Impact of neighborhood socioeconomic conditions on the risk of stroke in Japan

Access to mechanical thrombectomy and ischemic stroke mortality in Japan: a spatial ecological study

Background

Advances in stroke treatment have greatly improved outcomes; however, disparities in access to treatment might increase. Achieving equitable access to stroke treatment is a health policy challenge, as rapid treatment is essential for positive outcomes. This ecological cross-sectional study aimed to determine the relationship between the disparities in spatial accessibility to mechanical thrombectomy (SAMT) and stroke mortality rates in Japan, hypothesizing that disparities in SAMT may increase the differences in stroke mortality between regions.

Methods

We used the average number of ischemic stroke (IS) deaths between 2020 and 2021 as the response variable; and SAMT, medical resources, and socioeconomic characteristics of each municipality as explanatory variables. A conditional autoregressive model was used to examine the association between the risk of stroke mortality and SAMT. The standardized mortality ratio (SMR) was mapped to understand the nationwide disparities in stroke mortality risk.

Results

The median number of IS deaths was 17.5 persons per year in the municipalities (2020 to 2021). The study also found that municipalities with low SAMT were located in the northern part of Japan. The non-spatial regression model results indicated that poor accessibility, a small proportion of bachelor's degrees or higher, and a high proportion of workers in secondary industries were related to high IS mortality. Three models were evaluated using spatial analysis; Model 1 with accessibility indicators alone, Model 2 with medical resources added to Model 1, and Model 3 with socioeconomic characteristics added to Model 2. In Models 1 and 2, the population-weighted spatial accessibility index (PWSAI) showed a significant negative relationship with stroke mortality. However, this was not evident in Model 3. Mapping using Model 3 showed that the high-risk areas were predominantly located in northern Japan, excluding Hokkaido.

Conclusion

Access to mechanical thrombectomy was estimated, and regional differences were observed. The relationship between accessibility and IS mortality is unknown; however, regardless of accessibility, municipalities with a high proportion of workers in secondary industries and a small proportion with bachelor's degrees or above are at risk of death from stroke.

Impact of areal socioeconomic status on prehospital delay of acute ischaemic stroke: retrospective cohort study from a prefecture-wide survey in Japan

OBJECTIVES

To examine whether the Areal Deprivation Index (ADI), an indicator of the socioeconomic status of the community the patient resides in, is associated with delayed arrival at the hospital and poor outcomes in patients with acute ischaemic stroke from a prefecture-wide stroke database in Japan.

DESIGN

Retrospective study.

SETTING

Twenty-nine acute stroke hospitals in Kochi prefecture, Japan.

PARTICIPANTS

Nine thousand and six hundred fifty-one patients with acute ischaemic stroke who were urgently hospitalised, identified using the Kochi Acute Stroke Survey of Onset registry. Capital and non-capital areas were analysed separately.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prehospital delay defined as hospital arrival ≥4-hour after stroke onset, poor hospital outcomes (in-hospital mortality and discharge to a nursing facility) and the opportunities of intravenous recombinant tissue plasminogen activator (rt-PA) and endovascular reperfusion therapy.

RESULTS

In the overall cohort, prehospital delay was observed in 6373 (66%) patients. Among individuals residing in non-capital areas, those living in municipalities with higher ADI (more deprived) carried a significantly higher risk of prehospital delay (per one-point increase, OR (95% CI) 1.45 (1.26 to 1.66)) by multivariable logistic regression analysis. In-hospital mortality (1.45 (1.02 to 2.06)), discharge to a nursing facility (1.31 (1.03 to 1.66)), and delayed candidate arrival ≥2-hour of intravenous rt-PA (2.04 (1.30 to 3.26)) and endovascular reperfusion therapy (2.27 (1.06 to 5.00)), were more likely to be observed in the deprived areas with higher ADI. In the capital areas, postal-code-ADI was not associated with prehospital delay (0.97 (0.66 to 1.41)).

CONCLUSIONS

Living in socioeconomically disadvantaged municipalities was associated with prehospital delays of acute ischaemic stroke in non-capital areas in Kochi prefecture, Japan. Poorer outcomes of those patients may be caused by delayed treatment of intravenous rt-PA and endovascular reperfusion therapy. Further studies are necessary to determine social risk factors in the capital areas.

TRIAL REGISTRATION NUMBER

This article is linked to a clinical trial to UMIN000050189, No.: R000057166 and relates to its Result stage.

Differential effects of lifestyle activities on disability incidence based on neighborhood amenities

BACKGROUND

This study examined the effect of neighborhood amenities on disability risk among community-dwelling older adults in Japan, based on lifestyle activities.

METHOD

This was an observational prospective cohort study. Participants comprised 13,258 older adults from the National Center for Geriatrics and Gerontology-Study of Geriatric Syndromes. We calculated participants' Walk Score using their home addresses and divided them into three groups: "car-dependent," "somewhat walkable," and "very walkable." We then calculated the average value of lifestyle activities. We divided the neighborhood amenity groups into two groups, "fewer lifestyle activities" and "more lifestyle activities," for a total of six groups. After identifying interactions between neighborhood amenities and lifestyle activities, Cox proportional hazard models to calculate hazard ratios for incident disability risk, based on neighborhood amenities and lifestyle activities.

