Trends in socioeconomic disparities in stroke mortality in six european countries between 1981-1985 and 1991-1995

Socioeconomic inequalities across life and premature mortality from 1971 to 2016: findings from three British birth cohorts born in 1946, 1958 and 1970

INTRODUCTION

Disadvantaged socioeconomic position (SEP) in early and adult life has been repeatedly associated with premature mortality. However, it is unclear whether these inequalities differ across time, nor if they are consistent across different SEP indicators.

METHODS

British birth cohorts born in 1946, 1958 and 1970 were used, and multiple SEP indicators in early and adult life were examined. Deaths were identified via national statistics or notifications. Cox proportional hazard models were used to estimate associations between ridit scored SEP indicators and all-cause mortality risk-from 26 to 43 years (n=40 784), 26 to 58 years (n=35 431) and 26 to 70 years (n=5353).

RESULTS

More disadvantaged SEP was associated with higher mortality risk-magnitudes of association were similar across cohort and each SEP indicator. For example, HRs (95% CI) from 26 to 43 years comparing lowest to highest paternal social class were 2.74 (1.02 to 7.32) in 1946c, 1.66 (1.03 to 2.69) in 1958c, and 1.94 (1.20 to 3.15) in 1970c. Paternal social class, adult social class and housing tenure were each independently associated with mortality risk.

CONCLUSIONS

Socioeconomic circumstances in early and adult life show persisting associations with premature mortality from 1971 to 2016, reaffirming the need to address socioeconomic factors across life to reduce inequalities in survival to older age.

Progress in reducing inequalities in cardiovascular disease mortality in Europe

OBJECTIVE

To assess whether recent declines in cardiovascular mortality have benefited all socioeconomic groups equally and whether these declines have narrowed or widened inequalities in cardiovascular mortality in Europe.

METHODS

In this prospective registry-based study, we determined changes in cardiovascular mortality between the 1990s and the early 2010s in 12 European populations by gender, educational level and occupational class. In order to quantify changes in the magnitude of differences in mortality, we calculated both ratio measures of relative inequalities and difference measures of absolute inequalities.

RESULTS

Cardiovascular mortality has declined rapidly among lower and higher socioeconomic groups. Relative declines (%) were faster among higher socioeconomic groups; absolute declines (deaths per 100 000 person-years) were almost uniformly larger among lower socioeconomic groups. Therefore, although relative inequalities increased over time, absolute inequalities often declined substantially on all measures used. Similar trends were seen for ischaemic heart disease and cerebrovascular disease mortality separately. Best performer was England and Wales, which combined large declines in cardiovascular mortality with large reductions in absolute inequalities and stability in relative inequalities in both genders. In the early 2010s, inequalities in cardiovascular mortality were smallest in Southern Europe, of intermediate magnitude in Northern and Western Europe and largest in Central-Eastern European and Baltic countries.

CONCLUSIONS

Lower socioeconomic groups have experienced remarkable declines in cardiovascular mortality rates over the last 25 years, and trends in inequalities can be qualified as favourable overall. Nevertheless, further reducing inequalities remains an important challenge for European health systems and policies.

What causes the burden of stroke in Scotland? A comparative risk assessment approach linking the Scottish Health Survey to administrative health data

Background

The availability of robust evidence to inform effective public health decision making is becoming increasingly important, particularly in a time of competing health demands and limited resources. Comparative Risk Assessments (CRA) are useful in this regard as they quantify the contribution of modifiable exposures to the disease burden in a population. The aim of this study is to assess the contribution of a range of modifiable exposures to the burden of disease due to stroke, an important public health problem in Scotland.

Methods

We used individual-level response data from eight waves (1995–2012) of the Scottish Health Survey linked to acute hospital discharge records from the Scottish Morbidity Record 01 (SMR01) and cause of death records from the death register. Stroke was defined using the International Classification of Disease (ICD) 9 codes 430–431, 433–4 and 436; and the ICD10 codes I60-61 and I63-64 and stroke incidence was defined as a composite of an individual’s first hospitalisation or death from stroke. A literature review identified exposures causally linked to stroke. Exposures were mapped to the layers of the Dahlgren & Whitehead model of the determinants of health and Population Attributable Fractions were calculated for each exposure deemed a significant causal risk of stroke from a Cox Proportional Hazards Regression model. Population Attributable Fractions were not summed as they may add to more than 100% due to the possibility of a person being exposed to more than one exposure simultaneously.

Results

Overall, the results suggest that socioeconomic factors explain the largest proportion of incident stroke hospitalisations and deaths, after adjustment for confounding. After DAG adjustment, low education explained 38.8% (95% Confidence Interval 26.0% to 49.4%, area deprivation (as measured by the Scottish Index of Multiple Deprivation) 34.9% (95% CI 26.4 to 42.4%), occupational social class differences 30.3% (95% CI 19.4% to 39.8%), high systolic blood pressure 29.6% (95% CI 20.6% to 37.6%), smoking 25.6% (95% CI 17.9% to 32.6%) and area deprivation (as measured by the Carstairs area deprivation Index) 23.5% (95% CI 14.4% to 31.7%), of incident strokes in Scotland after adjustment.

Conclusion

This study provides evidence for prioritising interventions that tackle socioeconomic inequalities as a means of achieving the greatest reduction in avoidable strokes in Scotland. Future work to disentangle the proportion of the effect of deprivation transmitted through intermediate mediators on the pathway between socioeconomic inequalities and stroke may offer additional opportunities to reduce the incidence of stroke in Scotland.

Differences in declining mortality rates due to coronary heart disease by neighbourhood deprivation

BACKGROUND

Cardiovascular disease (CVD) is the main cause of death in most industrialised countries, including those in Europe. The mortality rates due to coronary heart disease (CHD), one of the most serious CVD conditions, have been decreasing in most European countries during the last decades. However, whether the trends over time in CHD mortality rates differ depending on neighbourhood deprivation has rarely been investigated.

METHODS

For each year of the study period, 1988-2012, in Sweden, age-standardised mortality rates were calculated for three different types of neighbourhoods, characterised by a Neighbourhood Deprivation Index. Joinpoint regression was used to investigate potential changes in age-standardised mortality rates by neighbourhood deprivation and over time.

RESULTS

Over the study period, age-standardised mortality rates due to CHD were consistently the highest in the deprived neighbourhoods and the lowest in the affluent neighbourhoods. We observed a statistically significant overall decline, ranging from 67% to 59%, in the age-standardised CHD mortality rates for each level of neighbourhood deprivation. Furthermore, the decline for the affluent neighbourhoods was significantly higher compared with the decline in the deprived neighbourhoods.

CONCLUSION

Age-standardised CHD mortality rates decreased significantly in Sweden between 1988 and 2012. This decline was more pronounced in the affluent neighbourhoods, which indicates that the improvements in prevention and treatment of CHD have not benefited individuals residing in deprived neighbourhoods to an equal extent. Knowledge of time trends in CHD mortality by level of neighbourhood deprivation may help guide decision-makers in the development of appropriate healthcare policies for deprived neighbourhoods.

