Educational Level and Stroke Mortality

Awareness of stroke, its signs, and risk factors: A cross-sectional population-based survey in Ghana

Background and Aims

The prevalence of stroke in sub-Saharan Africa is steadily rising, leading to a growing strain on the healthcare system in the region. In the context of Ghana, stroke ranks as the third most prevalent cause of mortality. The current body of scholarly research on stroke awareness in Ghana is quite limited. The aim of this study is to assess the level of awareness of stroke, as well as its signs and symptoms among the Ghanaian population.

Methods

The study employed a cross-sectional quantitative methodology, wherein 1000 participants completed self-administered structured questionnaires. Descriptive statistics were utilized to summarize the participants' socio-demographic characteristics and their responses. To assess the relationship between participants' sociodemographic traits and their awareness of stroke signs, symptoms, risk factors, and perception, the Chi-square test of independence was conducted using IBM SPSS version 26. A significance level of p < 0.05 was established.

Results

The study identified limited awareness regarding stroke symptoms, warning signs, and risk factors. The participants exhibited an overall knowledge range of 25.9% to 47.2% concerning stroke signs and symptoms, and a range of 24%-39% regarding its causes and risk factors. Notably, paralysis (70.8%) and diet (59.9%) were the most easily recognized warning signs and risk factors for stroke, respectively. Sociodemographic characteristics such as age, religion, educational status, exposure to stroke, employment status, and marital status were shown to be associated with participants knowledge of stroke (p < 0.05).

Conclusion

The study's results indicated a widespread lack of knowledge concerning the causes and risk factors of stroke among the Ghanaian population, highlighting the necessity for increased public education efforts to raise awareness about this condition.

Associations between socioeconomic status and stroke in American adults: A population-based study

Stroke is an acute cerebrovascular disease that can lead to disability and death. This study aimed to investigate the relationship between socioeconomic status (SES) and stroke. SES was evaluated by two variables: poverty to income ratio (PIR) and education level. In this multi-subject study, we collected data from the National Health and Nutrition Examination Survey (NHANES) database between 2009 and 2018, and finally 22,792 adults (≥20 years old) were included in the study. We proceeded with weighted multivariate logistic regression analysis as well as subgroup analysis. When analyzing the effect of PIR on stroke alone, the results showed that an increase in PIR levels was associated with a decrease in stroke incidence (OR = 0.764 95% CI: (0.711, 0.820), p < 0.001). The multivariate analysis presented a decline in stroke incidence in the highest quartile PIR group compared to the lowest quartile PIR group (OR = 0.296 95% CI: (0.214, 0.409), P＜0.001). Our results indicated that PIR is a protective factor for stroke, but there are exceptions in this relationship among different people. Hence, it is imperative that policymakers, healthcare providers, and clinicians take into account the inequality distribution of SES among adults while developing and executing stroke prevention and treatment strategies.

Long-term determinants of death after stroke in Ghana: Analysis by stroke types & subtypes

BACKGROUND

Determinants of long-term mortality after stroke by mechanistic type and subtype are unknown in sub-Saharan Africa (SSA). Such data are crucial for targeting specific pathophysiologic pathways to improve stroke outcomes in the region.

PURPOSE

To evaluate rates and predictors of mortality up to 8 years after stroke, by type and subtype, in Ghana.

METHODS

We prospectively collected data on stroke patients presenting at a tertiary medical facility in Ghana between 2013 and 2018 who were followed up until October 31, 2021. Stroke diagnosis was confirmed using a Computerized Tomography scan; ischemic strokes were mechanistically typed using the TOAST classification while intracerebral hemorrhages were subtyped using the SMASH-U scheme. Demographic and clinical predictors of stroke mortality were evaluated using Cox proportional hazards regression modelling.

RESULTS

Of 564 patients encountered during the study period, data on vital status were available for 556 (98.6%) subjects at discharge and 442 (78.4%) on follow-up. Mean age was 61.1 ±15.1 years, and 223 (53.1%) were male. Mortality rates at 1, 3, 12, 36, 60 and 96 months were 37.5%, 43.2%, 49.7%, 57.4%, 62.9%, and 73.7% respectively. Three (3) factors remained significantly associated with risk of death namely age, adjusted hazard ratios (aHR) of 1.12 (95%CI: 1.04-1.20), no formal education 1.36 (95% CI: 1.02-1.81) and modified Rankin score 1.67 (95%CI: 1.42 - 1.98) for each unit rise. For ischemic stroke the four (4) factors associated with long-term mortality were low formal education, low monthly income, having diabetes mellitus and higher functional score on admission. For intracerebral hemorrhage, the two factors were increasing age and high functional score.

CONCLUSION

Stroke severity is the key predictor of long-term mortality after an index stroke in Ghana, regardless of the underlying pathophysiologic mechanism. Instituting acute stroke systems of care to facilitate timely reperfusion efforts may greatly improve long term survival outcomes after stroke in SSA.

A cohort study on the relationship between education level and high-risk population of stroke

Objective

To explore the relationship between education level and high-risk population among stroke screening populations in Zunyi City, China.

Methods

The cluster sampling method was adopted to collect the medical history, laboratory examinations and physical examinations for the permanent residents of Zunyi City, Guizhou Province. Taking education level as a key socioeconomic status (SES) indicator, multivariate logistic regression analysis was used to evaluate the risk factors of high-risk groups with different education levels.

Results

Among the included 4149 subjects, 494 were in the high-risk group and 3655 were in the non-high-risk group. The proportion of the high-risk population with education level ≥ high secondary school (8.7%) was significantly higher than that of the low-risk population. After adjusting for age, gender, and BMI, the OR of those with education leve l ≥ high secondary school was 2.8 (95% CI 1.9-4.2), which was significantly higher than those with education level of illiterate/primary school. In the model adjusted for all confounding factors, compared with illiterate/primary school, people with education level ≥ high secondary school were more likely to be at high risk of stroke (OR 3.0, 95% CI 1.9-4.6).

Conclusion

Education level ≥ high secondary school is an independent influencing factor for the high-risk population of stroke in Zunyi, which may be related to smoking and lipid metabolism abnormalities of people with high education level. Key interventions for high-risk populations with high education levels may have positive significance in reducing the incidence of stroke.