RESULTS

An interaction occurred between neighborhood amenities and lifestyle activities (p < 0.05). Survival probabilities for incident disability based on lifestyle activities were estimated for each neighborhood amenity group: car-dependent, 1.62 (95% CI 1.07 to 2.46); somewhat walkable, 1.08 (95% CI 0.84 to 1.40); and very walkable, 1.05 (95% CI 0.87 to 1.27). Those with fewer lifestyle activities in the car-dependent group exhibited the highest risk of incident disability in the unadjusted and adjusted models.

CONCLUSION

Given that the aging population is increasing steadily, considering older adults' neighborhood amenities and lifestyle activities in their day-to-day lives can help clinicians to deliver more older adult-centered care. Incorporating the lifestyle activities and neighborhood amenities of older adults into care planning will lead to the design and development of integrated clinical and community screening programs.

School-Based Stroke Education Through On-Demand E-learning During Coronavirus Disease 2019 Pandemic: Itoigawa Stroke Awareness Campaign

Introduction Raising stroke awareness is important to shorten the interval from onset to consultation. We performed a school-based stroke education by on-demand e-learning during the coronavirus disease 2019 pandemic. Methods We performed on-demand e-learning and distributed the online- and paper-based manga about stroke for students and parental guardians in August 2021. We carried out this in a manner similar to the prior effective online stroke awareness initiatives in Japan. An online post-educational survey in October 2021 was conducted to evaluate the awareness effects by asking participants about their knowledge. We also investigated the modified Rankin Scale (mRS) at the discharge of stroke patients who were treated in our hospital during the before- and after-campaign periods, respectively. Results We distributed the paper-based manga and asked to work on this campaign to all 2,429 students (1,545 elementary school and 884 junior high school students) who lived in Itoigawa. We acquired 261 (10.7%) online responses from the students and 211 (8.7%) responses from their parental guardians. The number of students who chose all correct answers in the survey significantly increased after the campaign (205/261, 78.5%) compared to that before the campaign (135/261, 51.7%) and those of parental guardians showed similar trends (before campaign 93/211, 44.1%; after campaign 198/211, 93.8%). We investigated 282 stroke patients (90 patients before and 192 patients after-campaign period), and their mRS at discharge after-campaign seemed to be improved. Conclusion Only 10.7% of students and 8.7% of the parental guardians worked on the online survey. However, the number of those who chose correct answers about stroke increased after the campaign. After this campaign, the mRS of stroke patients at discharge improved although it was unclear if this is a direct result of this activity.

The impact of regional deprivation on stroke incidence, treatment, and mortality in Germany

BACKGROUND

Regional deprivation has been shown to be an influential factor in stroke incidence risk. However, there is a paucity of knowledge on regional differences in stroke incidence and mortality in Germany.

METHODS

We assessed data from the Diagnosis Related Groups statistics (2016-2019) and the German Federal Registry of Physicians (2019). Negative binomial regression analysis was used to examine the association between the German Index of Multiple Deprivation 2015 covering 401 districts and district-free cities in Germany and stroke incidence, treatment, and mortality.

RESULTS

The adjusted rate ratios of stroke incidence and mortality with the highest deprivation level compared with the least deprived area were 1.161 (95% CI [1.143, 1.179]) and 1.193 (95% CI [1.148, 1.239]), respectively. Moreover, this study revealed that physician density was higher in district-free cities compared to districts.

CONCLUSIONS

Our results indicate that regional deprivation is associated with incident and mortality cases of stroke, necessitating a more targeted approach to stroke prevention in deprived regions.

Eating Behaviors, Lifestyle, and Ischemic Stroke: A Lebanese Case-Control Study

BACKGROUND

Stroke is the second leading cause of death and the third leading cause of disability on a global scale. Most clinicians tend to underestimate the importance of diet and inadequate or dysfunctional eating attitudes in patients with a complicated relationship with food. Concerned about the potential of an independent Lebanese approach, and also because prior international research has revealed a link between eating intake or choice and ischemic stroke risk, it was considered vital to broaden the scope of the literature and evaluate further the association of disordered eating attitudes and focus on the distinct relationship with food in the case of orthorexia nervosa (ON) in the Lebanese community. Consequently, the purpose of the present study is to investigate the potential association between pre-existing disordered eating attitudes, specifically ON, and ischemic stroke risk, with an emphasis on the evidence supporting a Mediterranean-style diet.

METHODS

This research is a case-control survey study involving 113 Lebanese individuals with ischemic stroke and 451 age-(within 5 years) and sex-matched controls recruited from several hospitals in Lebanon (April 2020-April 2021).

RESULTS

According to the findings of our first regression model, living 100 m from a crowded road (adjusted odds ratio [aOR]: 3.421, 95% confidence interval [CI]: 1.585-7.387), living 100 m from an electricity generator (aOR: 3.686, 95% CI: 1.681-8.085), higher waterpipe dependence (aOR: 1.204, 95% CI: 1.117-1.297), higher exposure to passive smoking (aOR: 2.651, 95% CI: 2.051-3.426), being married (aOR: 3.545, 95% CI: 1.297-9.689), having a low educational attainment (aOR: 0.239, 95% CI: 0.084-0.679), vigorous physical activity (aOR: 1.003, 95% CI: 1.001-1.006), and having more inappropriate eating (aOR: 1.040, 95% CI: 1.006-1.074) were all associated with higher odds of having ischemic stroke. Furthermore, atrial fibrillation (aOR: 2.945, 95% CI: 1.010-8.585), diabetes (aOR: 2.550, 95% CI: 1.169-5.561), heart diseases (aOR: 6.193, 95% CI: 2.196-17.463), and hypertension (aOR: 2.744, 95% CI: 1.049-7.180) were also linked to an increased risk of stroke. Moreover, having more orthorexia nervosa tendencies (aOR: 1.123, 95% CI: 1.021-1.235) was related to a higher odds of having an ischemic stroke, whereas better adherence to the MeD was significantly linked (aOR: 0.691, 95% CI: 0.583-0.819) to lower odds of ischemic stroke.

