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
ReviewSocioeconomic status and stroke
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
References (81)
- et al.
Educational inequalities in cause specific mortality in middle-aged and older men and women in eight western European populations
Lancet
(2005) - et al.
Inequalities in the transition of cerebrovascular disease mortality in New South Wales, Australia 1969–1996
Soc Sci Med
(2002) - et al.
Education, poverty and stroke incidence in whites and blacks: the NHANES I epidemiologic follow-up study
J Clin Epidemiol
(2003) What MONICA told us about stroke
Lancet Neurol
(2005)- et al.
Social capital and health promotion: a review
Soc Sci Med
(2000) World Health Report 2004 Changing History
(2004)Neglected global epidemics: three growing threats
The challenge of health inequalities
- et al.
Socio-economic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature
Epidemiol Rev
(2004) - et al.
Optimal indicators of socioeconomic status for health research
Am J Public Health
(2002)
Measuring social class in US public health research: concepts, methodologies, and guidelines
Annu Rev Public Health
The socio-economic status of older adults: how should we measure it in studies of health inequalities?
J Epidemiol Community Health
Individual and area level socioeconomic status variables as predictors of mortality in a cohort of 179,383 persons
Am J Epidemiol
Education and occupational social class: which is the more important indicator of mortality risk?
J Epidemiol Community Health
Standard Occupational Classification
2000 Standard Occupational Classification (SOC) System
ISCO-88: International Standard Classification of Occupations
Deprivation and Health in Scotland
Health and Deprivation: Inequality and the North
Identification of underprivileged areas
BMJ
Underprivileged areas: validation and distribution of scores
BMJ
The structuring of ethnic inequalities in health: economic position, racial discrimination, and racism
Am J Public Health
Ethnic disparities in stroke: epidemiology, acute care and postacute outcomes
Stroke
All-cause and cause-specific mortality by socio-economic status among employed persons in 27 US states, 1984–1997
Am J Public Health
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
Socioeconomic inequalities in stroke mortality among middle-aged men. An international overview
Stroke
Educational level and stroke mortality: a comparison of 10 European populations during the 1990s
Stroke
Trends in socioeconomic disparities in stroke mortality in six European countries between 1981–1985 and 1991–1995
Am J Epidemiol
Geographic distribution of stroke incidence within an urban population
Stroke
The contribution of risk factors to stroke differentials, by socioeconomic position in adulthood: the Renfrew/Paisley study
Am J Public Health
Socioeconomic status and ischaemic stroke: the FINMONICA stroke register
Stroke
Socioeconomic inequalities in the incidence, mortality and prognosis of subarachnoid hemorrhage: the FINMONICA stroke register
Cerebrovasc Dis
Socioeconomic differences in the incidence, mortality and prognosis of intracerebral hemorrhage in Finnish adult population: the FINMONICA stroke register
Neuroepidemiology
Social patterning of myocardial infarction and stroke in Sweden: incidence and survival
Am J Epidemiol
Educational attainment and risk of stroke and myocardial infarction
Med Sci Monit
Socioeconomic differences in stroke among Dutch elderly women: the Rotterdam study
Stroke
Incidence and case fatality rates of stroke subtypes in a multiethnic population: the South London stroke register
J Neurol Neurosurg Psychiatry
Effect of socioeconomic status on treatment and mortality after stroke
Stroke
Study of the relationship between social deprivation and outcome after stroke
Stroke
Effect of area-based deprivation on the severity, subtype and outcome of ischemic stroke
Stroke
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