The Life Course, Cohort Dynamics, and International Differences in Aging Trajectories

In recent years, population health research has focused on understanding the determinants of later-life health. Two strands of that work have focused on (1) international comparisons of later-life health and (2) assessing the early-life origins of disease and disability and the importance of life course processes. However, the less frequently examined intersection of these approaches remains an important frontier. The present study contributes to the integration of these approaches. We use the Health and Retirement Study family of data sets and a cohort dynamic approach to compare functional health trajectories across 12 high-income countries and to examine the role of life course processes and cohort dynamics in contributing to variation in those trajectories. We find substantial international variation in functional health trajectories and an important role of cohort dynamics in generating that variation, with younger cohorts often less healthy at comparable ages than the older cohorts they are replacing. We further find evidence of heterogeneous effects of life course processes on health trajectories. The results have important implications for future trends in morbidity and mortality as well as public policy.

Determinants of the magnitude of socioeconomic inequalities in mortality: A study of 17 European countries

The magnitude of socioeconomic inequalities in mortality differs importantly between countries, but these variations have not been satisfactorily explained. We explored the role of behavioral and structural determinants of these variations, by using a dataset covering 17 European countries in the period 1970-2010, and by conducting multilevel multivariate regression analyses. Our results suggest that between-country variations in inequalities in current mortality can partly be understood from variations in inequalities in smoking, excessive alcohol consumption, and poverty. Also, countries with higher national income, higher quality of government, higher social transfers, higher health care expenditure and more self-expression values have smaller inequalities in mortality. Finally, trends in behavioral risk factors, particularly smoking and excessive alcohol consumption, appear to partly explain variations in inequalities in mortality trends. This study shows that analyses of variations in health inequalities between countries can help to identify entry-points for policy.

Urban and rural stroke mortality rates in China between 1988 and 2013: An age-period-cohort analysis

Objective

To evaluate effects attributable to age, time period and birth cohort, on stroke mortality data from urban and rural regions in China between 1988 and 2013.

Methods

Mortality data were obtained from the Chinese Health Statistics Annual Report (1987–2001) and Chinese Health Statistics Yearbooks (2003–2014). Population data were obtained from population censuses (i.e. 1982, 1990, 2000 and 2010). Data were analysed using an age-period-cohort (APC) model and intrinsic estimation (IE) method.

Results

The age effect suggested that all older residents had higher stroke mortality risk than younger residents. Period effect showed that compared with figures for 1988, stroke mortality in 2013 was 1.8 times higher for urban regions and 2.4 times higher for rural regions. After controlling for age and period effects, cohorts born before the Chinese economic reform had a steady decline in stroke mortality. However, mortality rates increased and fluctuated in post-reform cohorts.

Conclusions

This APC-IE analysis identified a modest period effect with large age and cohort contributions to both the overall mortality and the disparity between urban and rural stroke mortality. Identifying early life and cumulative risk factors for stroke, improving equality in stroke prevention and care are needed to reduce the stroke mortality in China.

Variations in vascular mortality trends, 2001-2010, among 1.3 million women with different lifestyle risk factors for the disease

AIMS

Vascular disease mortality has declined rapidly in most Western countries, against a background of improved treatments and falling prevalence of smoking, but rising obesity. We examined whether this decline differed by lifestyle risk factors for vascular disease.

METHODS AND RESULTS

During 2001-2010, there were 9241 vascular disease deaths in a prospective study of 1.3 million women in middle age, about one-quarter of all UK women in the eligible age range (50-64 years in 1996-2001). We estimated percentage declines in mortality from coronary heart disease, cerebrovascular disease and other vascular diseases, overall and by age, smoking, alcohol consumption, adiposity, physical activity, socioeconomic status and age at leaving school. Over 10 years, coronary heart disease mortality fell by half (52%), cerebrovascular disease mortality by two-fifths (42%) and other vascular disease mortality by one-fifth (22%). Lean women experienced greater declines in coronary heart disease mortality than overweight or obese women (70%, 48% and 26%, respectively; P < 0.001 for heterogeneity) and women in the highest and middle thirds of socioeconomic status experienced greater declines in other (non-coronary, non-cerebrovascular) vascular disease mortality than women in the lowest third (41% and 42% and -9%, respectively; P = 0.001). After accounting for multiple testing, there were no other significant differences in vascular mortality trends by any lifestyle risk factor, including by smoking status.

CONCLUSION

Vascular disease mortality trends varied in this cohort by adiposity and socioeconomic status, but not by smoking status or other lifestyle risk factors. Prevention and treatment of vascular disease appear not to have been equally effective in all subgroups of UK women.

Trends in socioeconomic status-related differences in mortality among people with chronic obstructive pulmonary disease

RATIONALE

Previous studies have demonstrated that people of higher socioeconomic status (SES) have better chronic obstructive pulmonary disease (COPD) health outcomes than those of lower SES. Mortality of people with COPD has decreased over the last decade; however, it is not known if all individuals with COPD have benefitted equally.

OBJECTIVE

The objective of the current study was to examine the impact of SES on mortality trends of individuals with COPD.

METHODS

We conducted a population-based study using health administrative data from Ontario, Canada, between 1996/7 and 2011/12. Individuals with COPD were identified using a previously validated case definition. SES was determined using average household income of the individual's neighborhood as per the Canadian Census. Trends in standardized COPD mortality rates among different SES quintiles were observed over time.

MEASUREMENTS AND MAIN RESULTS

Overall, age- and sex-standardized mortality of people with COPD decreased from 5.7% (95% confidence interval [CI], 5.5-5.8) in 1996/7 to 3.7% (95% CI, 3.6-3.8) in 2011/12, representing a 35% relative decrease. The mortality difference between the lowest and highest income quintiles increased from 67 per 10,000 individuals in 1996/7 to 86 per 10,000 individuals in 2011/12, representing a 28% relative increase (P < 0.001).

CONCLUSIONS

Mortality in people with COPD has decreased faster in people with the highest compared with the lowest SES, causing increased disparity between rich and poor. Further study and strategies are needed to explore and address factors responsible for this increasing disparity in the COPD population.

Georeferencing deaths from stroke in São Paulo: an intra-city stroke belt?

Background

The role of socioeconomic status in the worldwide stroke burden has been studied with various methods using vital statistics and research-generated data.

Aim

The objective of our study was to describe the stroke mortality rates and the stroke mortality distribution, and to evaluate the association between stroke mortality rates and geographical distribution with the human development index in São Paulo, Brazil.

Methods

This ecological study evaluated a historical series of stroke mortality in São Paulo, Brazil, from 2004 to 2010. Standard stroke mortality rate per 100 000 inhabitants at each year, the address of residence assumed as the place of living, and the human development index applied as a social indicator were used in order to evaluate if stroke mortality correlated with socioeconomic status.

