health behaviors, thereby preventing any widening of regional health gaps. Ultimately, policies and institutional improvements should be implemented to address and alleviate health disparities (Gostin and Friedman, 2020). To achieve this, both central and local government policies and interventions are crucial.

In 1980, the Black Report in the United Kingdom addressed the importance of health behaviors among other factors causing health inequalities, stating that health behaviors are distributed differently across social classes and that they can partially explain health inequalities (Macintyre, 1997). In 2008, the World Health Organization emphasized that reducing health inequities should expand beyond health issues and be addressed as a broader societal issue, drawing global attention to health policies and strategies based on the current inequalities in health status.

In 2007, South Korea initiated the Community Health Survey (CHS) as a pilot project targeting 20 cities, counties, and districts and expanded it to 254 regions. The CHS collects and observes health indicators annually to monitor regional health disparities. The Korea Disease Control and Prevention Agency (KDCA) regularly publishes “Regional Health Statistics at a Glance.” As a policy response to regional health disparities, eight regions (both metropolitan and basic local governments) with severe health disparities were selected as pilot areas since 2017 to identify the causes and develop solutions. However, policy research identifying and addressing the causes of regional health disparities remains unsatisfactory.

Previous studies on regional disparities reveal that groups with lower socioeconomic status, that is, low income and education levels, are less healthy with reduced life expectancy, and such groups benefit less from health improvements than those with higher status (Bahk et al., 2017; Khang and Kim, 2016). These groups also face higher risks of disease incidence and mortality, indicating health disparities (Subramania et al., 2001). Health inequality exists not only between urban and rural areas but also between the Seoul Metropolitan Area (centered around Seoul) and non-metropolitan regions, and within Seoul, specifically between the Gangnam and Gangbuk districts (Kim and Yoon, 2008; Lee et al., 2018). Furthermore, such inequities exist not only between regions but also within regions based on socioeconomic status which affect health behaviors such as smoking and obesity (Kim et al., 2018).

Gyeongsangbuk-do is a large administrative area, predominantly rural, with poor access to healthcare, resulting in significant differences in living standards. In fact, the province has become a superaged society, with the second-highest population of older adults among the 17 metropolitan and provincial regions in Korea. It also has the highest age-standardized mortality rate nationwide, and higher mortality rates than the national average for major chronic diseases, indicating significant regional disparities in health levels. Therefore, it is necessary to establish region-specific policies and strategies to address health disparities through prevention and research of chronic diseases in the Gyeongbuk region.

Recent studies have focused on socioeconomics (Blakely et al., 2002) and regional health disparities (Subramania et al., 2001). Although studies have focused on policy interventions and their impact, primarily aimed at addressing various health disparities between and within regions, there is a lack of in-depth research focusing on health disparities and trends in health indicators in Gyeongsangbuk-do and Daegu Metropolitan City. While the regional health statistics publication, Regional Health Statistics at a Glance, provides annual data on the overall health levels and key health indicators for each city, county, and district, including Gyeongsangbuk-do and Daegu Metropolitan City, in-depth analysis of region-specific requirements and detailed performance and trends in health indicators are lacking. This gap highlights the need for more comprehensive research to support the development of new health projects and policies to address health disparities and improve health outcomes in these regions. Evaluating the performance and achievement of health indicators in Gyeongsangbuk-do and Daegu Metropolitan City is key to not only for improving healthcare systems in the Gyeongbuk region (including Daegu), reducing health disparities, and enhancing the efficiency of resource allocation but also for developing effective health policies and promoting community health.

Therefore, this study compares Gyeongsangbuk-do and Daegu Metropolitan City to assess the extent of health disparities in Gyeongsangbuk-do. Additionally, by utilizing regional statistical data (such as the CHS) that examine trends in the performance and achievement of health indicators over a 12-year period, this study focused on identifying key health indicators with significant disparities between the two regions. This analysis provides essential foundational data for reducing health disparities and improving health among residents of the Gyeongbuk region and develops preventive health management strategies and health promotion policies.