CONCLUSIONS

Ischemic stroke patients were more likely to have disordered eating attitudes and orthorexic behaviors. Furthermore, the MeD has been found to be beneficial in reducing ischemic stroke risk. Despite the study's focus, outdoor pollution, waterpipe dependence, and passive smoking were linked to ischemic stroke. In summary, this review suggests that improving one's nutritional status and making a few lifestyle changes are key stroke prevention and treatment methods.

Life-Course Neighborhood Socioeconomic Status and Cardiovascular Events in Black and White Adults in the Atherosclerosis Risk in Communities Study

It has been reported that residents of low-socioeconomic-status (SES) neighborhoods have a higher risk of developing cardiovascular disease (CVD). However, most of the previous studies focused on 1-time measurement of neighborhood SES in middle-to-older adulthood and lacked demographic diversity to allow for comparisons across different race/ethnicity and sex groups. We examined neighborhood SES in childhood and young, middle, and older adulthood in association with CVD risk among Black and White men and women in the Atherosclerosis Risk in Communities Study (1996-2019). We found that lower neighborhood SES in young, middle, and older adulthood, but not in childhood, was associated with a higher risk of CVD later in life. When compared with the highest quartile, the lowest quartile of neighborhood SES in young, middle, and older adulthood was associated with 18% (hazard ratio (HR) = 1.18, 95% confidence interval (CI): 1.02, 1.36), 21% (HR = 1.21, 95% CI: 1.04, 1.39), and 12% (HR = 1.12, 95% CI: 0.99, 1.26) increases in the hazard of total CVD, respectively. The association between lower neighborhood SES in older adulthood and higher CVD hazard was particularly strong among Black women. Our study findings support the role of neighborhood SES in cardiovascular health in both Black and White adults.

The association between the socioeconomic deprivation level and ischemic heart disease mortality in Japan: an analysis using municipality-specific data

OBJECTIVES

Geographical variation in the standardized mortality ratio (SMR) for ischemic heart disease (IHD) among municipalities has not been assessed in Japan. Additionally, associations between area-level socioeconomic deprivation indices and IHD mortality have not been identified in Japan. The present study investigated this association.

METHODS

Information on IHD mortality was extracted from Vital Statistics data from 2018 to 2020 for each municipality in Japan. The socioeconomic deprivation level was derived from multiple socioeconomic characteristics. We classified municipalities into quintiles based on the deprivation level and investigated the association between the deprivation level and the SMR of IHD. Additionally, a Bayesian spatial regression model was used to investigate this association, adjusting for other municipal characteristics.

RESULTS

Geographical variation in the SMR of IHD was revealed, and municipalities with high SMRs were spatially clustered. There was a weak negative correlation between the socioeconomic deprivation level and the SMRs (correlation coefficient, -0.057 for men and -0.091 for women). In contrast, the regression analysis showed a statistically significant positive association between deprived areas and the IHD mortality rate, and the relative risks for the most deprived municipalities compared with the least deprived municipalities were 1.184 (95% credible interval [CrI], 1.110 to 1.277) and 1.138 (95% CrI, 1.048 to 1.249) for men and women, respectively.

CONCLUSIONS

A weak negative correlation between the socioeconomic deprivation level and the SMR was observed in the descriptive analysis, while the regression analysis showed that living in deprived areas was statistically positively associated with the IHD mortality rate.

Difference in the prevalence of hypertension and its risk factors depending on area-level deprivation in Japan

Objectives

Area-level deprivation is an important factor related to mortality or health behaviors; however, a study investigating differences in hypertension prevalence depending on area-level deprivation has not been conducted in Japan. We investigated differences in the prevalence of hypertension and its risk factors, i.e. obesity, smoking, alcohol consumption, and heavy alcohol drinking depending on area-level deprivation using nationwide health checkups data in 2018.

Results

Area-level deprivation was derived from census data. An analysis of the data by secondary medical areas revealed that the age-standardized proportions of individuals whose systolic blood pressure was ≥ 140 mmHg, those whose diastolic blood pressure was ≥ 90 mmHg, those whose body mass index was ≥ 25 or 30 kg/m², smokers, and heavy alcohol drinkers showed an increasing trend with an increase in the deprivation level. The relative index of inequality, which can be interpreted as the ratio of the age-standardized proportion for the most deprived area compared with that for the least deprived area, was significantly greater than 1 for all proportions, except for the proportion of drinkers in women. Overall, there was a disparity in the prevalence of hypertension and its risk factors depending on area-level deprivation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-05931-6.

An analysis of health inequalities depending on educational level using nationally representative survey data in Japan, 2019

Background

In recent years, socioeconomic differences in health statuses and behaviors have not been investigated from the nationally representative survey data in Japan. In this study, we showed differences in representative health behaviors and statuses depending on educational level using a nationally representative survey data in Japan.