Changes in oral health related quality of life and its associated factors in individuals with brain injury

Purpose: To evaluate changes in oral health-related quality of life (OHRQoL) and associated factors in individuals with acquired brain injury (ABI) during hospitalization.Methods: Forty-six individuals with ABI were examined at week 1 and 5 of hospitalization. OHRQoL was recorded through Oral Health Impact Profile-14 (OHIP-14), clinical oral examinations were conducted, while orofacial health-related 'motor' and 'cognitive' scores were retrieved from patients' e-journal. Association between variables were investigated using factor analysis and multilevel regression modeling.Results: There were no significant differences in the OHIP-14 scores between week 1 and 5. Factors analysis revealed two OHIP-14 domains, 'psychosocial' and 'physica'. Individuals who improved their cognitive skills over study period and those with 'severe' periodontitis at baseline had increased scores of OHIP-14 'psychosocial' domain. Individuals who improved orofacial health-related 'motor' skills over study period had decreased 'physical' domain scores. Increased cognition over study period, current smoking and dental calculus were associated with increased 'physical' domain.Conclusions: The OHRQoL was poor both at week 1 and 5. Individual's cognitive and motor skills as well as their oral health status influenced their OHRQoL. Thus, individual's awareness and involvement in addition to oral care seem to be imperative in improving the OHRQoL in neurorehabilitation setting.

Health related quality of life and satisfaction with care of stroke patients in Budapest: A substudy of the EuroHOPE project

BACKGROUND

Disadvantaged socioeconomic status is associated with higher stroke incidence and mortality, and higher readmission rate. We aimed to assess the effect of socioeconomic factors on case fatality, health related quality of life (HRQoL), and satisfaction with care of stroke survivors in the framework of the European Health Care Outcomes, Performance and Efficiency (EuroHOPE) study in Hungary, one of the leading countries regarding stroke mortality.

METHODS

We evaluated 200 consecutive patients admitted for first-ever ischemic stroke in a single center and performed a follow-up at 3 months after stroke. We recorded pre- and post-stroke socioeconomic factors, and assessed case fatality, HRQoL and patient satisfaction with the care received. Stroke severity at onset was scored by the National Institutes of Health Stroke scale (NIHSS), disability at discharge from acute care was evaluated by the modified Rankin Score (mRS). To evaluate HRQoL and patient satisfaction with care we used the EQ-5D-5L, 15D and EORTC IN PATSAT 32 questionnaires.

RESULTS

At 3 months after stroke the odds of death was significantly increased by stroke severity (NIHSS, OR = 1.209, 95%CI: 1.125-1.299, p<0.001) and age (OR = 1.045, 95%CI: 1.003-1.089, p = 0.038). In a multiple linear regression model, independent predictors of HRQoL were age, disability at discharge, satisfaction with care, type of social dwelling after stroke, length of acute hospital stay and rehospitalization. Satisfaction with care was influenced negatively by stroke severity (Coef. = -1.111, 95%C.I.: -2.159- -0.062, p = 0.040), and positively by having had thrombolysis (Coef. = 25.635, 95%C.I.: 5.212-46.058, p = 0.016) and better HRQoL (Coef. = 22.858, 95%C.I.: 6.007-39.708, p = 0.009).

CONCLUSION

In addition to age, disability, and satisfaction with care, length of hospital stay and type of social dwelling after stroke also predicted HRQoL. Long-term outcome after stroke could be improved by reducing time spent in hospital, i.e. by developing home care rehabilitation facilities thus reducing the need for readmission to inpatient care.

Socioeconomic status predicts the risk of stroke death: A systematic review and meta-analysis

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Low socioeconomic status influence on the risk of stroke mortality.

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Low income and ocuption for stroke mortality is higher than education.

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The heterogeneity of the study was mainly from different SES indicator.

Low socioeconomic status appears to be an independent risk factor for stroke mortality in epidemiology studies, but there has been no systematic assessment of this association. We performed a systematic review and meta-analysis evaluating the association between low socioeconomic status and stroke mortality. A systematic review of MEDLINE, EMBASE, and Web of Science for cohort studies that reported low socioeconomic status and stroke mortality was conducted from inception until July 2017. Research information, adjusted risk ratio (RR) estimates and 95% confidence intervals (Cls) were extracted. Estimates were pooled using a random-effects model. Heterogeneity was examined using the Q statistic and I². Twenty-seven prospective cohort studies (471,354,852 subjects; 429,886 deaths) assessing stroke mortality with low socioeconomic status were identified. Compared with the highest socioeconomic status, overall RR of stroke mortality was 1.39 (95% CI, 1.31–1.48) for those with the lowest after adjustment for confounding factors, but there was substantial heterogeneity between studies (I² = 89.9%, P = 0.001). Significant relationships were observed between risk of stroke mortality and the lowest education (RR = 1.21, 95% CI 1.11–1.33; I² = 70.9%, P < 0.001), income (RR = 1.54, 95% CI 1.30–1.82; I² = 91.6%, P < 0.001), occupation (RR = 1.54, 95% CI 1.35–1.75; I² = 78.3%, P < 0.001), composite socioeconomic status (RR = 1.37, 95% CI 1.25–1.51; I² = 69.5%, P = 0.001). After subgroup analysis, it was found that the heterogeneity of each SES indicator mainly came from the follow-up time, study population, stroke type, study area. Patients with low socioeconomic status had a higher risk of stroke mortality. The heterogeneity of income and occupation is larger, and the education and composite SES is smaller.

Socioeconomic gap between neighborhoods of Budapest: Striking impact on stroke and possible explanations

Introduction

Hungary has a single payer health insurance system offering free healthcare for acute cerebrovascular disorders. Within the capital, Budapest, however there are considerable microregional socioeconomic differences. We hypothesized that socioeconomic deprivation reflects in less favorable stroke characteristics despite universal access to care.

Methods

From the database of the National Health Insurance Fund, we identified 4779 patients hospitalized between 2002 and 2007 for acute cerebrovascular disease (hereafter ACV, i.e. ischemic stroke, intracerebral hemorrhage, or transient ischemia), among residents of the poorest (District 8, n = 2618) and the wealthiest (District 12, n = 2161) neighborhoods of Budapest. Follow-up was until March 2013.