Results

The mean standardized stroke mortality in São Paulo decreased from 66 to 46-7 per 100 000 inhabitants from 2004 to 2010. Stroke mortality differed according to human development index strata with an almost three times higher stroke mortality in the lowest when compared with the highest human development index stratum. Visual inspection of the map of the districts with high stroke mortality disclosed regional clusters with high mortality in the east, northwest, and south regions, a finding suggestive of the presence of a stroke belt inside the city of São Paulo.

Conclusions

In conclusion, between 2004 and 2010, stroke mortality rates decreased by 28-5% in São Paulo. A geographical pattern in stroke mortality could be observed, with considerable differences according the human development index level of the place of living.

Income inequalities and stroke mortality trends in Sao Paulo, Brazil, 1996-2011

Background

It is not clear the relationship between stroke mortality trends and socioeconomic inequalities in low- and middle-income countries.

Aims

We compared differences of trends in stroke mortality by socioeconomic status in the city of Sao Paulo, Brazil.

Methods

We analyzed the intra-urban distribution of stroke death rates from 1996 to 2011 for persons aged 35-74 years old according to income using joinpoint regression.

Results

We confirmed 77 848 stroke deaths in the period, 51-4% of them among persons aged 35-74 years old. For all areas, there was parallelism between genders, and the average annual percent changes combined was -5.2 (-5.7 to -4.6) from 1996 to 2005 and -30 (-4.3 to -1.7) from 2005 to 2011. The full period average annual percent changes of age-adjusted rates between persons living in the high- and low-income area were, respectively, -5.4 and -4.2 ( P = 0.002) for men and -5.9 vs.-4.9 ( P = 0.017) for women. Differences in the risk of stroke between the high- and low-income areas increased more than twofold in the period in both genders.

Conclusions

The risk of stroke death is decreasing in all regions, but the faster decline in mortality rates in the wealthiest area contributes to further greater inequalities.

Neighborhood geographic disparities in heart attack and stroke mortality: comparison of global and local modeling approaches

This study investigated neighborhood geographic disparities in myocardial infarction (MI) and stroke mortality risks in middle Tennessee and identified determinants of observed disparities. Descriptive and spatial analyses were performed on MI and stroke mortality data covering the time period 1999-2007. Besag, York and Molliè (BYM) model was used to investigate spatial patterns. Global (BYM) and local models [Poisson Geographically Weighted Generalized Linear Models (GWGLM)] were used to investigate determinants of the identified spatial patterns. Significant (p<0.05) differences in mortality risks by sex, race, age and education were observed. Rural census tracts (CT) and those with higher proportions of the older populations were associated with high MI and stroke mortality risks. Additionally, CTs with high proportions of widows had significantly higher mortality risks for stroke. There was evidence of geographical variability of all regression coefficients implying that local models complement the findings of the global models and provide useful information to guide local and regional disease control decisions and resource allocation. Identification of high risk CTs is essential for targeting resources and will aid the development of more needs-based prevention programs.

Rising inequality in mortality among working-age men and women in Sweden: a national registry-based repeated cohort study, 1990-2007

Background

In the past two decades, health inequality has persisted or increased in states with comprehensive welfare.

Methods

We conducted a national registry-based repeated cohort study with a 3-year follow-up between 1990 and 2007 in Sweden. Information on all-cause mortality in all working-age Swedish men and women aged between 30 and 64 years was collected. Data were subjected to temporal trend analysis using joinpoint regression to statistically confirm the trajectories observed.

Results

Among men, age-standardised mortality rate decreased by 38.3% from 234.9 to 145 (per 100 000 population) over the whole period in the highest income quintile, whereas the reduction was only 18.3% (from 774.5 to 632.5) in the lowest quintile. Among women, mortality decreased by 40% (from 187.4 to 112.5) in the highest income group, but increased by 12.1% (from 280.2 to 314.2) in the poorest income group. Joinpoint regression identified that the differences in age-standardised mortality between the highest and the lowest income quintiles decreased among men by 18.85 annually between 1990 and 1994 (p trend=0.02), whereas it increased later, with a 2.88 point increase per year (p trend <0.0001). Among women, it continuously increased by 9.26/year (p trend <0.0001). In relative terms, age-adjusted mortality rate ratios showed a continuous increase in both genders.

Conclusions

Income-based inequalities among working-age male and female Swedes have increased since the late 1990s, whereas in absolute terms the increase was less remarkable among men. Structural and behavioural factors explaining this trend, such as the economic recession in the early 1990s, should be studied further.

All part of the job? The contribution of the psychosocial and physical work environment to health inequalities in Europe and the European health divide

This study is the first to examine the contribution of both psychosocial and physical risk factors to occupational inequalities in self-assessed health in Europe. Data from 27 countries were obtained from the 2010 European Working Conditions Survey for men and women aged 16 to 60 (n = 21,803). Multilevel logistic regression analyses (random intercept) were applied, estimating odds ratios of reporting less than good health. Analyses indicate that physical working conditions account for a substantial proportion of occupational inequalities in health in both Central/Eastern and Western Europe. Physical, rather than psychosocial, working conditions seem to have the largest effect on self-assessed health in manual classes. For example, controlling for physical working conditions reduced the inequalities in the prevalence of"less than good health" between the lowest (semi- and unskilled manual workers) and highest (higher controllers) occupational groups in Europe by almost 50 percent (Odds Ratio 1.87, 95% Confidence Interval 1.62-2.16 to 1.42, 1.23-1.65). Physical working conditions contribute substantially to health inequalities across "post-industrial" Europe, with women in manual occupations being particularly vulnerable, especially those living in Central/Eastern Europe. An increased political and academic focus on physical working conditions is needed to explain and potentially reduce occupational inequalities in health.

Trends in socioeconomic inequalities in ischemic heart disease mortality in small areas of nine Spanish cities from 1996 to 2007 using smoothed ANOVA

The aim of this study was to analyze the evolution of socioeconomic inequalities in mortality due to ischemic heart diseases (IHD) in the census tracts of nine Spanish cities between the periods 1996-2001 and 2002-2007. Among women, there are socioeconomic inequalities in IHD mortality in the first period which tended to remain stable or even increase in the second period in most of the cities. Among men, in general, no socioeconomic inequalities have been detected for this cause in either of the periods. These results highlight the importance of intra-urban inequalities in mortality due to IHD and their evolution over time.

Socioeconomic Status and Care After Stroke

Background and Purpose—

Socioeconomic status is inversely associated with mortality after stroke; however, the reasons behind this finding are not well-understood. We undertook a study to determine whether posthospitalization care and medication adherence vary with neighborhood income.

