The contribution of risk factors to stroke differentials, by socioeconomic position in adulthood: the Renfrew/Paisley Study

Additive association of blood pressure and short stature with stroke incidence in 450,000 Japanese adults: the Shizuoka study

Short stature was suggested to be a risk factor for cardiovascular events. Because short stature increases central blood pressure, this study aimed to investigate a longitudinal association between short stature, blood pressure, and incidence of cardiovascular disease by the analysis of insurance-based real-world dataset. We analyzed data from 463,844 adults aged 40 or older with a mean age of 66.7 enrolled in National Health Insurance, excluding individuals who experienced a stroke or myocardial infarction, or required long-term care. Data from annual health checkups were used to obtain baseline clinical information. Comorbidities and incidences of stroke and myocardial infarction were obtained from the insurance data. During a 5.5-year follow-up period, we observed 11,027 cases of stroke. Adults of a short stature exhibited a higher incidence rate in both men (≤155 cm: 99.7, >175 cm: 24.4) and women (≤140 cm: 85.9, >160 cm: 13.7). Although those in the short stature group had higher blood pressure, and often took antihypertensive drugs, the inverse association between height and stroke incidence was independent of these factors (hazard ratio for 5 cm shorter in height; men: 1.06 [1.03-1.09], women: 1.11 [1.06-1.13]). Short stature and blood pressure showed additive association with stoke incidence (log-rank p < 0.001). No significant association was observed with myocardial infarction (men: 1.01 [0.95-1.06], women: 1.06 [0.98-1.14]). In a longitudinal analysis of a large general Japanese population, short stature was linked to an increased risk of stroke in both genders in any blood pressure range.

Matching participant address with public records database in a US national longitudinal cohort study

Background

Epidemiological studies utilize residential histories to assess environmental exposure risk. The validity from using commercially-sourced residential histories within national longitudinal studies remains unclear. Our study assessed predictors of non-agreement between baseline addresses from the commercially-sourced LexisNexis database and participants in the national longitudinal study, REasons for Geographic and Racial Differences in Stroke (REGARDS). Additionally, we assessed differences in stroke risk by neighborhood socioeconomic score (nSES) based on participant reported address compared to nSES from LexisNexis/REGARDS matched baseline address.

Methods

From January 2003–October 2007, REGARDS enrolled 30,239 black and white adults aged 45 and older within the continental United States and collected their baseline address. ArcGIS Desktop 10.5.1 with ESRI 2016 Business Analyst Data was used to geocode baseline addresses from LexisNexis and REGARDS. Logistic regression was used to estimate the likelihood that LexisNexis address matched REGARDS baseline address for each participant. Survival analysis was used to estimate association between nSES and incident stroke.

Results

Approximately 91% of REGARDS participants had a LexisNexis address. Of these geocoded addresses, 93% of REGARDS baseline addresses matched LexisNexis addresses. Odds of agreement between LexisNexis and REGARDS was higher for older-aged participants (OR = 1.02 per year, 95% CI: 1.01, 1.02), blacks compared to whites (OR = 1.16, 95% CI: 1.05, 1.29), females compared to males (OR = 1.15, 95% CI: 1.04, 1.26), participants with an income of $34k-74k compared to an income less than $20k (OR = 1.62, 95% CI: 1.39, 1.89). Odds of agreement were lower for residents in Midwest compared to residents in the south (OR = 0.82, 95% CI: 0.73, 0.94). No significant differences in nSES-stroke associations were observed between REGARDS only and LexisNexis/REGARDS matched addresses; however, differences in interactions were observed.

Conclusion

Agreement between LexisNexis and REGARDS addresses varied by sociodemographic groups, potentially introducing bias in studies reliant on LexisNexis alone for residential address data.

•

Approximately 9% of REGARDS participants did not have a LexisNexis address history available.

•

Of participants with both REGARDS and LexisNexis addresses available, 93% of these addresses matched.

•

Agreement between REGARDS and LexisNexis address varied by socio-demographics—potentially biasing environmental exposures.

•

Compared to LexisNexis, REGARDS addresses may be valuable in detecting interactions contributing to stroke disparities.

Stroke Incidence and Outcome Disparity in Rural Regions of Southern West Virginia

INTRODUCTION

West Virginia has the highest incidence of obesity, smoking, and diabetes within the United States, placing its population at higher risk of stroke. In addition to these endemic risk factors, Appalachia faces various socioeconomic and health care access challenges that could negatively impact stroke incidence and outcomes. At present, there are limited data regarding geographic variables on stroke outcomes in rural Appalachia. We set out to quantify Appalachian geographic patterns of stroke incidence and outcomes.

METHODS

This is a retrospective analysis of all patients hospitalized with a diagnosis of stroke in West Virginia's largest tertiary hospital. During the study (2000-2018), 14,488 patients were analyzed, with an emphasis on those who died from stroke (n = 1022). We first used institutional ICD-9/10 data alongside demographics information and chart reviews to evaluate disease patterns while also exploring emerging hot spot pattern changes over time; we then exploited an emerging time series analysis using temporal trends to assess differing instances of stroke occurrence regionally with hot spots defined as higher than expected incidences of stroke and stroke death.

RESULTS

Data analysis revealed several hot spots of increasing stroke and mortality rates, many of which achieved statistically significant variance compared to expected norms (P = 0.001). Moreover, this study revealed high-risk zones in rural West Virginia wherein the incidence and mortality rates of stroke are suggestively higher and less resistance to economic change than urban centers.

CONCLUSIONS

Stroke incidence and mortality were found to be higher than expected in many areas of rural West Virginia. The higher stroke risk populations correlate with area that may be impacted by socioeconomic factors and limited access to primary care. These high-risk areas may therefore benefit from investments in infrastructure, patient education, and unrestricted primary care.

Increased ischemic stroke risk in patients with Behçet's disease: A nationwide population-based cohort study

Background

Behçet’s disease (BD) is a recurrent, multisystemic, inflammatory disorder that mainly affects blood vessels. Because recurrent inflammation of blood vessels in the brain plays a crucial role in the development of ischemic stroke, we hypothesized that patients with BD might have an elevated risk of ischemic stroke. This potential association has been suggested in a few case reports, but not epidemiological studies. Hence, the present study aimed to examine the relation between BD and subsequent ischemic stroke in Taiwan using a nationwide, population-based database.