Methods

Aggregated (not individual level) data from the Comprehensive Survey of Living Conditions in 2019 were used to examine the association between educational level and outcome status of psychological distress (K6 scores > = 5), self-rated health, smoking, alcohol drinking, and cancer screening participation (stomach, lung, colorectal, breast, and uterine cancers). Data of 217,179 households in Japan were aggregated by the Ministry of Health, Labour, and Welfare in the survey, and the data of the estimated number of household members and persons corresponding to each response option for the questions in all of Japan were used. Five-year age groups from 20 to 24 to 80–84 years and over 84 years were analyzed, and the prevalence or participation rate by educational level were calculated. In addition, the age-standardized prevalence or participation rate according to educational level were also calculated by sex. Moreover, a Poisson regression model was applied for evaluating an association of educational level with the outcomes.

Results

As a result, a clear gradient by educational level was observed in almost all the age groups for the prevalence of psychological distress, poor self-rated health, and smoking and participation rates in cancer screening, and high educational level were associated with better health-related behaviors and statuses. Conversely, drinking prevalence was shown to be higher rather in highly educated people. In addition, a statistically significant association of educational level with all the outcomes was observed.

Conclusion

It was shown that disparities in health behaviors and statuses still persisted in recent years, and the findings suggested that further measures should be taken to tackle this disparity.

Socioeconomic status and lifestyle in young ischaemic stroke patients: a possible relationship to stroke recovery and risk of recurrent event

OBJECTIVES

Socioeconomic status (SES) and lifestyle have impact on recovery after ischaemic stroke (IS) and on risk of recurrent ischaemic stroke (RIS) in elderly patients. With regard to currently available limited data on young people, we aimed to assess SES and parameters of lifestyle and evaluate their relationship to stroke recovery and risk of RIS in young patients.

METHODS

We analysed consecutive young IS patients < 50 years enrolled in the prospective HISTORY (Heart and Ischaemic STrOke Relationship studY) study registered on ClinicalTrials.gov (NCT01541163). Data were acquired from structured a self-evaluating multiple-choice questionnaire. Clinical outcome was assessed using the Modified Rankin Scale (MRS) after 3 months with score 0-1 for excellent outcome.

RESULTS

Data were obtained from 297 (163 males, mean age 39.6 ± 7.8 years) young patients. Patients with MRS 0-1 (237, 79.8%) did not differ in SES except university education (21.1 vs. 3.3%; p = 0.001), less smoked (16.5 vs. 58.3%; p < 0.001), more of them did regular sport activities (79.1 vs. 51.6%; p = 0.02) and passed regular preventive medical checks (45.6 vs. 24.2%; p = 0.01). Twelve (4%) patients suffered from RIS during a follow-up with median of 25 months. They did not differ in SES but had higher body mass index (31.6 vs. 26.7; p = 0.007), reported less regular sport activities (16.7 vs. 73.0%; p < 0.001) and less regular medical checks (8.3 vs. 40.0%; p = 0.001).

CONCLUSION

In young patients, SES had no relationship to clinical outcome after IS and to risk of RIS except education level. Some parameters of health lifestyle were presented more in patients with excellent outcome and without RIS during the follow-up.

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.

Neighborhood Socioeconomic Status and Stroke Incidence: A Systematic Review

OBJECTIVE

To summarize overall patterns of the impact of neighborhood socioeconomic status (nSES) on stroke incidence and uncover potential gaps in the literature, we conducted a systematic review of studies examining the association between nSES and stroke incidence, independent of individual SES.

METHODS

Four electronic databases and reference lists of included articles were searched, and corresponding authors were contacted to locate additional studies. A keyword search strategy included the 3 broad domains of neighborhood, SES, and stroke. Eight studies met our inclusion criteria (e.g., nSES as an exposure, individual SES as a covariate, and stroke incidence as an outcome). We coded study methodology and findings across the 8 studies.

RESULTS

The results provide evidence for the overall nSES and stroke incidence association in Sweden and Japan, but not within the United States. Findings were inconclusive when examining the nSES-stroke incidence association stratified by race. We found evidence for the mediating role of biological factors in the nSES-stroke incidence association.

CONCLUSIONS

Higher neighborhood disadvantage was found to be associated with higher stroke risk, but it was not significant in all the studies. The relationship between nSES and stroke risk within different racial groups in the United States was inconclusive. Inconsistencies may be driven by differences in covariate adjustment (e.g., individual-level sociodemographic characteristics and neighborhood-level racial composition). Additional research is needed to investigate potential intermediate and modifiable factors of the association between nSES and stroke incidence, which could serve as intervention points.

How does area-level deprivation depress an individual's self-rated health and life satisfaction? Evidence from a nationwide population-based survey in Japan

BACKGROUND

Area-level deprivation is well known to have an adverse impact on mortality, morbidity, or other specific health outcomes. This study examined how area-level deprivation may affect self-rated health (SRH) and life satisfaction (LS), an issue that is largely understudied.

METHODS

We used individual-level data obtained from a nationwide population-based internet survey conducted between 2019 and 2020, as well as municipality-level data obtained from a Japanese government database (N = 12,461 living in 366 municipalities). We developed multilevel regression models to explain an individual's SRH and LS scores using four alternative measures of municipality-level deprivation, controlling for individual-level deprivation and covariates. We also examined how health behavior and interactions with others mediated the impact of area-level deprivation on SRH and LS.

RESULTS

Participants in highly deprived municipalities tended to report poorer SRH and lower LS. For example, when living in municipalities falling in the highest tertile of municipality-level deprivation as measured by the z-scoring method, SRH and LS scores worsened by a standard deviation of 0.05 (p < 0.05) when compared with those living in municipalities falling in the lowest tertile of deprivation. In addition, health behavior mediated between 17.6 and 33.1% of the impact of municipality-level deprivation on SRH and LS, depending on model specifications.