Methods—

We conducted a cohort study of 11 050 patients with ischemic stroke or transient ischemic attack admitted to any of 11 specialized stroke centers in Ontario, Canada, between July 1, 2003 and March 31, 2008. Socioeconomic status measured as neighborhood income quintiles was imputed from the 2006 Canadian Census. We used linkages to administrative databases to evaluate processes of stroke care and medication adherence within 1 year of discharge. We used multivariable analyses to assess whether differences in stroke care and medication adherence existed across income groups after adjustment for age, sex, stroke severity, and comorbid conditions.

Results—

Higher income was associated with higher rates of stroke unit admission, neurology consultations, referrals to secondary prevention clinics, and physician visits after hospital discharge; however, the absolute differences in rates were small. There was no difference across income quintiles in the use of postdischarge homecare services or in adherence to antihypertensive, antithrombotic, or lipid-lowering medications.

Conclusions—

Higher income is associated with improvements in some aspects of stroke care delivery. However, the magnitude of the care gap across income quintiles is small and is unlikely to account for the previously observed association between socioeconomic status and survival after stroke.

Health Inequalities in Global Context

The existence of social inequalities in health is well established. One strand of research focuses on inequalities in health within a single country. A separate and newer strand of research focuses on the relationship between inequality and average population health across countries. Despite the theorization of (presumably variable) social conditions as "fundamental causes" of disease and health, the cross-national literature has focused on average, aggregate population health as the central outcome. Controversies currently surround macro-structural determinants of overall population health such as income inequality. We advance and redirect these debates by conceptualizing inequalities in health as cross-national variables that are sensitive to social conditions. Using data from 48 World Values Survey countries, representing 74% of the world's population, we examine cross-national variation in inequalities in health. The results reveal substantial variation in health inequalities according to income, education, sex, and migrant status. While higher socioeconomic position is associated with better self-rated health around the globe, the size of the association varies across institutional context, and across dimensions of stratification. There is some evidence that education and income are more strongly associated with self-rated health than sex or migrant status.

Neighborhood income and stroke care and outcomes

OBJECTIVE

To evaluate factors that may contribute to the increased stroke case fatality rates observed in individuals from low-income areas.

METHODS

We conducted a cohort study on a population-based sample of all patients with stroke or TIA seen at 153 acute care hospitals in the province of Ontario, Canada, between April 1, 2002, and March 31, 2003, and April 1, 2004, and March 31, 2005. Socioeconomic status measured as income quintiles was imputed from median neighborhood income. In the study sample of 7,816 patients we determined 1-year mortality by grouped income quintile and used multivariable analyses to assess whether differences in survival were explained by cardiovascular risk factors, stroke severity, stroke management, or other prognostic factors.

RESULTS

There was no significant gradient across income groups for stroke severity or stroke management. However, 1-year mortality rates were higher in those from the lowest income group compared to those from the highest income group, even after adjustment for age, sex, stroke type and severity, comorbid conditions, hospital and physician characteristics, and processes of care (adjusted hazard ratio for low- vs high-income groups, 1.18; 95 confidence interval 1.03 to 1.29).

CONCLUSIONS

In Ontario, 1-year survival rates after an index stroke are higher for those from the richest compared to the least wealthy areas, and this is only partly explained by age, sex, comorbid conditions, and other baseline risk factors.

Does an immigrant health paradox exist among Asian Americans? Associations of nativity and occupational class with self-rated health and mental disorders

A robust socioeconomic gradient in health is well-documented, with higher socioeconomic status (SES) associated with better health across the SES spectrum. However, recent studies of U.S. racial/ethnic minorities and immigrants show complex SES-health patterns (e.g., flat gradients), with individuals of low SES having similar or better health than their richer, U.S.-born and more acculturated counterparts, a so-called "epidemiological paradox" or "immigrant health paradox". To examine whether this exists among Asian Americans, we investigate how nativity and occupational class (white-collar, blue-collar, service, unemployed) are associated with subjective health (self-rated physical health, self-rated mental health) and 12-month DSM-IV mental disorders (any mental disorder, anxiety, depression). We analyzed data from 1530 Asian respondents to the 2002-2003 National Latino and Asian American Study in the labor force using hierarchical multivariate logistic regression models controlling for confounders, subjective social status (SSS), material and psychosocial factors theorized to explain health inequalities. Compared to U.S.-born Asians, immigrants had worse socioeconomic profiles, and controlling for age and gender, increased odds for reporting fair/poor mental health and decreased odds for any DSM-IV mental disorder and anxiety. No strong occupational class-health gradients were found. The foreign-born health-protective effect persisted after controlling for SSS but became nonsignificant after controlling for material and psychosocial factors. Speaking fair/poor English was strongly associated with all outcomes. Material and psychosocial factors were associated with some outcomes--perceived financial need with subjective health, uninsurance with self-rated mental health and depression, social support, discrimination and acculturative stress with all or most DSM-IV outcomes. Our findings caution against using terms like "immigrant health paradox" which oversimplify complex patterns and mask negative outcomes among underserved sub-groups (e.g., speaking fair/poor English, experiencing acculturative stress). We discuss implications for better measurement of SES and health given the absence of a gradient and seemingly contradictory finding of nativity-related differences in self-rated health and DSM-IV mental disorders.

Trends in social inequalities for premature coronary heart disease mortality in Great Britain, 1994-2008: a time trend ecological study

OBJECTIVE

To compare trends in metrics of socioeconomic inequalities in premature coronary heart disease (CHD) mortality in Great Britain.

DESIGN

Time trend ecological study with area-level deprivation as exposure.

SETTING

Great Britain, 1994-2008.

PARTICIPANTS

Men and women aged younger than 75 years. No lower age limit.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

CHD mortality rates.

RESULTS

There has been a decrease in socioeconomic inequalities in CHD mortality in absolute terms but an increase in relative terms. CHD mortality rates in men aged younger than 75 years fell by 69 per 100 000 (95% CIs 64 to 74) in the least deprived quintile and by 92 per 100 000 (95% CI 86 to 98) in the most deprived quintile (p for trend: <0.001). Mortality rate ratios comparing the most deprived quintile to the least deprived quintile increased in women aged younger than 75 years from 1.77 (95% CI 1.68 to 1.86) to 2.32 (95% CI 2.14 to 2.52). There was a weak negative association between the average decline of relative rates and area deprivation.

CONCLUSIONS

It could either be said that inequalities in premature mortality from CHD between affluent and deprived areas have widened or narrowed between 1994 and 2008 depending on the measurement technique. In the context of falling CHD mortality rates, narrowing of absolute inequalities is to be expected, but increases in relative inequalities are a cause for concern.

Predictors of dependency on nursing care after stroke: results from the Dortmund and Münster stroke registry

BACKGROUND

The long-term effects of stroke have been inadequately studied. We identified social and clinical factors that were associated with application for insurance payments for long-term care within 3.6 years after stroke.

METHODS

In a quality-assurance project called "Stroke Northwest Germany," information was obtained from 2286 stroke patients on their socio-demographic background, type of stroke, comorbidities, and degree of physical impairment during their hospital stay, as measured on the Rankin Scale, the Barthel Index, and the Neurological Symptom Scale. We used logistic regression models to identify possible associations between these factors and application for insurance payments for long-term care within 3.6 years after stroke. We developed an appropriate prognostic model by means of backward selection.