Results

Mean age at onset of ACV was 70±12 and 74±12 years for District 8 and 12 (p<0.01). Age-standardized incidence was higher in District 8 than in District 12 (680/100,000/year versus 518/100,000/year for ACV and 486/100,000/year versus 259/100,000/year for ischemic stroke). Age-standardized mortality of ACV overall and of ischemic stroke specifically was 157/100,000/year versus 100/100,000/year and 122/100,000/year versus 75/100,000/year for District 8 and 12. Long-term case fatality (at 1,5, and 10 years) for ACV and for ischemic stroke was higher in younger District 8 residents (41–70 years of age at the index event) compared to D12 residents of the same age. This gap between the districts increased with the length of follow-up. Of the risk diseases the prevalence of hypertension and diabetes was higher in District 8 than in District 12 (75% versus 66%, p<0.001; and 26% versus 16%, p<0.001).

Discussion

Despite universal healthcare coverage, the disadvantaged district has higher ACV incidence and mortality than the wealthier neighborhood. This difference affects primarily the younger age groups. Long-term follow-up data suggest that inequity in institutional rehabilitation and home-care should be investigated and improved in disadvantaged neighborhoods.

Epidemiology of Stroke in Costa Rica: A 7-Year Hospital-Based Acute Stroke Registry of 1319 Consecutive Patients

BACKGROUND

Limited data on stroke exist for Costa Rica. Therefore, we created a stroke registry out of patients with stroke seen in the Acute Stroke Unit of the Hospital Calderon Guardia.

METHODS

We analyzed 1319 patients enrolled over a 7-year period, which incorporated demographic, clinical, laboratory, and neuroimaging data.

RESULTS

The mean age of patients with stroke was 68.0 ± 15.5 years. Seven hundred twenty-five were men and the age range was 13-104 years. The most prevalent risk factors were hypertension (78.8%), dyslipidemia (36.3%), and diabetes (31.9%). Fifteen percent had atrial fibrillation and 24.7% had a previous stroke or transient ischemic attack. Prevalence of hypertension and atrial fibrillation increased with age; however, younger patients were more associated with thrombophilia. We documented 962 (72.9%) ischemic and 270 (20.5%) hemorrhagic strokes. Of the ischemic strokes, 174 (18.1%) were considered secondary to large-artery atherothrombosis, 175 (18.2%) were due to cardiac embolism, 19 (2.0%) were due to lacunar infarcts, and 25 (2.6%) were due to other determined causes. Five hundred sixty-nine (59.1%) remained undetermined. Atherothrombotic strokes were mostly associated with dyslipidemia, diabetes, metabolic syndrome, and obesity, whereas lacunar infarcts were associated with hypertension, smoking, sedentary lifestyle, and previous stroke or transient ischemic attack. Of our patients, 69.9% scored between 0 and 9 in the initial National Institutes of Health Stroke Scale (NIHSS).

CONCLUSIONS

We found differences in sociodemographic features, risk factors, and stroke severity among stroke subtypes. Risk factor prevalence was similar to other registries involving Hispanic populations.

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.

Socioeconomic Status and the Risk of Stroke Recurrence

Background and Purpose—

This nationwide observational study aimed to investigate how socioeconomic status is associated with risk of stroke recurrence and how possible associations change over time.

Methods—

This study included 168 295 patients, previously independent in activities of daily living, with a first-ever stroke in the Swedish Stroke Register (Riksstroke) 2001 to 2012. Riksstroke was linked with Statistics Sweden as to add individual information on education and income. Subdistribution hazard regression was used to analyze time from 28 days after first stroke to stroke recurrence, accounting for the competing risk of other causes of death.

Results—

Median time of follow-up was 3.0 years. During follow-up, 23 560 patients had a first recurrent stroke, and 53 867 died from other causes. The estimated cumulative incidence of stroke recurrence was 5.3% at 1 year, and 14.3% at 5 years. Corresponding incidence for other deaths were 10.3% and 30.2%. Higher education and income were associated with a reduced risk of stroke recurrence. After adjusting for confounding variables, university versus primary school education returned a hazard ratio of 0.902; 95% confidence interval, 0.864 to 0.942, and the highest versus the lowest income tertile a hazard ratio of 0.955; 95% confidence interval, 0.922 to 0.989. The risk of stroke recurrence decreased during the study period, but the inverse effect of socioeconomic status on risk of recurrence did not change significantly.

Conclusions—

Despite a declining risk of stroke recurrence over time, the differences in recurrence risk between different socioeconomic groups remained at a similar level in Sweden during 2001 to 2012.

The effects of household income distribution on stroke prevalence and its risk factors of high blood pressure and smoking: a cross-sectional study in Saskatchewan, Canada

Background:

Stroke is a major chronic disease and a common cause of adult disability and mortality. Although there are many known risk factors for stroke, lower income is not one that is often discussed.

Aims:

To determine the unadjusted and adjusted association of income distribution on the prevalence of stroke in Saskatchewan, Canada.

Methods:

Information was collected from the Canadian Community Health Survey conducted by Statistics Canada for 2000–2008. In total, 178 variables were analysed for their association with stroke.

Results:

Prior to statistical adjustment, stroke was seven times more common for lower income residents than higher income residents. After statistical adjustment, only four covariates were independently associated with stroke prevalence, including having high blood pressure (odds ratio (OR) = 2.62; 95% confidence interval (CI) = 2.12–3.24), having a household income below CAD$30,000 per year (OR = 2.49; 95% CI = 1.88–3.29), being a daily smoker (OR = 1.36; 95% CI = 1.16–1.58) and being physically inactive (OR = 1.27; 95% CI = 1.13–1.43). After statistical adjustment, there were five covariates independently associated with high blood pressure prevalence, including having a household income below CAD$30,000 per year (OR = 1.52; 95% CI = 1.41–1.63). After statistical adjustment, there were five covariates independently associated with daily smoking prevalence, including having a household income below CAD$30,000 per year (OR = 1.29; 95% CI = 1.25–1.33).

Conclusions:

Knowledge of disparities in the prevalence, severity, disability and mortality of stroke is critically important to medical and public health professionals. Our study found that income distribution was strongly associated with stroke, its main disease intermediary – high blood pressure – and its main risk factor – smoking. As such, income is an important variable worthy of public debate as a modifiable risk factor for stroke.