Methods

To establish a study cohort, the longitudinal data of 306 patients newly diagnosed with BD during 2000–2010 were extracted from the National Health Insurance Research Database, Taiwan. For comparison of ischemic stroke incidence, a control cohort of 1224 subjects without BD was established using a frequency-matched ratio of 1:4 for age, sex, and pre-existing comorbidities.

Results

During the 10-year follow-up, 13 (4.2%) patients with BD and 20 (1.6%) control subjects experienced ischemic stroke. Kaplan–Meier analysis revealed the higher prevalence of ischemic stroke in the BD group (log-rank test, p = 0.001). After adjusting for comorbidities and demographic characteristics, Cox regression analysis revealed that patients with BD had a 2.77-fold risk of ischemic stroke (95% confidence interval, 1.38–5.57) compared to control subjects.

Conclusions

Patients with BD have an elevated risk of ischemic stroke. Hence, BD may affect the vascular system in the brain, resulting in a stroke event.

The contribution of health behaviors to socioeconomic inequalities in health: A systematic review

Unhealthy behaviors and their social patterning have been frequently proposed as factors mediating socioeconomic differences in health. However, a clear quantification of the contribution of health behaviors to the socioeconomic gradient in health is lacking. This study systematically reviews the role of health behaviors in explaining socioeconomic inequalities in health. Published studies were identified by a systematic review of PubMed, Embase and Web-of-Science. Four health behaviors were considered: smoking, alcohol consumption, physical activity and diet. We restricted health outcomes to cardiometabolic disorders and mortality. To allow comparison between studies, the contribution of health behaviors, or the part of the socioeconomic gradient in health that is explained by health behaviors, was recalculated in all studies according to the absolute scale difference method. We identified 114 articles on socioeconomic position, health behaviors and cardiometabolic disorders or mortality from electronic databases and articles reference lists. Lower socioeconomic position was associated with an increased risk of all-cause mortality and cardiometabolic disorders, this gradient was explained by health behaviors to varying degrees (minimum contribution -43%; maximum contribution 261%). Health behaviors explained a larger proportion of the SEP-health gradient in studies conducted in North America and Northern Europe, in studies examining all-cause mortality and cardiovascular disease, among men, in younger individuals, and in longitudinal studies, when compared to other settings. Of the four behaviors examined, smoking contributed the most to social inequalities in health, with a median contribution of 19%. Health behaviors contribute to the socioeconomic gradient in cardiometabolic disease and mortality, but this contribution varies according to population and study characteristics. Nevertheless, our results should encourage the implementation of interventions targeting health behaviors, as they may reduce socioeconomic inequalities in health and increase population health.

Individual and Area-Based Socioeconomic Factors Associated With Dementia Incidence in England: Evidence From a 12-Year Follow-up in the English Longitudinal Study of Ageing

IMPORTANCE

Lower educational attainment is associated with a higher risk of dementia. However, less clear is the extent to which other socioeconomic markers contribute to dementia risk.

OBJECTIVE

To examine the relationship of education, wealth, and area-based deprivation with the incidence of dementia over the last decade in England and investigate differences between people born in different periods.

DESIGN, SETTING, AND PARTICIPANTS

Data from the English Longitudinal Study of Ageing, a prospective cohort study that is representative of the English population, were used to investigate the associations between markers of socioeconomic status (wealth quintiles and the index of multiple deprivation) and dementia incidence. To investigate outcomes associated with age cohorts, 2 independent groups were derived using a median split (born between 1902-1925 and 1926-1943).

MAIN OUTCOMES AND MEASURES

Dementia as determined by physician diagnosis and the Informant Questionnaire on Cognitive Decline in the Elderly.

RESULTS

A total of 6220 individuals aged 65 years and older enrolled in the study (median [interquartile range] age at baseline, 73.2 [68.1-78.3] years; 3410 [54.8%] female). Of these, 463 individuals (7.4%) had new cases of dementia ascertained in the 12 years between 2002-2003 and 2014-2015. In the cohort born between 1926 and 1943, the hazard of developing dementia was 1.68 times higher (hazard ratio [HR] = 1.68 [95% CI, 1.05-2.86]) for those in the lowest wealth quintile compared with those in the highest quintile, independent of education, index of multiple deprivation, and health indicators. Higher hazards were also observed for those in the second-highest quintile of index of multiple deprivation (HR = 1.62 [95% CI, 1.06-2.46]) compared with those in the lowest (least deprived) quintile.

CONCLUSIONS AND RELEVANCE

In an English nationally representative sample, the incidence of dementia appeared to be socioeconomically patterned primarily by the level of wealth. This association was somewhat stronger for participants born in later years.

Re-look at socioeconomic inequalities in stroke prevalence among urban Chinese: is the inflexion approaching?

Background

The present association between socioeconomic status (SES) and stroke is positive in developing communities, but it is negative in developed countries where a positive SES-stroke relationship was recorded several decades ago. We hypothesized that the SES-stroke relationship in developing societies mirrors the trajectory of the Western countries at some stage of economic development. This study aimed to examine whether this inflexion is approaching in China.

Methods

This study comprises of two cross-sectional surveys conducted in the same urban areas of Nanjing, China in 2000 (S2000) and 2011 (S2011) using the same selection criteria (i.e., aged≥35 years) and sampling approach. Physician-diagnosed stroke was the outcome event, while family average income (FAI) was the explanatory variable and tertiled in our anlaysis. Mixed-effects models were used to examine the FAI-stroke association.

Results

Overall, 19,861 (response rate = 90.1%) and 7824 (response rate = 82.8%) participants participated in the S2000 and S2011, respectively. The prevalence of stroke increased by 2.5-folds (95%CI = 2.2, 2.9) from 2000 (2.1%, 95%CI = 1.9%, 2.3%) to 2011 (5.1%, 95%CI = 4.6%, 5.6%) (p < 0.01). Compared with the lower FAI category, the positive association between stroke prevalence and the higher FAI group decreased from 1.99 (95%CI = 1.55, 2.56) in 2000 to 1.49 (95%CI = 1.09, 2.03) in 2011 after control for potential confounders. A similar pattern was also observed for the middle FAI group (1.60, 95% CI = 1.23, 2.08 in 2000 vs. 1.37, 95%CI = 1.01, 1.88 in 2011).

Conclusions

This study revealed that socioeconomic inequalities in stroke were diminishing in regional China during the recent 11-year period, although the SES-stroke association was still positive. Tailored intervention against stroke should currently target on SES-vulnerable people.