RESULTS

734 (32.1%) of the patients participated in follow-up and reported whether they had applied for insurance payments for long-term care. 22.5% had submitted an application. The rate of application was positively correlated with age, female sex, the number of comorbidities and complications during hospitalization, and the degree of physical impairment.

CONCLUSION

Stroke has major long-term effects. The probability that a stroke patient will apply for insurance payments for long-term care is a function of the patient's age, sex, previous stroke history, and physical impairment as measured on the Rankin Scale and the Barthel Index.

Anthropometric and gynaecological history according to the socioeconomic status of postmenopausal women: poverty and the menopause

Background

Less advantaged social classes usually have unhealthier lifestyles and have more difficult access to health resources. In this work we study the possible association between poverty and the prevalence of obesity and oophorectomy in a population of postmenopausal women.

Design

Cross-sectional observational study.

Objective

To study in a population of postmenopausal women in poverty the possible differences in the prevalence of obesity and oophorectomy, and to compare some other gynaecological data: age at menarche, age at menopause, fertile years, number of pregnancies, breastfeeding and the use of hormonal replacement therapy (HRT).

Method

All patients were interviewed personally. A questionnaire was used to find out about their lifestyles and the medication they were taking. Their medical records were reviewed to confirm the existence of some diseases. A complete physical examination was performed with every patient. Weight and height were measured with the patient dressed in light clothes. Blood was obtained in a fasting state in order to carry out some analyses. Poverty was defined according to the Spanish National Institute of Statistics criteria.

Results

We enrolled 1225 postmenopausal women; 449 (36.6%) were under the threshold of poverty, defined by the Spanish National Institute of Statistics. Postmenopausal women in poverty had higher body mass index (29.2 ± 4.8 versus 27.0 ± 4.7 kg/m2 P < 0.001), and a higher prevalence of obesity than postmenopausal women not in poverty (44.2% versus 24.3%, P = 0.001). The prevalence of oophorectomy was also higher in women in poverty (32.7% versus 27.2%, P < 0.04). Women in poverty had had a greater number of pregnancies (3 versus 2, P = 0.001). They also showed a higher rate of breastfeeding than women in medium and high social classes (65% versus 59%, P = 0.037). There were no statistically significant differences between the groups in either the age of menopause or fertile years, nor in the use of HRT.

Conclusions

Postmenopausal women in poverty have higher levels of obesity, and also a greater prevalence of oophorectomy than women of medium and high social classes. They also presented a higher rate of breastfeeding and a greater number of pregnancies than those women not in poverty.

A review of the early discharge experiences of stroke survivors and their carers

AIMS AND OBJECTIVES

Understanding the experiences of stroke patients and their carers during the early days following discharge from hospital is an important aspect of providing appropriate care during this crucial time.

BACKGROUND

Due to the diverse changes that can result from a stroke, adjustment to returning home may raise many issues for those involved. A review of research was undertaken with the aim of identifying what is already known about experiences at this time.

DESIGN

Systematic review.

METHOD

Search of electronic databases.

RESULTS

The review revealed that recognition of the impact of stroke on patients and carers is improving, with many studies focussing on the longer-term aspects of stroke recovery. Research into the early discharge experiences of stroke patients and/or their carers is often limited to retrospective, longitudinal studies. With the continuing shift towards care in the community, patients and carers can increasingly expect more recovery to be taking place at home at an even earlier stage. Earlier discharge may have important implications for those involved. The review also highlighted that patients with aphasia have frequently been excluded from stroke research and that social roles are important aspects in stroke recovery.

CONCLUSIONS

To prepare patients and carers better for the impact of returning home, further research is needed into their experiences at this significant time, particularly in the UK. There is also a need to facilitate the inclusion of those with aphasia in stroke research.

RELEVANCE TO CLINICAL PRACTICE

An improved understanding of the issues facing stroke patients and carers during their early days at home should facilitate the preparation for discharge in the hospital setting and allow more focussed follow-up services in the community.

Socioeconomic inequalities in diabetes mellitus across Europe at the beginning of the 21st century

AIMS/HYPOTHESIS

The aim of this study was to determine and quantify socioeconomic position (SEP) inequalities in diabetes mellitus in different areas of Europe, at the turn of the century, for men and women.

METHODS

We analysed data from ten representative national health surveys and 13 mortality registers. For national health surveys the dependent variable was the presence of diabetes by self-report and for mortality registers it was death from diabetes. Educational level (SEP), age and sex were independent variables, and age-adjusted prevalence ratios (PRs) and risk ratios (RRs) were calculated.

RESULTS

In the overall study population, low SEP was related to a higher prevalence of diabetes, for example men who attained a level of education equivalent to lower secondary school or less had a PR of 1.6 (95% CI 1.4-1.9) compared with those who attained tertiary level education, whereas the corresponding value in women was 2.2 (95% CI 1.9-2.7). Moreover, in all countries, having a disadvantaged SEP is related to a higher rate of mortality from diabetes and a linear relationship is observed. Eastern European countries have higher relative inequalities in mortality by SEP. According to our data, the RR of dying from diabetes for women with low a SEP is 3.4 (95% CI 2.6-4.6), while in men it is 2.0 (95% CI 1.7-2.4).

CONCLUSIONS/INTERPRETATION

In Europe, educational attainment and diabetes are inversely related, in terms of both morbidity and mortality rates. This underlines the importance of targeting interventions towards low SEP groups. Access and use of healthcare services by people with diabetes also need to be improved.

Socioeconomic status, hospital volume, and stroke fatality in Canada

BACKGROUND AND PURPOSE

Low socioeconomic status is associated with stroke fatality; however, the mechanism behind this association is uncertain. We sought to determine whether residence in a low-income neighborhood was associated with admission to low-volume facilities and whether this contributed to differences in fatality after stroke.

METHODS

All hospitalizations for ischemic stroke from April 2003 to March 2004 were identified from a national administrative database containing patient-level sociodemographic, diagnostic, procedural, and administrative information. Patients were assigned to income quintiles based on the median income of their primary neighborhood of residence and then categorized as low income (quintiles 1 and 2) or high income (quintiles 3 through 5). Hospitals were categorized as low or high volume on the basis of their annual number of stroke admissions. Multivariable analyses were performed to compare stroke fatality at 7 days and at discharge in patients in low- and high-income groups seen at low- and high-volume facilities.

RESULTS

Overall, 25,228 patients with ischemic stroke were included in the analysis. Those from high-income areas were more likely to be admitted to high-volume hospitals. Fatality at 7 days was 8.4%, 8.2%, 7.7%, 7.1, and 6.6% (chi(2)=0.002) for income quintiles 1 (lowest) to 5 (highest), respectively. Low-income patients admitted to low-volume hospitals had the highest risk-adjusted stroke fatality.