Low socioeconomic status is an independent risk factor for ischemic stroke: a case-control study in North Indian population

BACKGROUND

Stroke is a multifactorial disease and is influenced by complex environmental interactions. The contribution of various risk factors to the burden of stroke worldwide is not well known, particularly in developing countries. The present case-control study is aimed at exploring the association between a low socioeconomic status and the risk of ischemic stroke among the North Indian population.

METHODS

The study design was a hospital-based, case-control study. Age- and sex-matched controls were included. The demographic characteristics and risk factor variables were documented by means of a personal interview through a standardized case record form. The household asset index for determining the socioeconomic status (HAISS) was used for the assessment of the socioeconomic status of the population. HAISS was validated with the widely used Kuppuswamy scale for measurement of socioeconomic status. The multivariable logistic regression model was used to estimate the odds ratio associated with stroke.

RESULTS

In all, 224 ischemic stroke patients and 224 controls were recruited between February 2009 and February 2012. The mean age of cases and controls was 53.47 ± 14 and 52.92 ± 13.4, respectively. The low economic status was independently associated with the risk of ischemic stroke after adjustment for demographic and risk factor variables (OR 2.8; 95% CI 1.2-6.3).

CONCLUSION

Our findings suggest that there is a significant association between a low socioeconomic status and the risk of ischemic stroke risk in North Indian population. Well-designed studies embedded with long-term prospective cohorts are required for confirming the results.

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.

The modifying influence of country development on the effect of individual educational attainment on self-rated health

OBJECTIVES

We investigated how much the Human Development Index (HDI), a global measure of development, modifies the effect of education on self-reported health.

METHODS

We analyzed cross-sectional World Health Survey data on 217,642 individuals from 49 countries, collected in 2002 to 2005, with random-intercept multilevel linear regression models.

RESULTS

We observed greater positive associations between educational levels and self-reported good health with increasing HDI. The magnitude of this effect modification of the education-health relation tended to increase with educational attainment. For example, before adjustment for effect modification, at comparable HDI, on average, finishing primary school was associated with better general health (b = 1.49; 95% confidence interval [CI] = 1.18, 1.80). With adjustment for effect modification by HDI, the impact became 4.63 (95% CI = 3.63, 5.62) for every 0.1 increase in HDI. Among those who completed high school, these associations were, respectively, 5.59 (95% CI = 5.20, 5.98) and 9.95 (95% CI = 8.89, 11.00).

CONCLUSIONS

The health benefits of educational attainment are greater in countries with greater human development. Health inequalities attributable to education are, therefore, larger in more developed countries.

Worldwide socioeconomic status and stroke mortality: an ecological study

Introduction

The effect of socioeconomic status (SES) on stroke mortality at population level has been controversial. This study explores the association of SES in childhood and adulthood with stroke mortality, as well as variations in this association among countries/regions.

Methods

Sex-specific stroke mortality at country level with death registry covering ≥ 70% population was obtained from the World Health Organization. Human Development Index (HDI) developed by the United Nations was chosen as the SES indicator. The associations between the latest available stroke mortality with HDI in 1999 (adulthood SES) and with HDI in 1960 (childhood SES) for the group aged 45–54 years among countries were examined with regression analysis. Age-standardized stroke mortality and HDI during 1974–2001 were used to estimate the association by time point.

Results

The population data were available mostly for low-middle to high income countries. HDI in 1960 and 1999 were both inversely associated with stroke mortality in the group aged 45–54 years in 39 countries/regions. HDI in 1960 accounted for 37% of variance of stroke mortality among countries/regions; HDI in 1999 for 35% in men and 53% in women (P < 0.001). There was a quadratic relationship between age-standardized stroke mortality and HDI for the countries from 1974 to 2001: the association was positive when HDI < 0.77 but it became negative when HDI > 0.80.

Conclusions

SES is a strong predictor of stroke mortality at country level. Stroke mortality increased with improvement of SES in less developed countries/region, while it decreased with advancing SES in more developed areas.

Education and the gender gaps in health and mortality

The positive associations between education and health and survival are well established, but whether the strength of these associations depends on gender is not. Is the beneficial influence of education on survival and on self-rated health conditioned by gender in the same way, in opposite ways, or not at all? Because women are otherwise disadvantaged in socioeconomic resources that are inputs to health, their health and survival may depend more on education than will men's. To test this hypothesis, we use data from the National Health Interview Survey-Linked Mortality Files (NHIS-LMF). We find that education's beneficial influence on feeling healthy and on survival are conditional on gender, but in opposite ways. Education has a larger effect on women's self-rated health than on men's, but a larger effect on men's mortality. To further examine the mortality results, we examine specific causes of death. We find that the conditional effect is largest for deaths from lung cancer, respiratory disease, stroke, homicide, suicide, and accidents. Because women report worse health but men's mortality is higher, education closes the gender gap in both health and mortality.

Occupational class inequalities in behavioral and biological risk factors for cardiovascular disease among workers in medium- and small-scale enterprises

The aim of this cross-sectional study was to examine whether occupational class inequalities existed in the behavioral and biological risk factors for cardiovascular disease among workers in medium- and small-scale enterprises. We asked 1,900 enterprises in the Ishikawa prefecture who were users of an external heath check-up facility to supply anonymous individual data in 2009. The 446 enterprises consented to the invitation. The study population was 12,625 individuals (8,104 males and 4,521 females) 16-59 yr of age. We compared indices among occupational classes. The indices of lipid and glucose metabolism were used only for subjects 40-59 yr of age. The results of this study revealed occupational class inequalities in the prevalence of current smoking, heavy drinking and hypertension in men. These inequalities were more prominent among men in the younger age group than in the older age group. In men, the most disadvantaged occupational class was transportation workers, followed by laborers. Occupational class inequalities in smoking were also found among female workers. However, the influences of occupational class on obesity and indices of lipid or glucose metabolism were inconsistent. A strategy for health promotion that targets the disadvantaged population is necessary for the prevention of cardiovascular disease.

