Elsevier

The Lancet Neurology

Volume 5, Issue 2, February 2006, Pages 181-188
The Lancet Neurology

Review
Socioeconomic status and stroke

https://doi.org/10.1016/S1474-4422(06)70351-9Get rights and content

Summary

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.

Introduction

Stroke causes 5·5 million deaths and the loss of 49 million disability-adjusted life years worldwide each year.1 In developed countries it is the second commonest cause of death for men and women after heart disease. In developing countries it is assuming increasing importance with two-thirds of all stroke deaths now happening in these regions. Estimates suggest that by the year 2020 stroke will be the second leading cause of death worldwide and one of the five leading causes of disability.2

There are substantial variations in the effects of stroke worldwide as measured by incidence, case severity, mortality, and survival. The contribution of socioeconomic status to this severe disease has been explored with various methods using routine and research generated data. This paper presents a critical review of the current evidence of the associations between socioeconomic status and stroke.

First, we review the evidence of associations between socioeconomic status and mortality, incidence, survival, and severity and report trends where they are available. We also explore the evidence for some of the causal pathways that might explain these associations including risk-factor prevalence, early-life experience, and provision of care. Finally we discuss the implications for further research.

Section snippets

Concepts and definitions

Although links between health and socioeconomic status are widely established, the pathways through which socioeconomic status affect health are not well understood. There are probably many mechanisms that interact differently for different disease outcomes.3 Conceptual models that define these causal associations continue to be developed.4 Generally, factors that affect health have been categorised at the individual level to include material (eg, income, possessions, environment), behavioural

Mortality

There are variations in patterns of all cause mortality by socioeconomic status. Of disease-specific mortality rates, stroke has one of the strongest inverse relations with socioeconomic status in the USA, Japan, and western Europe.19, 20, 21 This inverse relation increases with age. An overview of socioeconomic inequalities in stroke mortality in the USA and northern European countries done in the 1980s reported high stroke mortality in people with manual occupations and low mortality in the

Trends in mortality

Mortality differentials between socioeconomic groups widened in the USA between 1984 and 1997, despite the overall decrease in mortality, with the highest socioeconomic quartile having the lowest rates.19 Similar patterns were observed in Australia between 1969 and 1996:24 mortality fell by 66–69% among professional and administrative workers but only by 38–42% among manual workers and farmers. Differentials between occupational groups increased over time. In Japan, the mortality differential

Incidence

Studies of stroke incidence and socioeconomic status (table 2)26, 27, 28, 29, 30, 31, 32, 33, 34, 35 are heterogeneous in design and outcome measures used. Only some studies meet the criteria for the “gold standard” for comparable stroke-incidence studies, but all report an inverse association between socioeconomic status and stroke incidence. The studies that examine socioeconomic status by stroke type find an association for haemorrhagic stroke that is similar to or stronger than that for all

Survival

Studies by Kapral and colleagues36 and Jakovljevic and co-workers29, 30, 31 show that socioeconomic status is linked to an increased risk of death both at 30 days and 1 year. Gillum and Mussolino27 report poor survival in those with less than 8 years of education and those in the lowest quartiles of the poverty index. Other studies report either no association or a weak association between socioeconomic status and survival.32, 37, 38 Adjusting for stroke severity and risk factors attenuated the

Risk factors for stroke

Studies of general populations in developed countries show a high prevalence of many of the classic stroke risk factors in the low socioeconomic groups.43, 44, 45 Inverse associations for blood pressure, smoking, diabetes, physical inactivity, and obesity (particularly for women) have been widely reported (figure).46, 47, 48 The evidence for a link between socioeconomic status and cholesterol is inconclusive.43, 45

In developing countries a direct relation has been observed between socioeconomic

Early-life influences on stroke risk

Several studies have suggested that socioeconomic deprivation in early life is associated with increased risk of stroke in adulthood.53, 54, 55, 56 In a review of childhood socioeconomic circumstances and adult mortality, four of six studies of stroke reported high overall risk of stroke in those with poor socioeconomic circumstances in childhood.56 Paternal social class had the strongest association with stroke risk;57 this risk remains after adjusting for risk factors and does not improve

Provision of stroke care

Studies of cardiovascular care report some inequality in service and treatment provision for those in low-income groups.43 Fewer studies have investigated the influence of socioeconomic status on the provision of stroke care, although there is evidence of variation in stroke care both within and between countries.58, 59, 60, 61, 62

A recent study analysed data from the population-based south London stroke register, identifying patterns of clinical service provision against 22 indicators of

Discussion

The associations between socioeconomic status, morbidity and mortality are well known and have long been recognised. The overall message is clear: poverty is associated with health inequality in terms of increased rates of disease and early death. What drives such associations is however unclear. In this review we have considered evidence from available studies that have investigated the interplay between patient socioeconomic status and stroke incidence, outcomes, and service delivery. The

Implications

Although many studies have investigated associations between socioeconomic status and cardiovascular disease, our review suggests that relatively few studies have investigated socioeconomic status and stroke. There may be lessons to learn from studies of cardiovascular disease, particularly with respect to risk factors but it cannot be assumed that the same patterns exist. We suggest that there is a need for further studies to test out associations between socioeconomic status and stroke

Search strategy and selection criteria

A MEDLINE search of articles published in English between 1966–2005 was done in September, 2005 with the search and MESH terms “cerebrovascular accident”, “cerebrovascular disorders”, “cerebral haemorrage”, “subarachnoid haemorrhage”, “socioeconomic factors”, “social class”, “income”, “education”, “poverty”, “inequality”, “deprivation”. Studies were included in the review if they contained data that quantified the relation between any measure of socioeconomic status and stroke. The search

References (81)

  • N Krieger et al.