Health Inequalities Associated with Post-Stroke Visual Impairment in the United Kingdom and Ireland: A Systematic Review

The aim of this study was to report on the health inequalities facing stroke survivors with visual impairments as described in the current literature. A systemic review of the literature was conducted to investigate the potential health inequalities facing stroke survivors with subsequent visual impairments. A quality-of-evidence and risk-of-bias assessment was conducted for each of the included articles using the appropriate tool dependent on the type of article. Only four articles discussed health inequalities affecting stroke survivors with visual impairment specifically. A further 23 articles identified health inequalities after stroke, and 38 reported on health inequalities within the visually impaired UK or Irish population. Stroke survivors with visual impairment face inconsistency in eye care provision nationally, along with variability in the assessment and management of visual disorders. The subgroups identified as most at risk were females; black ethnicity; lower socioeconomic status; older age; and those with lower education attainment. The issue of inconsistent service provision for this population must be addressed in future research. Further research must be conducted in order to firmly establish whether or not stroke survivors are at risk of the aforementioned sociodemographic and economic inequalities.

Socioeconomic variation in incidence of primary and secondary major cardiovascular disease events: an Australian population-based prospective cohort study

BACKGROUND

Cardiovascular disease (CVD) disproportionately affects disadvantaged people, but reliable quantitative evidence on socioeconomic variation in CVD incidence in Australia is lacking. This study aimed to quantify socioeconomic variation in rates of primary and secondary CVD events in mid-age and older Australians.

METHODS

Baseline data (2006-2009) from the 45 and Up Study, an Australian cohort involving 267,153 men and women aged ≥ 45, were linked to hospital and death data (to December 2013). Outcomes comprised first event - death or hospital admission - for major CVD combined, as well as myocardial infarction and stroke, in those with and without prior CVD (secondary and primary events, respectively). Cox regression estimated hazard ratios (HRs) for each outcome in relation to education (and income and area-level disadvantage), separately by age group (45-64, 65-79, and ≥ 80 years), adjusting for age and sex, and additional sociodemographic factors.

RESULTS

There were 18,207 primary major CVD events over 1,144,845 years of follow-up (15.9/1000 person-years), and 20,048 secondary events over 260,357 years (77.0/1000 person-years). For both primary and secondary events, incidence increased with decreasing education, with the absolute difference between education groups largest for secondary events. Age-sex adjusted hazard ratios were highest in the 45-64 years group: for major CVDs, HR (no qualifications vs university degree) = 1.62 (95% CI: 1.49-1.77) for primary events, and HR = 1.49 (1.34-1.65) for secondary events; myocardial infarction HR = 2.31 (1.87-2.85) and HR = 2.57 (1.90-3.47) respectively; stroke HR = 1.48 (1.16-1.87) and HR = 1.97 (1.42-2.74) respectively. Similar but attenuated results were seen in older age groups, and with income. For area-level disadvantage, CVD gradients were weak and non-significant in older people (> 64 years).

CONCLUSIONS

Individual-level data are important for quantifying socioeconomic variation in CVD incidence, which is shown to be substantial among both those with and without prior CVD. Findings reinforce the opportunity for, and importance of, primary and secondary prevention and treatment in reducing socioeconomic variation in CVD and consequently the overall burden of CVD morbidity and mortality in Australia.

Neighborhood socioeconomic index and stroke incidence in a national cohort of blacks and whites

OBJECTIVE

To assess the relationship between neighborhood socioeconomic characteristics and incident stroke in a national cohort of black and white participants.

METHODS

The study comprised black (n = 10,274, 41%) and white (n = 14,601) stroke-free participants, aged 45 and older, enrolled in 2003-2007 in Reasons for Geographic and Racial Differences in Stroke (REGARDS), a national population-based cohort. A neighborhood socioeconomic score (nSES) was constructed using 6 neighborhood variables. Incident stroke was defined as first occurrence of stroke over an average 7.5 (SD 3.0) years of follow-up. Proportional hazards models were used to estimate associations between nSES score and incident stroke, adjusted for demographics (age, race, sex, region), individual socioeconomic status (SES) (education, household income), and other risk factors for stroke.

RESULTS

After adjustment for demographics, compared to the highest nSES quartile, stroke incidence increased with each decreasing nSES quartile. The hazard ratio (95% confidence interval) ranged from 1.28 (1.05-1.56) in quartile 3 to 1.38 (1.13-1.68) in quartile 2 to 1.56 (1.26-1.92) in quartile 1 (p < 0.0001 for linear trend). After adjustment for individual SES, the trend remained marginally significant (p = 0.085). Although there was no evidence of a differential effect by race or sex, adjustment for stroke risk factors attenuated the association between nSES and stroke in both black and white participants, with greater attenuation in black participants.

CONCLUSIONS

Risk of incident stroke increased with decreasing nSES but the effect of nSES is attenuated through individual SES and stroke risk factors. The effect of neighborhood socioeconomic characteristics that contribute to increased stroke risk is similar in black and white participants.

The Association between Educational Level and Cardiovascular and Cerebrovascular Diseases within the EPICOR Study: New Evidence for an Old Inequality Problem

BACKGROUND

A consistent association has been reported between low socioeconomic status (SES) and cardiovascular events (CE), whereas the association between SES and cerebrovascular events (CBVD) is less clear. The aim of this study was to investigate the association between SES (measured using education) and CE/CBVD in a cohort study, as well as to investigate lifestyle and clinical risk factors, to help to clarify the mechanisms by which SES influences CE/CBVD.

MATERIAL AND METHODS

We searched for diagnoses of CE and CBVD in the clinical records of 47,749 members of the EPICOR cohort (average follow-up time: 11 years). SES was determined by the relative index of inequality (RII).

RESULTS

A total of 1,156 CE and 468 CBVD were found in the clinical records. An increased risk of CE was observed in the crude Cox model for the third tertile of RII compared to the first tertile (hazard ratio [HR] = 1.39; 95% confidence interval [CI] 1.21-1.61). The increased risk persisted after adjustment for lifestyle risk factors (HR = 1.19; 95%CI 1.02-1.38), clinical risk factors (HR = 1.35; 95%CI 1.17-1.56), and after full adjustment (HR = 1.17; 95%CI 1.01-1.37). Structural equation model showed that lifestyle rather than clinical risk factors are involved in the mechanisms by which education influences CE. No significant association was found between education and CBVD. A strong relationship was observed between education and diabetes at baseline.

CONCLUSION

The most important burden of inequality in CE incidence in Italy is due to lifestyle risk factors.