The prospective association of socioeconomic status with C-reactive protein levels in the CARDIA study

Better health is a well-documented benefit of having a higher socioeconomic status (SES). Inflammation may be one pathway through which SES influences health. Using 2658 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) Study, we examine whether two measures of SES assessed at baseline (mean age, 32 ± 4 years)-years of education and household income-predict change in C-reactive protein (CRP) concentrations over the course of 13 years. We also examine whether four health-related behaviors-smoking, fruit and vegetable consumption, physical activity, and alcohol consumption-mediate the prospective association of SES with CRP. Both higher education and household income predicted smaller increases in CRP over the 13 years of follow-up independent of age, sex, race, CARDIA center, body mass, medical diagnoses, medications, and hormone use (among women). Associations did not differ by race or sex. When examined in separate analyses, smoking and fruit and vegetable intake each accounted for a significant proportion of the respective effects of education and household income on CRP change, and physical activity a significant proportion of the effect of household income. These findings suggest that poor health behaviors among persons of lower socioeconomic status can have long-term effects on inflammation.

Income and education as predictors of return to working life among younger stroke patients

BACKGROUND

Socioeconomic conditions are not only related to poor health outcomes, they also contribute to the chances of recovery from stroke. This study examines whether income and education were predictors of return to work after a first stroke among persons aged 40-59.

METHODS

All first-stroke survivors aged 40-59 who were discharged from a hospital in 1996-2000 and who had received income from work during the year prior to the stroke were sampled from the Swedish national register of in-patient care (n = 7,081). Income and education variables were included in hazard regressions, modelling the probability of returning to work from one to four years after discharge. Adjustments for age, sex, stroke subtype, and length of in-patient care were included in the models.

RESULTS

Both higher income and higher education were associated with higher probability of returning to work. While the association between education and return to work was attenuated by income, individuals with university education were 13 percent more likely to return than those who had completed only compulsory education, and individuals in the highest income quartile were about twice as likely to return as those in the lowest. The association between socioeconomic position and return to work was similar for different stroke subtypes. Income differences between men and women also accounted for women's lower probability of returning to work.

CONCLUSIONS

The study demonstrates that education and income were independent predictors of returning to work among stroke patients during the first post-stroke years. Taking the relative risk of return to work among those in the higher socioeconomic positions as the benchmark, there may be considerable room for improvement among patients in lower socioeconomic strata.

The decline in stroke mortality: exploration of future trends in 7 Western European countries

BACKGROUND AND PURPOSE

This article aims to make projections of future trends in stroke mortality in the Year 2030 based on recent trends in stroke mortality in 7 Western European countries.

METHODS

Mortality data were obtained from national cause of death registries. Annual rates of decline in stroke mortality of 1980 to 2005 were determined for men and women in the United Kingdom, France, the Netherlands, and 4 Nordic countries on the basis of regression analysis. Estimated rates of decline were extrapolated until 2030. Cause-elimination life tables were used to determine the effect of stroke in 2030 in terms of potential gain in life expectancy. The absolute numbers of stroke deaths in 2030 were estimated using national population projections of Eurostat.

RESULTS

In all countries, stroke mortality rates declined incessantly until 2005 among both men and women. If these trends were to continue, age-adjusted mortality rates would decline by approximately half between 2005 and 2030 with larger declines in France (approximately two thirds) and smaller declines in the Netherlands, Denmark, and Sweden (approximately one fourth). Similar rates of decline would be observed in terms of potential gain in life expectancy. Because of population aging, the absolute number of stroke deaths would decline slowly in the United Kingdom and France and stabilize or even increase in other countries.

CONCLUSIONS

In the near future, stroke may lose much of its effects on life expectancy but remain a frequent cause of death among elderly populations. The prevention of stroke-related disability instead of mortality may become increasingly more important.

Incidence of ischaemic stroke according to income level among older people: the 3C study

BACKGROUND

stroke has been shown to follow a social gradient with incidence rising as socioeconomic status decreases.

OBJECTIVE

to examine the relationship between socioeconomic status and ischaemic stroke risk amongst older people.

SETTING

the Cities of Bordeaux, Dijon and Montpellier in France.

SUBJECTS AND METHODS

nine thousand and two hundred and ninety-four non-institutionalised persons aged 65 years or more followed for 6 years.

RESULTS

the distribution of cardiovascular risks factors was consistent with the classical finding of more favourable risk profiles among the advantaged socioeconomic groups. One hundred and thirty-six individuals developed a first ever ischaemic stroke (incidence rate: 3.2 per 1,000 py (person-years), 95% CI 2.7-3.8). The age- and sex-adjusted incidence of ischaemic stroke increased with increasing level of income (from 2.4 to 4.1 per 1,000 py, P = 0.04). In the multivariable analysis adjusting for cardiovascular risk factors, the higher income group displayed a 80% increased risk of ischaemic stroke compared with less wealthy participants (hazards ratio 1.77, 95% CI 1.20-2.61).

CONCLUSIONS

in this community-based sample of older individuals, a higher level of household income was associated with a higher risk of ischaemic stroke, a reversal of the social gradient usually reported in younger age groups. Selective survival is one of the potential explanations for this unexpected finding.

Quantifying links between stroke and risk factors: a study on individual health risk appraisal of stroke in a community of Chongqing

The objective of this study is to investigate the risk factors of stroke in a community in Chongqing by setting quantitative criteria for determining the risk factors of stroke. Thus, high-risk individuals can be identified and laid a foundation for predicting individual risk of stroke. 1,034 cases with 1:2 matched controls (2,068) were chosen from five communities in Chongqing including Shapingba, Xiaolongkan, Tianxingqiao, Yubei Road and Ciqikou. Participants were interviewed with a uniform questionnaire. The risk factors of stroke and the odds ratios of risk factors were analyzed with a logistic regression model, and risk exposure factors of different levels were converted into risk scores using statistical models. For men, ten risk factors including hypertension (5.728), family history of stroke (4.599), and coronary heart disease (5.404), among others, were entered into the main effect model. For women, 11 risk factors included hypertension (5.270), family history of stroke (4.866), hyperlipidemia (4.346), among others. The related risk scores were added to obtain a combined risk score to predict the individual's risk of stoke in the future. An individual health risk appraisal model of stroke, which was applicable to individuals of different gender, age, health behavior, disease and family history, was established. In conclusion, personal diseases including hypertension, diabetes mellitus, etc., were very important to the prevalence of stoke. The prevalence of stroke can be effectively reduced by changing unhealthy lifestyles and curing the positive individual disease. The study lays a foundation for health education to persuade people to change their unhealthy lifestyles or behaviors, and could be used in community health services.