    Measuring social class in US public health research: concepts, methodologies, and guidelines

    Annu Rev Public Health

    (1997)
  • E Grundy et al.

    The socio-economic status of older adults: how should we measure it in studies of health inequalities?

    J Epidemiol Community Health

    (2001)
  • K Steenland et al.

    Individual and area level socioeconomic status variables as predictors of mortality in a cohort of 179,383 persons

    Am J Epidemiol

    (2004)
  • G Davey Smith et al.

    Education and occupational social class: which is the more important indicator of mortality risk?

    J Epidemiol Community Health

    (1998)
  • Standard Occupational Classification

    (1991)
  • 2000 Standard Occupational Classification (SOC) System

  • ISCO-88: International Standard Classification of Occupations

    (1990)
  • V Carstairs et al.

    Deprivation and Health in Scotland

    (1991)
  • P Townsend et al.

    Health and Deprivation: Inequality and the North

    (1987)
  • B Jarman

    Identification of underprivileged areas

    BMJ

    (1983)
  • B Jarman

    Underprivileged areas: validation and distribution of scores

    BMJ

    (1984)
  • J Nazroo

    The structuring of ethnic inequalities in health: economic position, racial discrimination, and racism

    Am J Public Health

    (2003)
  • JP Stansbury et al.

    Ethnic disparities in stroke: epidemiology, acute care and postacute outcomes

    Stroke

    (2005)
  • K Steenland et al.

    All-cause and cause-specific mortality by socio-economic status among employed persons in 27 US states, 1984–1997

    Am J Public Health

    (2004)
  • Y Fukuda et al.

    Cause-specific mortality differences across socio-economic position of municipalities in Japan, 1973–1977 and 1993–1998: increased importance of injury and suicide in inequality for ages under 75

    Int J Epidemiol

    (2005)
  • AE Kunst et al.

    Socioeconomic inequalities in stroke mortality among middle-aged men. An international overview

    Stroke

    (1998)
  • M Avendano et al.

    Educational level and stroke mortality: a comparison of 10 European populations during the 1990s

    Stroke

    (2004)
  • M Avendano et al.

    Trends in socioeconomic disparities in stroke mortality in six European countries between 1981–1985 and 1991–1995

    Am J Epidemiol

    (2005)
  • G Engstrom et al.

    Geographic distribution of stroke incidence within an urban population

    Stroke

    (2001)
  • CL Hart et al.

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

    Am J Public Health

    (2000)
  • D Jakovljevic et al.

    Socioeconomic status and ischaemic stroke: the FINMONICA stroke register

    Stroke

    (2001)
  • D Jakovljevic et al.

    Socioeconomic inequalities in the incidence, mortality and prognosis of subarachnoid hemorrhage: the FINMONICA stroke register

    Cerebrovasc Dis

    (2001)
  • D Jakovljevic et al.

    Socioeconomic differences in the incidence, mortality and prognosis of intracerebral hemorrhage in Finnish adult population: the FINMONICA stroke register

    Neuroepidemiology

    (2001)
  • M Peltonen et al.

    Social patterning of myocardial infarction and stroke in Sweden: incidence and survival

    Am J Epidemiol

    (2000)
  • AI Qureshi et al.

    Educational attainment and risk of stroke and myocardial infarction

    Med Sci Monit

    (2003)
  • CT van Rossum et al.

    Socioeconomic differences in stroke among Dutch elderly women: the Rotterdam study

    Stroke

    (1999)
  • CDA Wolfe et al.

    Incidence and case fatality rates of stroke subtypes in a multiethnic population: the South London stroke register

    J Neurol Neurosurg Psychiatry

    (2002)
  • MK Kapral et al.

    Effect of socioeconomic status on treatment and mortality after stroke

    Stroke

    (2002)
  • NU Weir et al.

    Study of the relationship between social deprivation and outcome after stroke

    Stroke

    (2005)
  • S Aslanyan et al.

    Effect of area-based deprivation on the severity, subtype and outcome of ischemic stroke

    Stroke

    (2003)
  • Cited by (272)

    • Educational differences in mortality but not in risk of recurrence following first-time pulmonary embolism: A Danish nationwide register-based study

      2022, Thrombosis Research
      Citation Excerpt :

      In arterial disease such as ischemic heart disease and stroke, the influence of socioeconomic position is well known and addressed in several studies, all showing that low income and short education is associated with both increased disease incidences and higher mortality [11–13]. The inequality seems to be explained by a larger burden of cardiovascular risk factors, such as hypertension, hypercholesterolemia and smoking, more prevalent in individuals with low socioeconomic position [14,15]. Due to few overlapping risk factors between arterial and venous disease, less is known about the association between socioeconomic position and PE.

    View all citing articles on Scopus
    View full text