CONCLUSION

Results showed that area-level deprivation modestly decreased an individual's general health conditions and subjective well-being, underscoring the need for public health policies to improve area-level socioeconomic conditions.

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.

Socioeconomic Disparities in All-Cause and Cause-Specific Mortality Rates among Municipalities in Japan, 1999-2019

Differences in all-cause and cause-specific mortality rates depending on municipal socioeconomic status (SES) in Japan have not been revealed over the last 20 years. This study exposes the difference in 1999 and 2019 using the Vital Statistics. All of the municipalities were grouped into five quintiles based on their SES, and standardized mortality ratio (SMR) of each municipal quintile compared with all of Japan was calculated for all-cause mortality and representative cause of deaths. As a result, although SMR for all-cause mortality for women tended to be lower in low SES quintiles in 1999, the reverse phenomenon was observed in 2019. Additionally, although SMR for all-cause of mortality for men was the lowest in the highest SES quintiles already in 1999, the difference in the SMR for all-cause mortality rates between the lowest and highest SES quintiles increased in 2019. The improvement of the SMR in the highest SES quintile and the deterioration in the lowest was also observed in representative types of cancer, heart disease, stroke, pneumonia, liver disease, and renal failure for men and women. Therefore, this study indicates a disparity in mortality depending on municipal SES enlarged in the last 20 years.

Association between neighborhood disadvantage and fulfillment of desired postpartum sterilization

BACKGROUND

Adequacy of prenatal care is associated with fulfillment of postpartum sterilization requests, though it is unclear whether this relationship is indicative of broader social and structural determinants of health or reflects the mandatory Medicaid waiting period required before sterilization can occur. We evaluated the relationship between neighborhood disadvantage (operationalized by the Area Deprivation Index; ADI) and the likelihood of undergoing postpartum sterilization.

METHODS

Secondary analysis of a single-center retrospective cohort study examining 8654 postpartum patients from 2012 to 2014, of whom 1332 (15.4%) desired postpartum sterilization (as abstracted from the medical record at time of delivery hospitalization discharge) and for whom ADI could be calculated via geocoding their home address. We determined the association between ADI and sterilization completion, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery via logistic regression and time to sterilization via Cox proportional hazards regression.

RESULTS

Of the 1332 patients included in the analysis, patients living in more disadvantaged neighborhoods were more likely to be younger, more parous, delivered vaginally, Black, unmarried, not college educated, and insured via Medicaid. Compared to patients living in less disadvantaged areas, patients living in more disadvantaged areas were less likely to obtain sterilization (44.8% vs. 53.5%, OR 0.84, 95% CI 0.75-0.93), experienced greater delays in the time to sterilization (HR 1.23, 95% CI 1.06-1.44), were less likely to attend postpartum care (58.9% vs 68.9%, OR 0.86, CI 0.79-0.93), and were more likely to have a subsequent pregnancy within a year of delivery (15.1% vs 10.4%, OR 1.56, 95% CI 1.10-1.94). In insurance-stratified analysis, for patients with Medicaid, but not private insurance, as neighborhood disadvantage increased, the rate of postpartum sterilization decreased. The rate of subsequent pregnancy was positively associated with neighborhood disadvantage for both Medicaid as well as privately insured patients.

CONCLUSION

Living in an area with increased neighborhood disadvantage is associated with worse outcomes in terms of desired postpartum sterilization, especially for patients with Medicaid insurance. While revising the Medicaid sterilization policy is important, addressing social determinants of health may also play a powerful role in reducing inequities in fulfillment of postpartum sterilization.

Social and physical environmental factors in daily stepping activity in those with chronic stroke

BACKGROUND, PURPOSE/OBJECTIVE

Walking behavior in the chronic stroke population is multi-factorial. Previous work focused on the role of physical and biopsychosocial factors in understanding daily stepping post stroke. However, qualitative evidence suggests that social and physical environmental factors also affect daily stepping in those with stroke. The purpose of this study was to understand the role of social and physical environmental factors in daily stepping after stroke.

METHODS

A total of 249 individuals ≥6 months post stroke were included in this cross-sectional analysis (129 females, mean age 62.98 years, SD 11.94). The social environment included living situation, work status, and marital status. The physical environment included the Area Deprivation Index (ADI) and Walk Score. At least 3 days of stepping was collected using an accelerometry-based device. Predictors were entered sequentially into a regression model: demographic characteristics, social environmental factors, and physical environmental factors.

RESULTS

After adjusting for demographic factors, social environmental factors explained 6.2% (p =.017) of the variance in post stroke daily stepping. The addition of physical environmental factors improved the model (ΔR² =.029, p =.024). The final model explained 9.2% (p =.003) of the variance in daily stepping. Lower area deprivation (ADI β = -0.178, p =.015) and working (working vs. retired β = -0.187, p = .029 and working vs. unemployed β = -0.227, p =.008) were associated with greater daily stepping.

DISCUSSION/CONCLUSION

Social and physical environmental factors predicted daily stepping and should be considered when setting expectations relative to the effects of rehabilitation on daily stepping in individuals poststroke.

Association of Neighborhood-Level Disadvantage With Cerebral and Hippocampal Volume

Importance

Identifying risk factors for brain atrophy during the aging process can help direct new preventive approaches for dementia and cognitive decline. The association of neighborhood socioeconomic disadvantage with brain volume in this context is not well known.