This study examined the health issues and disparities between Gyeongsangbuk-do and Daegu Metropolitan City using the performance and achievement of health indicators over a 12-year period between 2011 and 2022, divided into the fifth to seventh phases of the CHS conducted by the KDCA. The specific study objectives are as follows: examine the trends in demographic factors. Assess the performance and achievement of health behavior indicators. Evaluate the performance and achievement of health outcome indicators. Analyze the performance and achievement of healthcare utilization indicators.

Using raw data collected between 2011 and 2022 by the CHS and KOSIS, this study attempted to identify the health inequality status between Gyeongsangbuk-do and Daegu by examining trends in demographic factors, health behaviors, health outcomes, medical use status performance, and goal achievement in cities, counties, and districts.

In terms of demographic characteristics, particularly population size and growth rate, Gyeongsangbuk-do has a high population decline rate (ranking second nationwide). This indicates a significant disparity in population compared to the Seoul Metropolitan Area, thus highlighting the severe imbalances in regional population in Gyeongsangbuk-do. Note that Gyeongsangbuk-do has the second-highest proportion of individuals aged 65 years or above in South Korea (23.9%) and is now designated as a “superaged society.” Therefore, national and regional policy measures that address economic and health disparities in older residents are imperative. South Korea has implemented a 5-year basic plan since 2006 to address issues related to declining birth rates, aging, and population decline. However, owing to the temporary nature of the policies and limited financial investments, the birth rate has not improved. Therefore, solutions that address the root causes of low birth rates should be developed rather than temporary measures.

Among the 16 indicators of health behavior, Gyeongsangbuk-do achieved five indicators (31.3%) and improved 11 (68.7%), and Daegu Metropolitan City achieved 11 indicators (68.7%) and improved five (31.3%). Among the health behavior indicators, Daegu Metropolitan City had five indicators (1.4 regions on average), whereas Gyeongsangbuk-do had seven indicators (4.4 regions on average), indicating that the health behavior of Gyeongsangbuk-do residents did not show improvement compared to that of Daegu Metropolitan City residents. Among health behaviors, self-reported obesity rate was the most deteriorating indicator in Gyeongsangbuk-do, observed in 13 cities, counties, and districts (56.2%). Thus, projects focused on obesity rate improvement should be accorded highest priority among health behaviors. The annual high-risk drinking rate, attempt to abstain from consuming alcohol, walking practice rate, and healthy life practice rate deteriorated in four cities, counties, and districts (17.4%) in Gyeongsangbuk-do. However, in Daegu Metropolitan City, abstaining from alcohol consumption showed the highest deterioration (three regions, 37.5%), followed by one region in annual high-risk drinking rate, walking practice rate, healthy life practice rate, and obesity rate (self-report). The obesity rate (self-reported) shows an annually increasing trend, similar to the national average. The primary cause of obesity is decreased physical activity. The increase in obesity rates during the seventh phase, which coincided with the corona-virus disease 2019 (COVID-19) pandemic, can be attributed to the following factors. First, changes in lifestyle patterns such as social isolation and reduced outings significantly contributed toward an increase in obesity. Second, the boom in home delivery services during the pandemic (Li et al., 2022) in South Korea increased the consumption of food and meal kit products. This shift from cooking at home to dining out or ordering may result in obesity changes. Robinson et al. (2021) revealed an increase in body mass index during the COVID-19 isolation period; it is likely that the reduction in physical activity and changes in eating patterns contributed to an increase in obesity rates. Obesity is the root cause of many diseases and is associated with a metabolic syndrome, diabetes, coronary artery disease, and cancer (Robinson et al., 2021). Therefore, reducing the obesity rate is crucial for preventing chronic diseases. Improving health-related behaviors and implementing programs that target obesity reduction are essential to address this issue.