The effects of socioeconomic status on stroke risk and outcomes

The latest evidence on socioeconomic status and stroke shows that stroke not only disproportionately affects low-income and middle-income countries, but also socioeconomically deprived populations within high-income countries. These disparities are reflected not only in risk of stroke but also in short-term and long-term outcomes after stroke. Increased average levels of conventional risk factors (eg, hypertension, hyperlipidaemia, excessive alcohol intake, smoking, obesity, and sedentary lifestyle) in populations with low socioeconomic status account for about half of these effects. In many countries, evidence shows that people with lower socioeconomic status are less likely to receive good-quality acute hospital and rehabilitation care than people with higher socioeconomic status. For clinical practice, better implementation of well established treatments, effective management of risk factors, and equity of access to high-quality acute stroke care and rehabilitation will probably reduce inequality substantially. Overcoming barriers and adapting evidence-based interventions to different countries and health-care settings remains a research priority.

Stroke: a Hidden Danger of Margin Trading in Stock Markets

Using 10-year population data from 2000 through 2009 in Taiwan, this is the first paper to analyze the relationship between margin trading in stock markets and stroke hospitalizations. The results show that 3 and 6 days after an increase of margin trading in the Taiwan stock markets are associated with greater stoke hospitalizations. In general, a 1 % increase in total margin trading positions is associated with an increment of 2.5 in the total number of stroke hospitalizations, where the mean number of hospital admissions is 233 cases a day. We further examine the effects of margin trading by gender and age groups and find that the effects of margin trading are significant for males and those who are 45-74 years old only. In summary, buying stocks with money you do not have is quite risky, especially if the prices of those stocks fall past a certain level or if there is a sudden and severe drop in the stock market. There is also a hidden danger to one's health from margin trading. A person should be cautious before conducting margin trading, because while it can be quite profitable, danger always lurks just around the corner.

The incidence of stroke by socioeconomic status, age, sex, and stroke subtype: a nationwide study in Korea

Objectives

To date, studies have not comprehensively demonstrated the relationship between stroke incidence and socioeconomic status. This study investigated stroke incidence by household income level in conjunction with age, sex, and stroke subtype in Korea.

Methods

Contributions by the head of household were used as the basis for income levels. Household income levels for 21 766 036 people were classified into 6 groups. The stroke incidences were calculated by household income level, both overall within income categories and further by age group, sex, and stroke subtype. To present the inequalities among the six ranked groups in a single value, the slope index of inequality and relative index of inequality were calculated.

Results

In 2005, 57 690 people were first-time stroke patients. The incidences of total stroke for males and females increased as the income level decreased. The incidences of stroke increased as the income level decreased in those 74 years old and under, whereas there was no difference by income levels in those 75 and over. Intracerebral hemorrhage for the males represented the highest inequality among stroke subtypes. Incidences of subarachnoid hemorrhage did not differ by income levels.

Conclusions

The incidence of stroke increases as the income level decreases, but it differs according to sex, age, and stroke subtype. The difference in the relative incidence is large for male intracerebral hemorrhage, whereas the difference in the absolute incidence is large for male ischemic stroke.

Evaluation of the Healthy LifeCheck programme: a vascular risk assessment service for community pharmacies in Leicester city, UK

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death globally. Vascular risk assessment is recognized as playing a key role in reducing premature CVD-related morbidity and mortality. The current study evaluated the effectiveness of a pharmacy-led risk assessment service in Leicester City, UK.

METHODS

The vascular risk assessment was offered opportunistically to individuals between 40 and 70 years without any prior diagnosis of CVD on attending their community pharmacist. Individuals were risk stratified using the Framingham score and those classified as high risk were referred to their general practitioner (GP).

RESULTS

Overall, 2521 individuals were recruited from 39 pharmacies consisting of 1059 (42%) males, 1696 (67%) South Asians and 199 (7.9%) individuals not registered with a GP. A total of 462 (18%) individuals were referred to primary care and 52.6% of a representative subset were subsequently recorded as having attended an appointment with their GP; diagnoses and treatments commenced were recorded.

CONCLUSIONS

Cardiovascular risk assessment led by community pharmacies can successfully assess people from large, multi-ethnic UK populations and identify those at high cardiovascular risk or with undiagnosed cardiovascular disease. The service may improve rates of assessments undertaken by individuals who do not access health care through traditional routes.

Stock or stroke? Stock market movement and stroke incidence in Taiwan

This paper investigates the impact of stock market movement on incidences of stroke utilizing population-based aggregate data in Taiwan. Using the daily data from the Taiwan Stock Exchange Capitalization Weighted Stock Index and from the National Health Insurance Research Database during 2001/1/1–2007/12/31, which consist of 2556 observations, we examine the effects of stock market on stroke incidence – the level effect and the daily change effects. In general, we find that both a low stock index level and a daily fall in the stock index are associated with greater incidences of stroke. We further partition the data on sex and age. The level effect is found to be significant for either gender, in the 45–64 and 65≥ age groups. In addition, two daily change effects are found to be significant for males and the elderly. Although stockholdings can increase wealth, they can also increase stroke incidence, thereby representing a cost to health.

Neighborhood disparities in stroke and myocardial infarction mortality: a GIS and spatial scan statistics approach

BACKGROUND

Stroke and myocardial infarction (MI) are serious public health burdens in the US. These burdens vary by geographic location with the highest mortality risks reported in the southeastern US. While these disparities have been investigated at state and county levels, little is known regarding disparities in risk at lower levels of geography, such as neighborhoods. Therefore, the objective of this study was to investigate spatial patterns of stroke and MI mortality risks in the East Tennessee Appalachian Region so as to identify neighborhoods with the highest risks.

METHODS

Stroke and MI mortality data for the period 1999-2007, obtained free of charge upon request from the Tennessee Department of Health, were aggregated to the census tract (neighborhood) level. Mortality risks were age-standardized by the direct method. To adjust for spatial autocorrelation, population heterogeneity, and variance instability, standardized risks were smoothed using Spatial Empirical Bayesian technique. Spatial clusters of high risks were identified using spatial scan statistics, with a discrete Poisson model adjusted for age and using a 5% scanning window. Significance testing was performed using 999 Monte Carlo permutations. Logistic models were used to investigate neighborhood level socioeconomic and demographic predictors of the identified spatial clusters.