Socioeconomic position, psychosocial work environment and cerebrovascular disease among women: the Finnish public sector study

BACKGROUND

The excess risk of fatal and non-fatal cerebrovascular disease in people from low socioeconomic positions is only partially explained by conventional cerebrovascular risk factors. This has led to the suggestion that poor psychosocial work environments provide important additional explanatory power. However, little evidence is available for women.

METHODS

We examined whether job demands or job control contributed to the socioeconomic gradient in cerebrovascular disease among 48 361 women aged 18-65 years. Job demands, job control and behavioural risk factors were self-reported in 2000-2002; socioeconomic position (as indexed by occupational class) and all of the health measures were obtained from registers. The outcome was recorded hospitalization or death from cerebrovascular disease.

RESULTS

During a mean follow-up of 3.4 years, 124 women had a new cerebrovascular disease event. The risk was 2.3 (95% CI 1.3-3.9) times higher among women in low vs high socioeconomic positions. Adjustment for conventional risk factors, such as prevalent hypertension, coronary heart disease, diabetes, smoking, heavy alcohol consumption, physical inactivity and obesity, attenuated this excess risk by 23%. In contrast, adjustment for job demands and job control actually amplified the gradient by 36% suggesting a suppression effect.

CONCLUSIONS

In this contemporary cohort of employed women, job demands-alone and in combination with job control-suppressed rather than explained socioeconomic differences in cerebrovascular disease.

Stroke Incidence, Recurrence, and Case-Fatality in Relation to Socioeconomic Position

Background and Purpose— Low socioeconomic status is associated with increased incidence of stroke. This study investigated stroke incidence, recurrence, and case-fatality after stroke among middle-aged Swedish men and women and whether this association differs by gender or stroke subtype.

Methods— A total of 69 625 (49% men) citizens, aged 40 to 65 years, living in the city of Malmö in 1990 were studied in relation to total annual income and occupation class, ie, 2 indicators of socioeconomic status. Incidence of first-ever stroke, stroke recurrence, and case-fatality (death within 28 days or 1 year after stroke) were studied over 10 years of follow-up.

Results— During the follow-up, a total of 1648 subjects developed a first-ever stroke of whom 275 also experienced a recurrent stroke. By using Cox regression model with covariate adjustments, the incidence of stroke was significantly increased (relative risk: 1.75, 95% CI:1.36 to 2.25) in women who were in the lowest quartile of income compared with the women being in the highest quartile. Corresponding relative risk in men was 1.29 (1.06 to 1.58). Both in men and women, income was significantly associated with ischemic, but not hemorrhagic, subtypes of stroke. Similar relationships were observed between occupation level and incidence of stroke. In addition, low income was associated with higher 28-day and 1-year fatality rates in men (relative risk: 3.13, 1.35 to 7.24 and 2.17, 1.18 to 4.00, respectively), but not in women. In contrast, recurrence of stroke was inversely associated with income only in women.

Conclusions— Incidence of stroke, stroke recurrence, and case-fatality increased with decreasing socioeconomic status; however, this relationship differed by gender and subtype of events.

Stroke disparities in older Americans: is wealth a more powerful indicator of risk than income and education?

BACKGROUND AND PURPOSE

This study examines the independent effect of wealth, income, and education on stroke and how these disparities evolve throughout middle and old age in a representative cohort of older Americans.

METHODS

Stroke-free participants in the Health and Retirement Study (n=19,565) were followed for an average of 8.5 years. Total wealth, income, and education assessed at baseline were used in Cox proportional hazards models to predict time to stroke. Separate models were estimated for 3 age-strata (50 to 64, 65 to 74, and >or=75), and incorporating risk factor measures (smoking, physical activity, body mass index, hypertension, diabetes, and heart disease).

RESULTS

1542 subjects developed incident stroke. Higher education predicted reduced stroke risk at ages 50 to 64, but not after adjustment for wealth and income. Wealth and income were independent risk factors for stroke at ages 50 to 64. Adjusted hazard ratios comparing the lowest decile with the 75th-90th percentiles were 2.3 (95% CI 1.6, 3.4) for wealth and 1.8 (95% CI 1.3, 2.6) for income. Risk factor adjustment attenuated these effects by 30% to 50%, but coefficients for both wealth (HR=1.7, 95% CI 1.2, 2.5) and income (HR=1.6, 95% CI 1.2, 2.3) remained significant. Wealth, income, and education did not consistently predict stroke beyond age 65.

CONCLUSIONS

Wealth and income are independent predictors of stroke at ages 50 to 64 but do not predict stroke among the elderly. This age patterning might reflect buffering of the negative effect of low socioeconomic status by improved access to social and health care programs at old ages, but may also be an artifact of selective survival.

The combined effect of age, education, and stroke on dementia and cognitive impairment no dementia in the elderly

BACKGROUND

This study aims to detect the impact of stroke on the occurrence of dementia and cognitive impairment/no dementia (CIND) in different age, sex, and education groups.

METHODS

Persons with dementia (DSM-III-R) or CIND were identified by a two-phase study design among 7,930 persons from the population-based Faenza Community Aging Study.

RESULTS

Subjects with a history of stroke had increased risk of both dementia [risk ratio (RR) = 3.7; 95% confidence interval (CI) = 3.1-4.4] and CIND (RR = 1.7, 95% CI = 1.4-2.2). These associations were stronger in the younger-old (61-74 years) than in the older-old (75+ years), and among higher-educated (4+ years) than lower-educated (0-3 years of schooling) persons. Dementia and CIND prevalence among stroke subjects was similar to the prevalence detected among subjects 10 years older but without a history of stroke. In stroke subjects, dementia prevalence became higher than CIND prevalence 10 years earlier than in non-stroke subjects. A combined effect for dementia due to a history of stroke, increasing age, and decreasing years of schooling was detected.

CONCLUSIONS

Stroke is a strong risk factor for dementia among younger-old and higher-educated subjects; in the presence of a stroke, dementia onset might occur about 10 years earlier, possibly by accelerating the progression from CIND to dementia.

