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Impact of Multiple Social Determinants of Health on Incident Stroke
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The average annual age-adjusted stroke incidence rate at age ≥20 years, per 100, 000 population, was 223 for blacks, 196 for Hispanics, and 93 for whites. Blacks had a 2.4-fold and Hispanics a twofold increase in stroke incidence compared with whites. Cerebral infarct accounted for 77 percent of all strokes, intracerebral hemorrhage for 17 percent, and subarachnoid hemorrhage for 6 percent. These data from the Northern Manhattan Stroke Study suggest that part of the reported excess stroke mortality among blacks in the United States may be a reflection of racial/ethnic differences in stroke incidence.
We found that among adults <75 years, as the number of SDOH within the same individual increased, the incidence of stroke increased and was nearly two and a half times higher in those with ≥3 SDOH compared with those with no SDOH. After controlling for potential confounders, stroke risk remained 50% higher among those with ≥3 SDOH compared with those without any SDOH.
Individuals with multiple SDOH such as black women living in impoverished neighborhoods in the Southeast may be excellent targets for focused interventions to reduce incidence of strokes.
Healthcare professionals should consider heightening their vigilance to prevent the development of risk factors and achieve improved physiological risk factor control in persons with multiple SDOH. Elimination of disparities in the incidence of stroke may require societal interventions targeted at SDOH, especially in younger individuals.
Schroff et al,43 observed that among individuals with an indication for statins, only 45% of those with 4+ SDOH were taking statins compared with 65% of individuals without any SDOH.43 These findings support the value of examining multiple SDOH to identify particularly high-risk individuals for effective population health management.
Durable policy solutions are needed to eliminate the deleterious influences of SDOH on health outcomes, especially for adults younger than 75 years.
Ample evidence shows that there is need for continued improvement in the prevention of and control of stroke risk factors such as behavioral interventions to help people to quit smoking, eat a healthy diet, and be physically active.33


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