RESULTS

There were 3,824 stroke deaths and 5,018 MI deaths. Neighborhoods with significantly high mortality risks were identified. Annual stroke mortality risks ranged from 0 to 182 per 100,000 population (median: 55.6), while annual MI mortality risks ranged from 0 to 243 per 100,000 population (median: 65.5). Stroke and MI mortality risks exceeded the state risks of 67.5 and 85.5 in 28% and 32% of the neighborhoods, respectively. Six and ten significant (p < 0.001) spatial clusters of high risk of stroke and MI mortality were identified, respectively. Neighborhoods belonging to high risk clusters of stroke and MI mortality tended to have high proportions of the population with low education attainment.

CONCLUSIONS

These methods for identifying disparities in mortality risks across neighborhoods are useful for identifying high risk communities and for guiding population health programs aimed at addressing health disparities and improving population health.

Identifying unique neighborhood characteristics to guide health planning for stroke and heart attack: fuzzy cluster and discriminant analyses approaches

BACKGROUND

Socioeconomic, demographic, and geographic factors are known determinants of stroke and myocardial infarction (MI) risk. Clustering of these factors in neighborhoods needs to be taken into consideration during planning, prioritization and implementation of health programs intended to reduce disparities. Given the complex and multidimensional nature of these factors, multivariate methods are needed to identify neighborhood clusters of these determinants so as to better understand the unique neighborhood profiles. This information is critical for evidence-based health planning and service provision. Therefore, this study used a robust multivariate approach to classify neighborhoods and identify their socio-demographic characteristics so as to provide information for evidence-based neighborhood health planning for stroke and MI.

METHODS AND FINDINGS

The study was performed in East Tennessee Appalachia, an area with one of the highest stroke and MI risks in USA. Robust principal component analysis was performed on neighborhood (census tract) socioeconomic and demographic characteristics, obtained from the US Census, to reduce the dimensionality and influence of outliers in the data. Fuzzy cluster analysis was used to classify neighborhoods into Peer Neighborhoods (PNs) based on their socioeconomic and demographic characteristics. Nearest neighbor discriminant analysis and decision trees were used to validate PNs and determine the characteristics important for discrimination. Stroke and MI mortality risks were compared across PNs. Four distinct PNs were identified and their unique characteristics and potential health needs described. The highest risk of stroke and MI mortality tended to occur in less affluent PNs located in urban areas, while the suburban most affluent PNs had the lowest risk.

CONCLUSIONS

Implementation of this multivariate strategy provides health planners useful information to better understand and effectively plan for the unique neighborhood health needs and is important in guiding resource allocation, service provision, and policy decisions to address neighborhood health disparities and improve population health.

Education level explains differences in stroke incidence among city districts in Joinville, Brazil: a three-year population-based study

BACKGROUND

Current evidence suggests an inverse association between socioeconomic status and stroke incidence. Our aim was to measure the variation in incidence among different city districts (CD) and their association with socioeconomic variables.

METHODS

We prospectively ascertained all possible stroke cases occurring in the city of Joinville during the period 2005-2007. We determined the incidence for each of the 38 CD, age-adjusted to the population of Joinville. By linear regression analysis, we correlated incidence data with mean years of education (MYE) and mean income per month (MIPM).

RESULTS

Of the 1,734 stroke cases registered, 1,034 were first-ever strokes. In the study period, the crude incidence in Joinville was 69.5 per 100,000 (95% confidence interval, 65.3-73.9). The stroke incidence among CD ranged from 37.5 (22.2-64.6) to 151.0 per 100,000 (69.0-286.6). The stroke incidence was inversely correlated with years of education (r = -0.532; p < 0.001). MYE and MIPM were strongly related (R = 0.958), resulting in exclusion of MIPM by collinearity.

CONCLUSIONS

Years of education can explain a wide incidence variation among CD. These results may be useful to guide the allocation of resources in primary prevention policies.

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.

Gender differences in the association between education and the incidence of cardiovascular events in Northern Italy

BACKGROUND

The educational differences in the incidence of major cardiovascular events are under-studied in Southern Europe and among women.

METHODS

The study sample includes n = 5084 participants to 4 population-based Northern Italian cohorts, aged 35-74 at baseline and with no previous cardiovascular events. The follow-up to ascertain the first onset of coronary heart disease (CHD) or ischaemic stroke ended in 2002. At baseline, major cardiovascular risk factors were investigated adopting the standardized MONICA procedures. Two educational classes were obtained from years of schooling. Age- and risk factors-adjusted hazard ratios of first CHD or ischaemic stroke were estimated through sex-specific separate Cox models (high education as reference).

RESULTS

Median follow-up time was 12 years. Event rates were 6.38 (CHD) and 2.12 (ischaemic stroke) per 1000 person-years in men; and 1.59 and 0.94 in women. In men, low education was associated with higher mean Body Mass Index and prevalence of diabetes and cigarette smokers; but also with higher HDL cholesterol and a more favourable alcohol intake pattern. Less-educated women had higher mean systolic blood pressure, Body Mass Index and HDL cholesterol and were more likely to have diabetes. Men and women in the low educational class had a 2-fold increase in ischaemic stroke and CHD incidence, respectively, after controlling for major risk factors. Education was not associated with CHD incidence in men. Higher ischaemic stroke rates were observed among more educated women.

CONCLUSION

In this northern Italian population, the association between education and cardiovascular risk seems to vary by gender.

Adult height and the risk of cardiovascular disease among middle aged men and women in Japan

An inverse association between height and risk of cardiovascular disease has been reported, but the evidence is limited for stroke subtypes, in particular in Asian populations. Further, few studies have examined how socioeconomic status in adulthood influence the relationship between height and risk of cardiovascular disease. This study examined the association between height and risks of stroke and coronary heart disease, and whether education level, an indicator of adult socioeconomic status, modify the effect of height on those risks, within a cohort of the Japan Public Health Center-based Prospective Study (JPHC Study). The hazard ratios for the incidence of cardiovascular disease associated with height were calculated by a 16-year follow-up of 15,564 Japanese men and women, aged 40-59. The hazard ratios were adjusted for age, gender, area, education, occupation and cardiovascular risk factors. Height was inversely associated with risks of total stroke, either hemorrhagic or ischemic stroke but not with coronary heart disease. The adjusted hazard ratios (95% confidence interval (CI)) of total stroke, hemorrhagic stroke, and ischemic stroke for a 1 SD height increments were 0.82 (95% CI: 0.74, 0.90), 0.80 (95% CI: 0.70, 0.92), and 0.83 (95% CI: 0.73, 0.95), respectively. No multiplicative interaction was observed between height and education level on stroke risk. Short stature was associated with increased risk of total stroke, either hemorrhagic or ischemic stroke, independent of adult socioeconomic status and cardiovascular risk factors, but not with risk of coronary heart disease in Japanese men and women.