Objective

To test whether neighborhood-level socioeconomic disadvantage is associated with decreased brain volume in a cognitively unimpaired population enriched for Alzheimer disease risk.

Design, Setting, and Participants

This study, conducted from January 6, 2010, to January 17, 2019, at an academic research neuroimaging center, used cross-sectional data on 951 participants from 2 large, ongoing cohort studies of Alzheimer disease (Wisconsin Registry for Alzheimer's Prevention and Wisconsin Alzheimer's Disease Research Center clinical cohort). Participants were cognitively unimpaired based on National Institute on Aging-Alzheimer's Association workgroup diagnostic criteria for mild cognitive impairment and Alzheimer disease, confirmed through a consensus diagnosis panel. The cohort was enriched for Alzheimer disease risk based on family history of dementia. Statistical analysis was performed from April 3 to September 27, 2019.

Main Outcomes and Measures

The Area Deprivation Index, a geospatially determined index of neighborhood-level disadvantage, and cardiovascular disease risk indices were calculated for each participant. Linear regression models were fitted to test associations between relative neighborhood-level disadvantage (highest 20% based on state of residence) and hippocampal and total brain tissue volume, as assessed by magnetic resonance imaging.

Results

In the primary analysis of 951 participants (637 women [67.0%]; mean [SD] age, 63.9 [8.1] years), living in the 20% most disadvantaged neighborhoods was associated with 4.1% lower hippocampal volume (β = -317.44; 95% CI, -543.32 to -91.56; P = .006) and 2.0% lower total brain tissue volume (β = -20 959.67; 95% CI, -37 611.92 to -4307.43; P = .01), after controlling for intracranial volume, individual-level educational attainment, age, and sex. Robust propensity score-matched analyses determined that this association was not due to racial/ethnic or demographic characteristics. Cardiovascular risk score, examined in a subsample of 893 participants, mediated this association for total brain tissue but not for hippocampal volume.

Conclusions and Relevance

For cognitively unimpaired individuals, living in the most disadvantaged neighborhoods was associated with significantly lower cerebral volumes, after controlling for maximal premorbid (total intracranial) volume. This finding suggests an association of community socioeconomic context, distinct from individual-level socioeconomic status, with brain volume during aging. Cardiovascular risk mediated this association for total brain tissue volume but not for hippocampal volume, suggesting that neighborhood-level disadvantage may be associated with these 2 outcomes via distinct biological pathways.

Diet Quality Affects the Association between Census-Based Neighborhood Deprivation and All-Cause Mortality in Japanese Men and Women: The Japan Public Health Center-Based Prospective Study

Background: Individuals residing in more deprived areas with a lower diet quality might have a higher mortality risk. We aimed to examine the association between deprivation within an area and all-cause mortality risk according to diet quality. Methods: We conducted a population-based prospective study on 27,994 men and 33,273 women aged 45–75 years. Neighborhood deprivation was assessed using the Japanese areal deprivation index (ADI). Dietary intakes were assessed using a validated 147-item food frequency questionnaire. Results: Individuals residing in the most deprived area had the lowest dietary scores. During the 16.7-year follow-up, compared to individuals with a high quality diet residing in the least deprived area, individuals with a low quality diet had a higher risk of mortality according to increment of ADI (p trend = 0.03); the multivariate-adjusted hazard ratio (95% confidence interval) was 1.09 (0.999–1.19), 1.17 (1.08–1.27), and 1.19 (1.08–1.32) in those residing in the lowest through the highest third of ADI, respectively. However, individuals with a high quality diet had no significant association between ADI and mortality. Conclusion: A well-balanced diet may prevent early death associated with neighborhood socioeconomic status among those residing in highly deprived areas.

Effects of socioeconomic status on risk of ischemic stroke: a case-control study in the Guangzhou population

BACKGROUND

The association between socioeconomic status (SES) and stroke risk remains controversial around the world. It is not clear that the effect of SES on stroke in China due to the lack of relevant research. We aimed to assess the association between SES and risks of first-ever ischemic stroke in Guangzhou, China.

METHODS

Cases were recruited from neurology department in the First Affiliated Hospital of Guangdong Pharmaceutical University during September 2016-October 2017. Age- and sex-matched controls were derived from surgical departments, over the same period. SES was assessed based on education, occupation, and income. Education was divided into ≤6 years, 6-9 years, 10-12 years, and > 12 years. Family monthly income per capita was categorized into ≤¥1000, ¥1001-3000, ¥3001-5000, and > ¥5001. Occupation was stratified into manual, non-manual, no job, and retired. A multivariate logistic regression model was used to determine the association between SES and risk of ischemic stroke.

RESULTS

In total, 347 ischemic stroke patients and 347 controls were recruited, with mean ages of 60.54 ± 13.13 and 60.56 ± 13.07 years, respectively. After adjusting for confounding factors, odds ratio (OR) for 6-9 years of education was 2.63 (95% confidence interval [CI] 1.45-4.75); > 12 years, 2.18 (1.25-3.82) compared with those for < 6 years of education. ORs for the second lowest, third lowest, and highest incomes were 1.96 (1.21-3.15), 4.16 (2.39-7.22), and 2.83(1.25-6.39), respectively, compared with those for the lowest income. ORs for manual workers and non-manual workers were 1.95 (1.23-3.07) and 1.87 (1.05-3.33), compared with individuals without jobs.