Three of the nine health outcome indicators deteriorated in Daegu Metropolitan City (average: 2.7 regions, 33.3%); whereas seven (average of the seven regions: 30.4%) declined in Gyeongsangbuk-do. Health results did not show more improvement in Gyeongsangbuk-do than in Daegu Metropolitan City. The most common indicators of exacerbation in Gyeongsangbuk-do was depression (13 regions, 56.6%), followed by diabetes (11 regions, 47.8%), high blood pressure (10 regions, 43.5%), subjective health awareness (five regions, 21.7%), suicide rate (five regions, 21.7%), stress awareness rate (three regions, 13.0%), and treatment rate (two regions, 8.7%) for those diagnosed with diabetes and over 30 years of age. In Daegu Metropolitan City, highest exacerbation was observed in depression (four regions, 50.0%), followed by diabetes (three regions, 37.5%), and subjective health awareness (one region, 12.5%). Evidently, the prevalence of depressive symptoms has steadily increased, similar to the national trend. There is a significant association between the COVID-19 pandemic and depressive symptoms (Ettman et al., 2020), and the worsening of depressive symptoms during the seventh phase may be attributed to its overlap with the pandemic period. Additionally, the outbreak of the Middle East respiratory syndrome in 2015 coincided with the sixth term, indicating a possible association between the increase in depressive symptoms from the sixth to the seventh phases following the outbreak of the infectious disease. These findings suggest that social isolation and the acute impact of infectious diseases may have heightened the sense of crisis and increased depressive symptoms (Leigh-Hunt et al., 2017). Depression can have adverse outcomes on health through mechanisms such as cardiovascular diseases and elevated blood pressure (Bludorn and Railey, 2024), and can also affect the management of chronic conditions such as hypertension, diabetes, and suicide. Therefore, mental health interventions that aim to improve depressive symptoms are crucial.

Of the three healthcare utilization indicators, two (average: 5.5 regions, 23.9%) deteriorated in Gyeongsangbuk-do, while one (average: two regions, 25.0%) in Daegu. It is evident that healthcare utilization did not improve as much in Gyeongsangbuk-do as in Daegu Metropolitan City. Among the healthcare utilization indicators, the most significant deterioration in Gyeongsangbuk-do was observed in the annual diabetes-related eye disease complication examination rate (eight regions, 34.8%) and annual diabetes-related kidney disease complication examination rate (three regions, 13.0%). In contrast, Daegu Metropolitan City experienced a deterioration in the annual diabetes-related eye disease complication examination rate (two regions, 25.0%). In the Gyeongsangbuk-do region (including Daegu), diagnosis rates for both hypertension and diabetes have continuously increased, similar to the national trend. In the Gyeongsangbuk-do region (including Daegu), treatment rates for individuals diagnosed with hypertension and diabetes have remained high at over 90% since the seventh phase, and the increasing rates are of concern. Additionally, the annual screening rates for diabetic retinopathy and nephropathy complications are lower than the national average, highlighting the need for attention and improvement in these areas. Management of hypertension and diabetes can prevent metabolic diseases and complications. Therefore, physical activity, lifestyle changes, and screening tests are important for managing chronic diseases (e.g., high blood pressure and diabetes), and continuity is required when conducting improvement projects. Through this study, it is evident that the Gyeongbuk region, particularly Gyeongsangbuk-do, is challenged by severe health disparities than Daegu Metropolitan City, with a greater number of communities experiencing worsening of health indicators. This study has also identified that psychological disorders, such as depression and obesity, and chronic diseases, such as hypertension and diabetes, are indicators that require continuous improvement efforts in Gyeongsangbuk-do.

This study has attempted to report stable changes in indicators by comparing average values over 12 years; however, a limitation is that it is difficult to separately interpret the social variables of COVID-19, and a comparison with recent years could not be conducted. Additionally, the analysis period was short (four months), and this has constrained the analysis to only 28 basic research indicators (intervention factors), resulting in recommendations for only limited indicator improvement projects.