Association between tobacco use and lifestyle in a sample of lower income urban African-Americans in the American south

There has been little research evaluating links between low-income populations' lifestyles and their tobacco use status. We surveyed 398 low-income individuals living in Housing Authority complexes in Columbus, Georgia. Current, former, and never tobacco users were compared for their health-related behaviors and lifestyles. Study findings suggest that current tobacco users were less healthy than comparisons, but had less unfavorable obesity measurements. In lifestyle choices, tobacco users were more likely than comparisons to be interested in sports (football, basketball, etc.), shopping, and participate in church activities.

Socioeconomic indicators and cardiovascular disease incidence among Japanese community residents: the Jichi Medical School Cohort Study

BACKGROUND

There has been little research in inequalities in risk of cardiovascular disease incidence by social class in Asia.

PURPOSE

The purpose of this study was to examine the association between socioeconomic indicators and risk of stroke and coronary heart disease in Japan.

METHOD

Data from the Jichi Medical School Study, a population-based prospective cohort study of approximately 11,000 Japanese men and women, were used. The average follow-up period was 11.7 years. Age- and area-adjusted hazard ratios with 95% confidence intervals (CIs) for education level/occupation were calculated using Cox proportional hazard regression analysis.

RESULTS

Compared to those who completed education at age 14 or younger, the age and area-adjusted hazard ratios of intraparenchymal hemorrhage incidence for men who completed education at age 15-17 and at age 18 or older were 0.42 (95% CI, 0.21-0.84) and 0.34 (95% CI, 0.14-0.84), respectively. The age- and area-adjusted hazard ratios of intraparenchymal hemorrhage and subarachnoid hemorrhage incidence for female white-collar workers compared to female blue-collar workers were 0.28 (95% CI, 0.08-0.98) and 3.23 (95% CI, 1.29, 8.01), respectively. No associations were found between education level and risk of coronary heart disease among both men and women.

CONCLUSION

These results suggest the pattern of social inequalities in health in Japan might be different from that in Western countries.

Social class, risk factors, and stroke incidence in men and women: a prospective study in the European prospective investigation into cancer in Norfolk cohort

BACKGROUND AND PURPOSE

The purpose of this study was to investigate the association between occupational social class and stroke incidence and the extent to which classical, lifestyle, and psychosocial risk factors may explain such relationships.

METHODS

A prospective population study was conducted of 22488 men and women aged 39 to 79 years living in the general community in Norfolk, UK, recruited in 1993 to 1997 and followed up for stroke incidence to 2007.

RESULTS

An inverse relationship was observed between social class and stroke incidence with an age- and sex-adjusted hazard ratio for social Class V compared with I of 2.62 (95% CI, 1.63 to 4.22; P=0.001). Adjusting for classical (systolic blood pressure, total blood cholesterol, smoking, history of diabetes, and body mass index), lifestyle (plasma vitamin C levels, alcohol intake, and physical activity), and psychosocial (5-item version of the Mental Health Inventory) risk factors had little effect, and a socioeconomic differential was still apparent: hazard ratio for social Class V compared with I of 2.55 (95% CI, 1.34 to 4.85, P=0.004 for comparison of V to I).

CONCLUSIONS

Stroke incidence increased with lower social class in both men and women. Adjustment for a comprehensive range of classical, lifestyle, and psychosocial risk factors did not explain the socioeconomic differential in stroke incidence. If we are to reduce inequalities in health, further understanding of the mechanisms underlying the association is needed.

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.

Adult height and the risk of mortality in South Korean women

To evaluate the association between adult height as a surrogate marker of childhood circumstances and the risk of mortality, 344,519 South Korean women aged 40-64 years categorized into six height groups were prospectively followed for mortality between 1994 and 2004. In Cox proportional hazards regression with adjustment for behavioral and biologic risk factors, there was an inverse association between height and total mortality; mortality risk decreased 7% for each 5-cm increment in height. The association did not materially change after adjustment for behavioral factors and adulthood socioeconomic factors or after full adjustment for all available covariates. When height-associated risks of death from specific causes were evaluated in a fully adjusted analysis, a 5-cm increment in height was associated with lower risks of death from respiratory diseases, stroke, diabetes mellitus, and external causes (hazard ratios were 0.84 (95% confidence interval (CI): 0.74, 0.96), 0.84 (95% CI: 0.80, 0.88), 0.87 (95% CI: 0.80, 0.96), and 0.88 (95% CI: 0.83, 0.94), respectively) and with a higher risk of death from cancer (hazard ratio = 1.05, 95% CI: 1.02, 1.09). Given that adult height reflects early-life conditions, the independent associations between height and mortality from all causes and specific causes support the view that early-life circumstances significantly influence health outcomes in adulthood.

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.

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.

Is the ‘Stroke Belt’ Worn From Childhood?

BACKGROUND AND PURPOSE

Most Stroke Belt studies define exposure based on residence at stroke onset. We assessed whether residence in the Stroke Belt during childhood confers extra stroke risk in adulthood, even among people who left the region.

METHODS

Stroke-free Health and Retirement Study participants (n=18 070) followed up (average, 8.4 years) for first stroke (1452 events) were classified as living in 1 of 7 Stroke Belt states in childhood or at study enrollment (average age, 63 years). We used Cox proportional-hazards models to compare stroke risk for people who had never lived in the Stroke Belt with those who had lived there at both ages, in childhood only, or in adulthood only.

RESULTS

Compared with never having lived in the Stroke Belt, the hazard ratio for Stroke Belt residence in both childhood and adulthood was 1.23 (95% CI, 1.06, 1.43) and for Stroke Belt residence in childhood only was 1.25 (95% CI, 1.02, 1.55). Stroke Belt residence at enrollment but not during childhood was not significantly related to stroke risk (hazard ratio=1.01; 95% CI, 0.70, 1.46), but the small sample in this group resulted in wide CIs. Results changed little after risk factor adjustment, including comprehensive adult socioeconomic measures. Subgroup analyses found similar patterns by sex and birth cohort. In contrast, blacks who had lived in the Stroke Belt in childhood only did not appear to have significantly elevated stroke risk compared with blacks who had never lived in the Stroke Belt.

CONCLUSIONS

The excess stroke risk for people who had lived in Stroke Belt states during childhood implicates early life exposures in the etiology of the Stroke Belt.