CONCLUSIONS

Higher SES is positively related with risks of ischemic stroke, explained by cardiovascular diseases and unhealthy lifestyles in Guangzhou, China. Thus, effective strategies such as extensive health education, promoting a healthy lifestyle, screening for risk factors to prevent stroke should be implemented to reduce ischemic stroke incidences among the high SES group.

A review of psychosocial factors and stroke: A new public health problem

The role of psychosocial factors (PSF) in increased risk of stroke is a novel public health challenge, but unclear definitions for PSF and the multiple stroke subtypes have led to inconsistent reports. A review of this issue is therefore warranted.

METHODS

Several databases were used for this narrative systematic review (Medline, Embase and Cochrane Library). Two independent reviewers evaluated articles from between 2001 and 2018 on the themes of PSF and stroke/transient ischemic attack (TIA). PSF criteria were job strain, psychological interpersonal and behavioral stress, and social deprivation. Ischemic and hemorrhagic stroke and TIA subtypes were also identified.

RESULTS

Forty-five cohorts, five case-control studies and two meta-analyses were included. Despite mixed results, PSF were associated with an increased risk of ischemic and hemorrhagic stroke in populations of all ages, and more predominantly in women.

CONCLUSION

This broad review shows that the presence of PSF is associated with an increased risk stroke and TIA. As such, PSF must figure in both public health policy and stroke prevention programs, similar to other established metabolic and environmental factors.

Geographic Variations of Stroke Hospitalization across France: A Diachronic Cluster Analysis

Background

This study evaluates the clustering of hospitalization rates for stroke and compares this clustering with two different time intervals 2009-2010 and 2012-2013, corresponding to the beginning of the French National Stroke Plan 2010–2014. In addition, these data will be compared with the deployment of stroke units as well as socioeconomic and healthcare characteristics at zip code level.

Methods

We used the PMSI data from 2009 to 2013, which lists all hospitalizations for stroke between 2009 and 2013, identified on the most detailed geographic scale allowed by this database. We identify statistically significant clusters with high or low rates in the zip code level using the Getis-Ord statistics. Each of the significant clusters is monitored over time and evaluated according to the nearest stroke unit distance and the socioeconomic profile.

Results

We identified clusters of low and high rate of stroke hospitalization (23.7% of all geographic codes). Most of these clusters are maintained over time (81%) but we also observed clusters in transition. Geographic codes with persistent high rates of stroke hospitalizations were mainly rural (78% versus 17%, P < .0001) and had a least favorable socioeconomic and healthcare profile.

Conclusion

Our study reveals that high-stroke hospitalization rates cluster remains the same during our study period. While access to the stroke unit has increased overall, it remains low for these clusters. The socioeconomic and healthcare profile of these clusters are poor but variations were observed. These results are valuable tools to implement more targeted strategies to improve stroke care accessibility and reduce geographic disparities.

Physical frailty and mortality risk in Japanese older adults

AIM

The association between frailty and increased mortality risk is unknown. The present study assessed the longitudinal relationship between frailty and mortality risk in Japanese community-dwelling older adults.

METHODS

Participants included 841 randomly chosen community-dwelling Japanese individuals, including 175 older adults aged 65-88 years with incomplete data at the baseline examination (July 2006-July 2008). Participants were followed from baseline to 31 December 2015 (mean 7.9 years). Frailty was diagnosed according to frailty criteria, including unintentional weight loss (shrinking), exhaustion, low activity, low grip strength and low gait speed. Information on deaths was obtained from a population dynamics survey. The relationship between frailty and mortality was assessed using Kaplan-Meier survival curves and Cox proportional hazards regression. The Cox proportional hazards model was used to control for potential confounders, including age at baseline, body fat, education, the Mini-Mental State Examination score, the Center for Epidemiologic Studies Depression Scale score, total physical activity, total caloric intake, alcohol intake, current smoking, household income and the number of current diseases.

RESULTS

The fully adjusted hazard ratio for all-cause mortality in the frailty group was 2.63 (95% confidence interval, 1.28-5.39; P for trend <0.01). The age- and sex-adjusted hazard ratio for mortality of cancer in the frailty group was 3.33 (95% confidence interval, 1.15-9.62; P for trend <0.05).

CONCLUSION

Complications of frailty, which include shrinking, exhaustion, low activity, weakness, and slowness, appear to be significant risks for mortality in Japanese older adults. Geriatr Gerontol Int 2018; 18: 1085-1092.

Socioeconomic Status and Cardiovascular Disease: an Update

PURPOSE OF REVIEW

The aim of this paper is to summarize the recent and relevant evidence linking socioeconomic status (SES) to cardiovascular disease (CVD) and cardiovascular risk factors (CVRFs).

RECENT FINDINGS

In high-income countries (HICs), the evidence continues to expand, with meta-analyses of large longitudinal cohort studies consistently confirming the inverse association between SES and several CVD and CVRFs. The evidence remains limited in low-income and middle-income countries (LMICs), where most of the evidence originates from cross-sectional studies of varying quality and external validity; the available evidence indicates that the association between SES and CVD and CVRFs depends on the socioeconomic development context and the stage in the demographic, epidemiological, and nutrition transition of the population. The recent evidence confirms that SES is strongly inversely associated with CVD and CVRFs in HICs. However, there remains a need for more research to better understand the way socioeconomic circumstances become embodied in early life and throughout the life course to affect cardiovascular risk in adult and later life. In LMICs, the evidence remains scarce; thus, there is an urgent need for large longitudinal studies to disaggregate CVD and CVRFs by socioeconomic indicators, particularly as these countries already suffer the greatest burden of CVD.