Environmental vascular risk factors: new perspectives for stroke prevention

Despite intensive evaluation of acute stroke patients, perhaps only half of the attributable stroke risk is usually identified. In addition to traditional and non-traditional vascular risk factors-including most recently homocysteine, inflammation, and alterations of coagulation-a number of environmental risk factors for stroke have been identified in the last decade. In this update we review the following: lower education and poor socioeconomic status (probable surrogates for exposure to traditional high-risk behaviors such as smoking, poor nutrition, lack of prenatal control, absence of preventive medical and dental care, and non-compliance of treatment of conditions such as hypertension); depression, stress and affective disorders; obstructive sleep apnea; passive smoking and environmental pollution; infections, in particular periodontal diseases that increase C-reactive protein (CRP); raised body mass index (obesity); exercise, and diet. The possible role of high-fructose corn syrup in the epidemic of obesity in the USA is reviewed. Protective diets include higher consumption of fish, olive oil, grains, fruits and vegetables (Mediterranean diet), as well as probiotic bacteria in yogurt and dairy products. Careful attention should be given to the patient's environment looking for modifiable factors. The effects of clean environmental air and water, adequate diet and appropriate nutrition, healthy teeth, exercise, and refreshing sleep in the prevention of stroke and cardiovascular disease appear to be quite compelling. Although some of these modifiable risk factors lack evidence-based information, judicious clinical sense should be used to counteract the potentially damaging effects of adverse environmental vascular risk factors.

Evidence for Age-Dependent Education-Related Differences in Men and Women with First-Ever Stroke

Several studies have shown a relationship between low socioeconomic status, age and stroke mortality. However, there is lack of similar studies in relation to stroke incidence. All cases of first-ever stroke occurring in a population aged 35-85 years from the city of Umeå were collected from hospital-based registers during a 2-year study period (2000-2002), from death certificates and also from nursing homes during a 6-month period. The WHO definition of stroke was used. Register data served to analyze educational level. A total of 457 first-ever strokes (244 women and 213 men) were registered, corresponding to an overall annual incidence rate of first-ever stroke of 413.4 per 100,000. The incidence of first-ever stroke was significantly higher among low-educated compared to high-educated men and women. The highest stroke incidence was found among low-educated women aged 75-85 years. The educational-related differences in stroke incidence persisted in the oldest age group (75-85 years), also after controlling for sex and age. This is one of the first studies that analyzes first-ever stroke incidence also among elderly men and women (75-85 years) in relation to socioeconomic status. More community-based studies are needed in order to confirm the results.

The reversed social gradient: higher breast cancer mortality in the higher educated compared to lower educated. A comparison of 11 European populations during the 1990s

Higher socioeconomic position has been reported to be associated with increased risk of breast cancer mortality. Our aim was to see if this is consistently observed within 11 European populations in the 1990s. Longitudinal data on breast cancer mortality by educational level and marital status were obtained for Finland, Norway, Denmark, England and Wales, Belgium, France, Switzerland, Austria, Turin, Barcelona and Madrid. The relationship between breast cancer mortality and education was summarised by means of the relative index of inequality. A positive association was found in all populations, except for Finland, France and Barcelona. Overall, women with a higher educational level had approximately 15% greater risk of dying from breast cancer than those with lower education. This was observed both among never- and ever-married women. The greater risk of breast cancer mortality among women with a higher level of education was a persistent and generalised phenomenon in Europe in the 1990s.

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.

Relationships of age at menarche and menopause, and reproductive year with mortality from cardiovascular disease in Japanese postmenopausal women: the JACC study

BACKGROUND

Early menopause is associated with increased risk of coronary heart disease in Caucasian women. However, this association has not been examined in Asian women.

METHODS

We conducted a 10-year cohort study of 37,965 Japanese post-menopausal women aged 40-79 years in the Japan Collaborative Cohort (JACC) Study. Causes of death were determined based on the International Classification of Disease.

RESULTS

There were 487 mortality of stroke and 178 mortality of coronary heart disease. Late menarche or early menopause, or shorter duration of reproductive period was not associated with risk of mortality from coronary heart disease. However, compared with women with age at menarche ≤13 years, those with age at menarche ≥17 years tended to have increased risk of mortality from stroke: the multivariable hazard ratio was 1.32 (95% confidence interval [CI]: 0.93-1.87, p = 0.10). Compared with women with age at menopause of ≥49 years, those with age at menopause of <49 years tended to have increased risk of coronary heart disease among women aged 40-64 years; the multivariable hazard ratio was 1.85 (95% CI: 0.92-3.73, p = 0.08).

CONCLUSIONS

The possible association between early menopause and coronary heart disease among middle-aged women was consistent with the result of observational studies for Caucasian women, and can be explained by a protective effect of endogenous estrogen on the development of atherosclerosis.

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 stroke incidence in the US elderly: the role of risk factors in the EPESE study

BACKGROUND AND PURPOSE

This study assesses the effect of socioeconomic status on stroke incidence in the elderly, and the contribution of risk factors to stroke disparities.

METHODS

Data comprised a sample of 2812 men and women aged 65 years and over from the New Haven cohort of the Established Populations for the Epidemiologic Studies of the Elderly. Individuals provided baseline information on demographics, functioning, cardiovascular and psychosocial risk factors in 1982 and were followed for 12 years. Proportional hazard models were used to model survival from initial interview to first fatal or nonfatal stroke.

RESULTS

Two hundred and seventy subjects developed incident stroke. At ages 65 to 74, lower socioeconomic status was associated with higher stroke incidence for both education (HR(lowest/highest)=2.07, 95% CI, 1.04 to 4.13) and income (HR(lowest/highest)=2.08, 95% CI, 1.01 to 4.27). Adjustment for race, diabetes, depression, social networks and functioning attenuated hazard ratios to a nonsignificant level, whereas other risk factors did not change associations significantly. Beyond age 75, however, stroke rates were higher among those with the highest education (HR(lowest/highest)=0.42, 95% CI, 0.22 to 0.79) and income (HR(lowest/highest)=0.43, 95% CI, 0.22 to 0.86), which remained largely unchanged after adjustment for risk factors.

CONCLUSIONS

We observed substantial socioeconomic disparities in stroke at ages 65 to 74, whereas a crossover of the association occurred beyond age 75. Policies to improve social and economic resources at early old age, and interventions to improve diabetes management, depression, social networks and functioning in the disadvantaged elderly can contribute to reduce stroke disparities.