Urbanization and stroke prevalence in Taiwan: analysis of a nationwide survey

This study aims to explore the prevalence of strokes among individuals and the association with urbanization levels. A total sample of 9,794 individuals was obtained from a nationwide survey on Taiwan for subsequent analysis in this study. After adjusting for gender, age, other risk factors for stroke and individual socioeconomic status, a multivariate logistic regression model was employed to investigate the relationships existing between the prevalence of strokes and the level of urbanization. This study finds that those living in areas at the highest level of urbanization (level 1) had the highest prevalence of strokes (2.49%). With decreasing urbanization level, there was a general decline in stroke prevalence. After adjusting for other factors, the multivariate logistic regression analyses showed that compared to participants living in the highest urbanization level, the respective odds ratios of suffering a stroke for those living in areas at the lowest levels of urbanization (levels 7 and 8), were 0.43 and 0.30. We conclude that after adjusting for other stroke risk factors, the level of urbanization is an important contributory factor to the overall prevalence of strokes in Taiwan.

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.

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.

Socioeconomic differences in incident depression in older adults: the role of psychosocial factors, physical health status, and behavioral factors

OBJECTIVE

The objective of this study was to examine the association between socioeconomic status (SES) and the onset of depression in older adults and to determine the relative contribution of psychosocial factors, physical health status, and behavioral factors in explaining this link.

METHODS

Data were from 2593 men and women, aged 55-85 years, participating in the Longitudinal Aging Study Amsterdam. Two indicators of SES were used: education and income. The onset of depression was measured over 9 years of follow-up.

RESULTS

Adjusted hazard ratios of incident depression were significantly higher in those with low education and low income. Psychosocial factors explained on average 16% of the SES differences in incident depression, physical health status on average 7%, and behavioral factors less than 5%.

CONCLUSION

In older adults, low SES predicted the incidence of depression. Part of this association was explained by psychosocial factors and physical health status.

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.

Association of inflammatory markers with socioeconomic status

BACKGROUND

This study examines the association between socioeconomic status (SES) and inflammatory markers in well-functioning older adults and seeks to determine whether any association remains after adjusting for biomedical and behavioral factors typically related to elevated serum levels of inflammatory markers.

METHODS

Data were obtained from 3044 men and women, aged 70-79 from Pittsburgh, Pennsylvania and Memphis, Tennessee participating in the Health, Aging and Body Composition study. Three indicators of SES were used: education, income, and ownership of financial assets. Serum levels of interleukin-6, C-reactive protein, and tumor necrosis factor-alpha were measured.

RESULTS

Low SES was associated with significantly elevated levels of interleukin-6, C-reactive protein, and tumor necrosis factor-alpha compared to high SES. Behavioral factors (including smoking, drinking, obesity) explained a substantial part of the inverse association between SES and inflammatory markers. Adjustment for prevalent diseases (including heart diseases, lung disease, and diabetes) associated with inflammation explained less of the association.

CONCLUSIONS

This study suggests that interventions to improve health behaviors, even in old age and especially in low SES groups, may be useful in reducing risks associated with inflammation.

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.

Occupation, Marital Status, and Low-Grade Inflammation

Objective— We explored the relationships between inflammatory proteins, occupation, and marital status, and their independent associations with incidence of cardiovascular disease (CVD).

Methods and Results— Five inflammation-sensitive proteins (ISPs) (fibrinogen, ceruloplasmin, haptoglobin, α1-antitrypsin, orosomucoid) were measured in 6075 apparently healthy men. Incidence of coronary events and stroke was followed over 18 years in relation to occupation and marital status. All ISPs showed higher concentrations in divorced men and in manual workers. Except for fibrinogen, this remained significant after adjustments for confounding factors. Adjusted for traditional cardiovascular risk factors, incidence of coronary events was significantly increased in unskilled manual workers and in divorced men. The relative risks were slightly reduced after further adjustments for ISPs (from 1.79 to 1.70 in unskilled manual workers; from 1.58 to 1.51 in divorced men). All ISPs were significantly associated with incidence of coronary events, after adjustments for traditional risk factors. This relationship was essentially unchanged after further adjustments for occupation and marital status.

Conclusion— Inflammation could contribute to, but not fully explain, the increased cardiovascular risk in manual workers and divorced men. Although the ISPs vary greatly by occupational and marital status, this does not confound the relationship between ISPs and incidence of CVD.

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.

Is there a biomedical explanation for socioeconomic differences in incident mobility limitation?

BACKGROUND

The association between low socioeconomic status and poor physical functioning has been well described; biomedical factors may play an important role in explaining these differences. This study examines the association between socioeconomic status and incident mobility limitation in well-functioning older adults, and seeks to determine whether this link could be explained by biomedical factors.

METHODS

Data were obtained from 3066 men and women, aged 70--79 years from Pittsburgh, Pennsylvania and Memphis, Tennessee participating in the Health, Aging and Body Composition (Health ABC) study. Three indicators of socioeconomic status were used: education, income, and ownership of financial assets. Mobility limitation was defined as reporting difficulty walking 1/4 mile or climbing 10 steps during two consecutive semiannual assessments over 4.5 years. Biomedical factors included a wide range of diseases (e.g., heart and cerebrovascular disease) and biological risk factors (e.g. hypertension, poor pulmonary function, and high serum levels of inflammatory markers).

RESULTS

Adjusted hazard ratios of incident mobility limitation were significantly higher in those persons with low education, low income, and few assets. Hazard ratios ranged from 1.66 to 2.80 in the lowest socioeconomic groups. Additional adjustment for biomedical factors reduced the hazard ratios by an average of 41% for education, 17% for income, and 29% for assets.

CONCLUSION

Biomedical factors can account for some of the association between socioeconomic status and incident mobility limitation. However, to reduce physical disabilities and, in particular, the socioeconomic differences therein, it may not be sufficient to solely intervene upon biological risk factors and risks of diseases.

Household income is strongly associated with health-related quality of life among Japanese men but not women

OBJECTIVES

As socio-economic status (SES) strongly reflects individual economic status, evaluating the association between SES and health could provide information that is important for planning integrated economic and public health policies. We examined the association between annual household income as a measure of SES and the eight scale scores of the Medical Outcomes Study Short Form-36 Health Survey (SF-36) as a quantifier of health-related quality of life (HRQOL) in Japan.

STUDY DESIGN

Cross-sectional survey.