CONCLUSIONS

Patients from low-income areas presenting with acute stroke are more likely to be seen in low-volume facilities. This subgroup of patients had a higher risk-adjusted fatality than those from high-income areas seen at high-volume facilities. Understanding the pathways through which socioeconomic status affects health care may lead to strategies for quality improvement.

Are social inequalities in mortality in Britain narrowing? Time trends from 1978 to 2005 in a population-based study of older men

OBJECTIVE

To examine whether social inequalities in all-cause and coronary heart disease (CHD) mortality in Britain have reduced between 1978 and 2005.

DESIGN

A prospective study of a socioeconomically representative population.

SETTING

24 British towns.

PARTICIPANTS

7735 Men, aged 40-59 years at recruitment in 1978-1980 and followed up until 2005 through the National Health Service Central Register (164 120 person-years).

MAIN OUTCOME MEASURES

Relative hazards and absolute risk differences for all-cause and CHD death comparing manual with non-manual social classes, calculated for different calendar periods.

RESULTS

3009 Deaths from all causes (1003 from CHD) occurred during follow-up. The overall hazard ratio (manual versus non-manual) was 1.56 (95% CI 1.45 to 1.69, p<0.001) for all-cause mortality and 1.54 (95% CI 1.35 to 1.76, p<0.001) for CHD mortality. The relative difference between these social groups tended to increase over time. The overall relative increase in hazard ratio comparing manual with non-manual groups over a 20-year calendar period was 1.22 (95% CI 0.83 to 1.80, p = 0.31) for all-cause mortality and 1.75 (95% CI 0.89 to 3.45, p = 0.11) for CHD mortality. The absolute difference in probability of survival to age 65 years between non-manual and manual groups fell from 29% in 1981 to 19% in 2001 for all-cause mortality and from 17% to 7% for CHD mortality.

CONCLUSION

Relative differences in all-cause and CHD mortality between manual and non-manual social class groups persisted and may have increased during this period. Absolute differences in mortality between these social groups decreased as a result of falling overall mortality rates. Greater effort is needed to reduce social inequalities in all-cause and CHD mortality in the new millennium.

Impact of socio-economic factors on stroke prevalence among urban and rural residents in Mainland China

Background

An inverse relationship between better socioeconomic status (total household income, education or occupation) and stroke has been established in developed communities, but family size has generally not been considered in the use of socioeconomic status indices. We explored the utility of Family Average Income (FAI) as a single index of socioeconomic status to examine the association with stroke prevalence in a region of China, and we also compared its performance as a single index of socioeconomic status with that of education and occupation.

Methods

A population-based cross-sectional study was conducted in Nanjing municipality of China during the period between October 2000 and March 2001. A total of 45 administrative villages were randomly selected using a multi-stage sampling approach and all regular local residents aged 35 years or above were included. Descriptive statistics and logistic regression models were used in analysis.

Results

The overall prevalence of diagnosed stroke was 1.54% in all 29,340 eligible participants. An elevated prevalence of stroke was associated with increasing levels of FAI. After adjustment for basic demographic variables (age, urban/rural area and gender) and a group of defined conventional risk factors, this gradient still remained significant, with participants in the highest (OR = 1.94, 95% CI = 1.40, 2.70) and middle (OR = 1.43, 95% CI = 1.01, 2.02) categories of FAI having higher risks compared with the lowest category. A significantly elevated OR of stroke prevalence was found in white collar workers compared to blue collar workers, while no significant relationship was observed with education.

Conclusion

Our study consistently revealed that the prevalence of stroke was associated with increasing levels of all SES indices, including FAI, education, and occupation. However, a significant gradient was only observed with FAI after controlling for important confounding factors. The findings suggested that, compared with occupation and education, FAI could be used as a more sensitive index of socio-economic status for public health studies in China.

Potential implications of missing income data in population-based surveys: an example from a postpartum survey in California

OBJECTIVES

Income data are often missing for substantial proportions of survey participants and these records are often dropped from analyses. To explore the implications of excluding records with missing income, we examined characteristics of survey participants with and without income information.

METHODS

Using statewide population-based postpartum survey data from the California Maternal and Infant Health Assessment, we compared the age, education, parity, marital status, timely prenatal care initiation, and neighborhood poverty characteristics of women with and without reported income data, overall, and by race/ethnicity/nativity.

RESULTS

Overall, compared with respondents who reported income, respondents with missing income information generally appeared younger, less educated, and of lower parity. They were more likely to be unmarried, to have received delayed or no prenatal care, and to reside in poor neighborhoods; and they generally appeared more similar to lower- than higher-income women. However, the patterns appeared to vary by racial/ethnic/nativity group. For example, among U.S.-born African American women, the characteristics of the missing-income group were generally similar to those of low-income women, while European American women with missing income information more closely resembled their moderate-income counterparts.

CONCLUSIONS

Respondents with missing income information may not be a random subset of population-based survey participants and may differ on other relevant sociodemographic characteristics. Before deciding how to deal analytically with missing income information, researchers should examine relevant characteristics and consider how different approaches could affect study findings. Particularly for ethnically diverse populations, we recommend including a missing income category or employing multiple-imputation techniques rather than excluding those records.

Disparity and its time trends in stroke mortality between urban and rural populations in China 1987 to 2001: changing patterns and their implications for public health policy

BACKGROUND AND PURPOSE

The purposes of this study were to describe stroke mortality in urban and rural populations in China and to monitor the transition using the best available surveillance data during the past 2 decades.

METHODS

Age- and sex-specific mortality data were obtained from the death registration and classification system covering 100 million population in selected urban and rural areas in China. The age-adjusted stroke mortality and its time trends for population at aged 35 years and over were compared between urban and rural populations during the period of 1987 to 2001.

RESULTS

The age-adjusted stroke mortality was higher in urban than in rural populations until the end of 1990 s. The urban:rural ratio was 1:16 for men and 1:21 for women in 1987, but this dropped to 0:77 and 0:79, respectively, in 2001 due to a remarkable decrease in stroke mortality in urban areas (-2.0% for men and -2.5% for women annually, P<0.001), but with little change in rural men (P=0.969) and women (-0.7%, P=0.021) over the period. The decrease is mainly observed in the elderly population. It increased in the population aged 35 to 54 years for all area-gender groups except for urban women.

CONCLUSIONS

The heavier burden of stroke shifted from urban to rural areas where a larger population resides and healthcare services are less developed than in urban areas in China. The increasing trend in the younger population will impose a greater burden in the near future. Healthcare policymakers need to focus their attention on this situation and take suitable measures to cope with the challenges it poses.

Should health studies measure wealth? A systematic review

BACKGROUND

Health researchers rarely measure accumulated wealth to reflect socioeconomic status/position (SES). In order to determine whether health research should more frequently include measures of wealth, this study assessed the relationship between wealth and health.