Cross-level interaction between individual socioeconomic status and regional deprivation on overall survival after onset of ischemic stroke: National health insurance cohort sample data from 2002 to 2013

INTRODUCTION

The literature on stroke mortality and neighborhood effect is characterized by studies that are often Western society-oriented, with a lack of racial and cultural diversity. We estimated the effect of cross-level interaction between individual and regional socioeconomic status on the survival after onset of ischemic stroke.

METHODS

We selected newly diagnosed ischemic stroke patients from 2002 to 2013 using stratified representative sampling data of 1,025,340 subjects. A total of 37,044 patients over the 10 years from 2004 to 2013 had newly diagnosed stroke. We calculated hazard ratios (HR) of 12- and 36-month mortality using the Cox proportional hazard model, with the reference group as stroke patients with high income in advantaged regions.

RESULTS

For the middle income level, the patients in advantaged regions showed low HRs for overall mortality (12-month HR 1.27; 95% confidence interval [CI], 1.13-1.44; 36-month HR 1.25; 95% CI, 1.14-1.37) compared to the others in disadvantaged regions (12-month HR 1.36; 95% CI, 1.19-1.56; 36-month HR 1.30; 95% CI, 1.17-1.44). Interestingly, for the low income level, the patients in advantaged regions showed high HRs for overall mortality (12-month HR 1.27; 95% CI, 1.13-1.44; 36-month HR 1.33; 95% CI, 1.22-1.46) compared to the others in disadvantaged regions (12-month HR 1.25; 95% CI, 1.09-1.43; 36-month HR 1.30; 95% CI, 1.18-1.44).

CONCLUSION

Although we need to perform further investigations to determine the exact mechanisms, regional deprivation, as well as medical factors, might be associated with survival after onset of ischemic stroke in low-income patients.

Perceived Neighborhood Safety Better Predicts Risk of Mortality for Whites than Blacks

AIM

The current study had two aims: (1) to investigate whether single-item measures of subjective evaluation of neighborhood (i.e., perceived neighborhood safety and quality) predict long-term risk of mortality and (2) to test whether these associations depend on race and gender.

METHODS

The data came from the Americans' Changing Lives Study (ACL), 1986-2011, a nationally representative longitudinal cohort of 3361 Black and White adults in the USA. The main predictors of interest were perceived neighborhood safety and perceived neighborhood quality, as measured in 1986 using single items and treated as dichotomous variables. Mortality due to all internal and external causes was the main outcome. Confounders included baseline age, socioeconomic status (education, income), health behaviors (smoking, drinking, and exercise), and health (chronic medical conditions, self-rated health, and depressive symptoms). Race and gender were focal effect modifiers. Cox proportional hazard models were ran in the pooled sample and stratified by race and gender.

RESULTS

In the pooled sample, low perceived neighborhood safety and quality predicted increased risk of mortality due to all causes as well as internal causes, net of all covariates. Significant interaction was found between race and perceived neighborhood safety on all-cause mortality, indicating a stronger association for Whites compared to Blacks. Race did not interact with perceived neighborhood quality on mortality. Gender also did not interact with perceived neighborhood safety or quality on mortality. Perceived neighborhood safety and quality were not associated with mortality due to external causes.

CONCLUSION

Findings suggest that single items are appropriate for the measurement of perceived neighborhood safety and quality. Our results also suggest that perceived neighborhood safety better predicts increased risk of mortality over the course of 25 years among Whites than Blacks.

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 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.

Combined effect of individual and neighborhood socioeconomic status on mortality in patients with newly diagnosed dyslipidemia: A nationwide Korean cohort study from 2002 to 2013

BACKGROUND AND AIM

The study aims to determine whether dyslipidemia patients living in less affluent neighborhood are at a higher risk of mortality compared to those living in more affluent neighborhoods.

METHODS AND RESULTS

A population-based cohort study was conducted using a stratified representative sampling from the National Health Insurance claim data from 2002 to 2013. The target subjects comprise patients newly diagnosed with dyslipidemia receiving medication. We performed a survival analysis using the Cox proportional hazard model. Of 11,946 patients with dyslipidemia, 1053 (8.8%) subjects died during the follow-up period. Of the dyslipidemia patients earning a middle-class income, the adjusted HR in less affluent neighborhoods was higher than that in the more affluent neighborhoods compared to the reference category of high individual SES in more affluent neighborhoods (less affluent; hazard ratio (HR) = 1.64, 95% confidence interval (CI): 1.35-1.99 vs. more affluent; HR = 1.48, 95% CI: 1.20-1.81, respectively). We obtained consistent results in patients with lower income, wherein the adjusted HR in less affluent neighborhoods was higher than that in more affluent neighborhoods (less affluent; HR = 1.52, 95% CI: 1.16-1.97 vs. more affluent; HR = 1.41, 95% CI: 1.04-1.92, respectively).

CONCLUSION

Living in a less affluent neighborhood contributes to higher mortality among dyslipidemia patients. The individual- and neighborhood-level variables cumulatively affect individuals such that the most at-risk individuals include those having both individual- and neighborhood-level risk factors. These findings raise important clinical and public health concerns and indicate that neighborhood SES approaches should be essentially considered in health-care policies similar to individual SES.