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.

Contribution of main causes of death to social inequalities in mortality in the whole population of Scania, Sweden

BACKGROUND

To more efficiently reduce social inequalities in mortality, it is important to establish which causes of death contribute the most to socioeconomic mortality differentials. Few studies have investigated which diseases contribute to existing socioeconomic mortality differences in specific age groups and none were in samples of the whole population, where selection bias is minimized. The aim of the present study was to determine which causes of death contribute the most to social inequalities in mortality in each age group in the whole population of Scania, Sweden.

METHODS

Data from LOMAS (Longitudinal Multilevel Analysis in Skåne) were used to estimate 12-year follow-up mortality rates across levels of socioeconomic position (SEP) and workforce participation in 975,938 men and women aged 0 to 80 years, during 1991-2002.

RESULTS

The results generally showed increasing absolute mortality differences between those holding manual and non-manual occupations with increasing age, while there were inverted u-shaped associations when using relative inequality measures. Cardiovascular diseases (CVD) contributed to 52% of the male socioeconomic difference in overall mortality, cancer to 18%, external causes to 4% and psychiatric disorders to 3%. The corresponding contributions in women were 55%, 21%, 2% and 3%. Additionally, those outside the workforce (i.e., students, housewives, disability pensioners, and the unemployed) showed a strongly increased risk of future mortality in all age groups compared to those inside the workforce. Even though coronary heart disease (CHD) played a major contributing role to the mortality differences seen, stroke and other types of cardiovascular diseases also made substantial contributions. Furthermore, while the most common types of cancers made substantial contributions to the socioeconomic mortality differences, in some age groups more than half of the differences in cancer mortality could be attributed to rarer cancers.

CONCLUSION

CHD made a major contribution to the socioeconomic differences in overall mortality. However, there were also important contributions from diseases with less well understood mechanistic links with SEP such as stroke and less-common cancers. Thus, an increased understanding of the mechanisms connecting SEP with more rare causes of disease might be important to be able to more successfully intervene on socioeconomic differences in health.

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.

Association of adult socioeconomic position with hypertension in older people

OBJECTIVE

To determine the role of obesity, adult behavioural risk factors, and markers of specific childhood exposures in the association between adult socioeconomic position and hypertension in a cohort of people aged 60 years and older.

DESIGN

Cross sectional study.

SETTING

Spain.

PARTICIPANTS

4009 subjects representative of the Spanish non-institutionalised population aged 60 years and older.

MAIN OUTCOME MEASURE

Prevalence of hyperteMarinhonsion according to education and social class, and proportion of excess difference in hypertension prevalence in lower socioeconomic groups explained by different risk factors for hypertension.

RESULTS

The highest prevalence of hypertension was seen in subjects with less education and in those belonging to a low social class. In men, the hypertension risk factors analysed did not explain the difference in prevalence by education, but they explained almost half of the difference by social class. In women, these risk factors explained the differences in hypertension prevalence by education and a substantial part of the differences by social class. Central and general obesity, and physical inactivity were the risk factors that were the most important in this association in women.

CONCLUSIONS

In women, socioeconomic position has no direct effect on hypertension in the case of education and only a small effect in the case of social class. In contrast, most of the effect of education and half of the effect of social class on hypertension in men is direct or, at least, is not explained by the risk factors analysed. The mechanisms that can explain the association between socioeconomic position and hypertension in older men remain to be established.

Education level inequalities and transportation injury mortality in the middle aged and elderly in European settings

OBJECTIVE

To study the differential distribution of transportation injury mortality by educational level in nine European settings, among people older than 30 years, during the 1990s.

METHODS

Deaths of men and women older than 30 years from transportation injuries were studied. Rate differences and rate ratios (RR) between high and low educational level rates were obtained.

RESULTS

Among men, those of low educational level had higher death rates in all settings, a pattern that was maintained in the different settings; no inequalities were found among women. Among men, in all the settings, the RR was higher in the 30-49 age group (RR 1.46, 95% CI 1.32 to 1.61) than in the age groups 50-69 and > or = 70 years, a pattern that was maintained in the different settings. For women for all the settings together, no differences were found among educational levels in the three age groups. In the different settings, only three had a high RR in the youngest age group, Finland (RR 1.33, 95% CI 1.01 to 1.74), Belgium (RR 1.38; 95% CI 1.13 to 1.67), and Austria (RR 1.49, 95% CI 0.75 to 2.96).

CONCLUSION

This study provides new evidence on the importance of socioeconomic inequalities in transportation injury mortality across Europe. This applies to men, but not to women. Greater attention should be placed on opportunities to select intervention strategies tailored to tackle socioeconomic inequalities in transportation injuries.

Are Mortality Differences and Trends by Education Any Better or Worse in New Zealand? A Comparison Study with Norway, Denmark and Finland, 1980–1990s

During the 1980s and early 1990s New Zealand experienced major social and economic change, decreasing all-cause mortality rates for the majority ethnic group, and high (but falling) cardiovascular disease (CVD) mortality rates. This paper explores whether inequalities in mortality by education were greater, and increased more, in New Zealand than in Nordic countries (Denmark, Finland, Norway), and determines the contribution of CVD to these differences and trends.

METHODS

We used mortality rates for 30-59 year olds by education, and slope (SII) and relative (RII) indices of inequality, calculated from comparable linked census mortality data.

RESULTS

Mortality inequalities in New Zealand were at the high end of the Nordic range when standardised by age only, but were mid-range when also standardised by ethnicity. Over time, relative inequalities in all-cause mortality increased similarly in all countries. In New Zealand a large increase in inequality for cardiovascular disease (CVD) mortality was the major contributor. In contrast both CVD and other causes of death were important drivers of increasing inequalities in Nordic countries. Absolute inequalities in all-cause mortality were stable over time among males across all countries, and increased modestly among females. The contribution of CVD to absolute inequality was stable or decreasing over time in all countries.

CONCLUSION

Overall, inequalities in mortality in New Zealand did not widen more rapidly than in northern European countries. However, rapid social and economic change may have affected trends in CVD mortality among low educated men and women, and especially the ethnic minority groups.