METHODS

Studies published between 1990 to 2006 were systematically reviewed. Included studies used wealth and at least one other SES measure as independent variables, and a health-related dependent variable.

RESULTS

Twenty-nine studies met inclusion criteria. Measures of wealth varied greatly. In most studies, greater wealth was associated with better health, even after adjusting for other SES measures. The findings appeared most consistent when using detailed wealth measures on specific assets and debts, rather than a single question. Adjusting for wealth generally decreased observed racial/ethnic disparities in health.

CONCLUSIONS

Health studies should include wealth as an important SES indicator. Failure to measure wealth may result in under-estimating the contribution of SES to health, such as when studying the etiology of racial/ethnic disparities. Validation is needed for simpler approaches to measuring wealth that would be feasible in health studies.

Stroke mortality in Belgrade, Serbia: age, period, and cohort analyses

OBJECTIVE

To assess the age, period, and cohort effects on stroke mortality in Belgrade, Serbia, between 1989 and 2003.

METHODS

Mortality data for stroke events were obtained from the Municipal Institute of Statistics. The age- and gender-specific mortality rates were calculated for the cohorts of individuals born between 1904-1908 and 1964-1968.

RESULTS

In males, the average mortality rate increased from 80.9/100,000 in 1989-1993 to 111.3/100,000 in 1994-1998, and decreased slightly to 101.8/100,000 in 1999-2003. A similar pattern was observed among females. Stroke mortality risk was strongly related to age in both genders. This age effect was present for both genders, independent of the cohort or time period. The majority of the successive generations in Belgrade had an increased risk of death from stroke in the recent cohorts especially among females.

CONCLUSIONS

Our results suggest the need to improve efforts in the primary and secondary prevention of stroke.

Cancer is overtaking cardiovascular disease as the main driver of socioeconomic inequalities in mortality: New Zealand (1981-99)

BACKGROUND

Relative socioeconomic disparities in cardiovascular mortality have increased in New Zealand, as in many Western countries in Northern Europe, the US and Australia during the late 20th century. However, substantial declines in cardiovascular mortality mean that its absolute contribution to overall mortality has decreased.

RESEARCH QUESTIONS

How did the absolute contribution of major causes of death to socioeconomic inequalities in New Zealand change during the 1980s and 90s?

METHODS

Linked census-mortality cohorts were used to calculate the contribution of different causes of death to inequalities in mortality, measured with the slope index of inequality, by household income.

RESULTS

Between 1981-4 and 1996-9, the contribution of cardiovascular disease (CVD) to total inequality declined from 55% to 28% among women, whereas at the same time the contribution of cancers increased from 14% to 37%. Among men, the contribution of CVD to total inequality peaked at 47% in 1986-9, then declined to 38% in 1996-9. The contribution of cancer increased from 19% to 26% in men.

CONCLUSION

CVD mortality has declined at all income levels and so too has the contribution of CVD to mortality inequalities. Concurrently, the contribution of cancer to inequalities in mortality by income has increased and, in women at least, is now greater than the contribution of CVD. It is hypothesised that a similar crossover is occurring in other populations where CVD mortality has declined, although socioeconomic differences in the distribution and effect of the obesity epidemic for CVD may ensure its continuing importance. Prevention efforts aimed at reducing socioeconomic inequalities in mortality will need to increasingly focus on socioeconomic inequalities in cancer mortality.

Disparities in stroke preventive care in general practice did not explain socioeconomic disparities in stroke

OBJECTIVE

To assess socioeconomic disparities in stroke incidence and in the quality of preventive care for stroke in the Netherlands.

STUDY DESIGN AND SETTINGS

A total of 190,664 patients who registered in 96 general practices were followed up for 12 months. Data were collected on diagnoses, referrals, prescriptions, and diagnostic procedures. Hazard ratios (HR) were calculated to assess the association between educational level and stroke incidence. Multilevel logistic regression was used to assess socioeconomic disparities in the quality of preventive care for stroke precursors.

RESULTS

Lower educational level was associated with higher incidence of stroke in men (HR=1.36, 95% CI=1.06-1.74) but not in women. Among both men and women, there were socioeconomic disparities in the prevalence of hypertension, hypercholesterolemia, diabetes, angina pectoris, heart failure, and peripheral artery disease. Lower educated hypercholesterolemia patients under medication were less likely to be prescribed statins (odds ratio=0.62, 95% CI=0.42-0.91). However, for other precursors of stroke, there were no major disparities in the quality of preventive care.

CONCLUSION

There are socioeconomic disparities in stroke incidence among men but not among women. Socioeconomic differences in factors such as hypertension and diabetes are likely to contribute to stroke disparities. However, general practitioners (GPs) provide care of a similar quality to patients from different socioeconomic groups.

The socioeconomic gradient in the incidence of stroke: a prospective study in middle-aged women in Sweden

BACKGROUND AND PURPOSE

A socioeconomic gradient in stroke has been demonstrated in a variety of settings, but mostly in men. Our purpose was to establish whether a socioeconomic gradient in stroke existed in a group of Swedish women and whether this gradient could be explained by established stroke risk factors or psychosocial factors.

METHODS

The Women's Lifestyle and Health Cohort Study includes 49 259 women from Sweden aged 30 to 50 years at baseline (1991 to 1992). The women completed an extensive questionnaire and were traced through linkages to national registries until the end of 2002. Among the 47 942 women included in these analyses, there were 200 cases of incident stroke during follow up (121 ischemic stroke, 47 hemorrhagic stroke, and 32 of unknown origin). Statistical analysis was through the Cox proportional hazards model.

RESULTS

The risk of stroke was significantly inversely related to years of education completed, our proxy for socioeconomic status (hazard ratio comparing lowest with highest education group=2.1, 95% CI: 1.4 to 2.9, P for trend <0.001). This association was reduced after adjustment for established risk factors, although remaining significant (1.5, 1.0 to 2.2, P for trend=0.04). The gradient was more pronounced for ischemic stroke (2.9, 1.8 to 4.7, P for trend <0.001) than for hemorrhagic stroke (1.4, 0.7 to 2.9, P for trend=0.35). Job strain and social support were unrelated to risk of stroke. Self-rated health was strongly related to risk of stroke mediated by established risk factors. Psychosocial factors did not contribute toward the socioeconomic gradient in stroke.

CONCLUSIONS

There was a strong gradient in risk of stroke by years of education, especially for ischemic stroke. Most of the social gradient was explained by established risk factors, particularly smoking and alcohol, but not by psychosocial factors.

The effect of socioeconomic status on three-year mortality after first-ever ischemic stroke in Nanjing, China

Background

Low socioeconomic status (SES) is associated with increased mortality after stroke in developed countries. This study was performed to determine whether a similar association also exists in China.

Methods

A total of 806 patients with first-ever ischemic stroke were enrolled in our study. From August 1999 to August 2005, the three-year all-cause mortality following the stroke was determined. Level of education, occupation, taxable income and housing space were used as indicators for SES. Stepwise univariate and multivariate COX proportional hazards models were used to study the association between the SES measures and the three-year mortality.