METHODS

Data were from the SF-36 national survey in Japan. A total of 4500 people aged 16 years or older were selected from the entire population of Japan using stratified-random sampling, and 3395 responded to the survey.

RESULTS

Men with lower levels of annual household income had lower scores in all SF-36 domains. However, only 'general health perceptions' and 'social functioning' showed statistically significant trends among the women surveyed. In the subgroup of women working full-time, there were no domains that showed significant trends.

CONCLUSIONS

A strong association exists between annual household income and SF-36 scores among men, but there is only a limited association among women. The employment and economic policies that affect annual household income potentially influence HRQOL.

Study of the Relationship Between Social Deprivation and Outcome After Stroke

BACKGROUND AND PURPOSE

Although the incidence and mortality of stroke are known to be inversely related to socioeconomic status (SES), the relationship between SES and recovery after stroke has been little-studied. This study has investigated the relationship between SES and case fatality, "death or dependency," and "death or institutional care" at 6 months after stroke.

METHODS

Patients with acute stroke (n=2709) were identified using routine hospital discharge data and SES was measured using Carstairs scores (an ecological index of social deprivation). Case mix and treatment data were collected by medical chart review, case fatality by record linkage, and functional status and place of residence by questionnaire. Logistic regression was used to adjust the association of social deprivation and outcome for case mix and selected treatment variables.

RESULTS

With increasing social deprivation, patients were younger, more likely to live alone, and, on admission, more likely to need help to walk. Social deprivation was not associated with case fatality or with "death or institutional care" in any analysis. However, patients residing in the most deprived areas (deprivation categories 6 and 7) were significantly more likely to be dead or dependent than patients from more affluent areas. This association was weakened but remained after adjusting for case mix and treatment variables.

CONCLUSIONS

These findings contribute to growing evidence of an inverse social gradient in disability after stroke. Institutionalization, as a proxy for functional outcome, may not reflect this fact. A marked social gradient in case fatality after stroke seems unlikely.

Educational inequalities in cause-specific mortality in middle-aged and older men and women in eight western European populations

BACKGROUND

Studies of socioeconomic disparities in patterns of cause of death have been limited to single countries, middle-aged people, men, or broad cause of death groups. We assessed contribution of specific causes of death to disparities in mortality between groups with different levels of education, in men and women, middle-aged and old, in eight western European populations.

METHODS

We analysed data from longitudinal mortality studies by cause of death, between Jan 1, 1990, and Dec 31, 1997. Data were included for more than 1 million deaths in 51 million person years of observation.

FINDINGS

Absolute educational inequalities in total mortality peaked at 2127 deaths per 100000 person years in men, and at 1588 deaths per 100000 person years in women aged 75 years and older. In this age-group, rate ratios were greater than 1.00 for total mortality and all specific causes of death, apart form prostate cancer in men and lung cancer in women, showing increased mortality in low versus high educational groups. In men, cardiovascular diseases accounted for 39% of the difference between low and high educational groups in total mortality, cancer for 24%, other diseases for 32%, and external causes for 5%. Among women, contributions were 60%, 11%, 30%, and 0%, respectively. The contributions of cerebrovascular disease, other cardiovascular diseases, pneumonia, and COPD strongly increased by age, whereas those of cancer and external causes declined. Although relative inequalities in total mortality were closely similar in all populations, we noted striking differences in the contribution of specific causes to these inequalities.

INTERPRETATION

Research needs to be broadened to include older populations, other diseases, and populations from different parts of Europe. Effective interventions should be developed and implemented to reduce exposure to cardiovascular risk factors in low-educational groups.

Educational Level and Stroke Mortality

BACKGROUND AND PURPOSE

Variations between countries in occupational differences in stroke mortality were observed among men during the 1980s. This study estimates the magnitude of differences in stroke mortality by educational level among men and women aged >or=30 years in 10 European populations during the 1990s.

METHODS

Longitudinal data from mortality registries were obtained for 10 European populations, namely Finland, Norway, Denmark, England/Wales, Belgium, Switzerland, Austria, Turin (Italy), Barcelona (Spain), and Madrid (Spain). Rate ratios (RRs) were calculated to assess the association between educational level and stroke mortality. The life table method was used to estimate the impact of stroke mortality on educational differences in life expectancy.

RESULTS

Differences in stroke mortality according to educational level were of a similar magnitude in most populations. However, larger educational differences were observed in Austria. Overall, educational differences in stroke mortality were of similar size among men (RR, 1.27; 95% CI, 1.24 to 1.30) and women (RR, 1.29; 95% CI, 1.27 to 1.32). Educational differences in stroke mortality persisted at all ages in all populations, although they generally decreased with age. Eliminating these differences would on average reduce educational differences in life expectancy by 7% among men and 14% among women.

CONCLUSIONS

Educational differences in stroke mortality were observed across Europe during the 1990s. Risk factors such as hypertension and smoking may explain part of these differences in several countries. Other factors, such as socioeconomic differences in healthcare utilization and childhood socioeconomic conditions, may have contributed to educational differences in stroke mortality across Europe.

North-South Gradients in Britain for Stroke and CHD

Background and Purpose— The geographic variation in CHD and stroke within Great Britain is well known. We aimed to quantify these variations and to determine the contribution of established risk factors.

Methods— This prospective study consisted of 7735 men 40 to 59 years of age in 24 British towns who were followed up for 20 years from screening in 1978 to 1980. We compared age-adjusted incidences of major stroke and CHD events in southern England and the rest of Britain before and after adjustment for established cardiovascular risk factors.

Results— At least 1 episode of stroke occurred in 467 men (3.54 per 1000 person-years, age standardized) and of CHD in 1299 men (10.05 per 1000 person-years). Event rates varied between towns, from 2.00 to 5.45 per 1000 person-years for stroke and from 6.16 to 12.21 per 1000 person-years for CHD. Incidence for both diseases was highest in Scottish towns and lowest in southern English towns (“north-south gradient”). The hazard ratio for stroke in the rest of Britain compared with southern England was 1.44 (95% confidence interval [CI], 1.16 to 1.78); for CHD, it was 1.32 (95% CI, 1.14 to 1.53). After adjustment for baseline systolic blood pressure, smoking status, physical activity, social class, and height, the hazard ratio was 1.24 (95% CI, 1.00 to 1.54) for stroke and 1.17 (95% CI, 1.02 to 1.35) for CHD.

Conclusions— Similar north-south gradients were observed for major stroke and major CHD events. The magnitude of these gradients was considerably diminished when individual risk variables were taken into account.