Results

Our analyses confirmed that occupation, taxable income and housing space were significantly associated with three-year mortality after first-ever stroke. Manual workers had a significant hazard ratio of 5.44 (95% CI 2.75 to 10.77) for death within three years when compared with non-manual workers. Those in the zero income group had a significant hazard ratio of 5.35 (95% CI 2.95 to 9.70) and those in the intermediate income group 2.10 (95% CI 1.24 to 3.58) when compared with those in the highest income group. Those in two of the three groups with the smallest housing space also had significant hazard ratios of 2.06 (95% CI 1.16 to 3.65) and 1.68 (95% CI 1.12 to 2.52) when compared with those in group with the largest housing space. These hazard ratios remained largely unchanged after multivariate adjustment for age, gender, baseline cardiovascular disease risk factors, and stroke severity. The analyses did not confirm an association with educational level.

Conclusion

Lower SES has a negative impact on the outcome of first-ever stroke in Nanjing, China. This confirms the need to improve preventive and secondary care for stroke among low SES groups.

Socioeconomic status and ischaemic heart disease mortality in 10 western European populations during the 1990s

OBJECTIVE

To assess the association between socioeconomic status and ischaemic heart disease (IHD) mortality in 10 western European populations during the 1990s.

DESIGN

Longitudinal study.

SETTING

10 European populations (95,009,822 person years).

METHODS

Longitudinal data on IHD mortality by educational level were obtained from registries in Finland, Norway, Denmark, England/Wales, Belgium, Switzerland, Austria, Turin (Italy), Barcelona (Spain), and Madrid (Spain). Age standardised rates and rate ratios (RRs) of IHD mortality by educational level were calculated by using Poisson regression.

RESULTS

IHD mortality was higher in those with a lower socioeconomic status than in those with a higher socioeconomic status among men aged 30-59 (RR 1.55, 95% confidence interval (CI) 1.51 to 1.60) and 60 years and over (RR 1.22, 95% CI 1.21 to 1.24), and among women aged 30-59 (RR 2.13, 95% CI 1.98 to 2.29) and 60 years and over (RR 1.36, 95% CI 1.33 to 1.38). Socioeconomic disparities in IHD mortality were larger in the Scandinavian countries and England/Wales, of moderate size in Belgium, Switzerland, and Austria, and smaller in southern European populations among men and younger women (p < 0.0001). For elderly women the north-south gradient was smaller and there was less variation between populations. No socioeconomic disparities in IHD mortality existed among elderly men in southern Europe.

CONCLUSIONS

Socioeconomic disparities in IHD mortality were larger in northern than in southern European populations during the 1990s. This partly reflects the pattern of socioeconomic disparities in cardiovascular risk factors in Europe. Population wide strategies to reduce risk factor prevalence combined with interventions targeted at the lower socioeconomic groups can contribute to reduce IHD mortality in Europe.

Socioeconomic status and stroke

This paper reviews the current evidence for the association between socioeconomic status and stroke incidence, survival, mortality, and other outcomes. The evidence is strongest for mortality and incidence of stroke, with high rates of stroke in low socioeconomic groups being a consistent finding. Low socioeconomic groups also have lower survival and greater stroke severity than high socioeconomic groups, although there is less evidence for this association. The mechanisms through which socioeconomic status affects stroke risk and outcomes are unclear but some studies report that differences in risk-factor prevalence could account for some of the variation. We discuss the implications of these findings and make recommendations for future research. Studies using prospective population-based methods with improved control for confounding factors are needed to confirm or refute these associations. Understanding the causal associations between socioeconomic status and stroke will allow interventions to be appropriately targeted and assessed.

Community-based stroke incidence in a Scottish population: the Scottish Borders Stroke Study

BACKGROUND AND PURPOSE

The purpose of this study was to determine the incidence and case fatality of stroke in a geographically defined region of Scotland, a nation with a high cardiovascular risk.

METHODS

All strokes occurring in residents of the Scottish Borders (population 106,352) were identified during a 24-month period from 1998 to 2000 using multiple overlapping methods of case-ascertainment. Standard criteria were used to define stroke and case fatality. Stroke subtypes were determined by computer tomography (CT) scan, MRI, or autopsy.

RESULTS

790 strokes were identified; 596 were first-ever-in-a-lifetime strokes (FES). 91.1% of FES underwent CT scan and/or autopsy. The crude annual incidence rate per 100,000 per year was: 280 (95% CI, 258 to 304) overall, 197 (95% CI 179-217) cerebral infarction, 24 (95% CI 17-31) intracerebral haemorrhage, 11 (95% CI 7-16) subarachnoid haemorrhage and 49 (95% CI 40-59) undetermined stroke. 28 day FES case fatality was 15.9% (95% CI, 13.2 to 19.1) increasing to 26.3% (95% CI, 23.0 to 30.0) at 1 year. Comparing 18 previous worldwide incidence studies with the SBSS showed a similar relative risk of stroke incidence and case fatality for FES and FES subtypes.

CONCLUSIONS

The SBSS crude incidence rate is one of the highest in the world but age-adjusted rates, case fatality and relative risk for all stroke and stroke subtypes were not significantly different from the majority of previous studies. Unlike cardiovascular disease, the Scottish risk of stroke would appear to be similar to other populations worldwide.

Socioeconomic Status Is a Risk Factor for Epilepsy in Icelandic Adults but Not in Children

PURPOSE

Two earlier population-based studies provide conflicting information on the association between low socioeconomic status (SES) and risk for epilepsy. Seizure etiologies (e.g., head injury, stroke) associated with low SES were not addressed in prior analyses. We assess the relation between SES indices and incident epilepsy separately for children and adults and in subgroups defined by seizure etiology.

METHODS

In this population-based case-control study, a surveillance system identified incident unprovoked seizure or first diagnosis of epilepsy throughout Iceland (n = 418). Controls were selected from the population registry as the next two same-sex births alive, residing in Iceland at the time of the index seizure, and without a history of unprovoked seizure on the date of the case's incident seizure (n = 835). The odds ratio measured the association between SES and epilepsy.

RESULTS

An association was found between epilepsy and SES among adults, but not among children. Among adults, low education was associated with an increased risk for epilepsy [odds ratio (OR), 2.29; 95% confidence interval (CI), 1.21-4.34), and home ownership was protective (OR, 0.63; 95% CI, 0.43-0.92). When analyses were repeated by seizure etiology, this association remained only in the group with epilepsy of unknown cause, even after adjusting for alcohol consumption.

CONCLUSIONS

Low SES, indexed by low education or lack of home ownership, is a risk factor for epilepsy in adults, but not in children, suggesting a cumulative effect of SES on risk for epilepsy. This association is not explained by established risk factors for epilepsy (e.g., head injury, stroke). We find no evidence of a downward social drift among cases whose parents had epilepsy.