Advances in the Understanding of Social Determinants of Health in Stroke

Abstract

ver the past decades, inequities in stroke have gained increasing attention. Social determinants of health (SDOH)-conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life-are known drivers of inequities. Yet, little is known about the impact of SDOH on stroke incidence, care, and outcomes. Understanding these relationships will be helpful in designing interventions to address inequities. The purpose of this review is to summarize articles published from 2022 through 2023 on the impact of SDOH on stroke. Three commissioned articles focused on SDOH and neurological disease. The American Heart Association Scientific Statement "Strategies to Reduce Racial and Ethnic Inequities in Stroke Preparedness, Care, Recovery, and Risk Factor Control" summarized intervention studies addressing racial and ethnic inequities in stroke care and outcomes. 1 The SDOH subgroup of the National Advisory Neurological Disorders and Stroke Council Working Group for Health Disparities and Inequities in Neurological Disorders published an article delineating key considerations for SDOH in neurological disease, outlining recent interventions, knowledge gaps, and recommendations to address SDOH. 2 Finally, the article "Determinants of Inequities in Neurologic Disease, Health, and Well-Being: The NINDS Social Determinants of Health Framework" illustrated a model for conceptualizing the impact of SDOH on inequities in neurological disease (Figure). 3 This model, adapted from 3 sources-the World Health Organization Commission on SDOH, 4 the Schulz et al 5 model, and the work of Williams et al 6 -shows the interplay between upstream structural determinants (cultural and social values; structural racism; economic, public, and social policies), social status determinants (socioeconomic position, class, education, occupation, and income), intermediate factors (public health and health care, built environment, and sociocultural environment), intrapersonal determinants (health behaviors and knowledge, psychosocial factors, and disability), biological determinants, and inequities in neurological health.With regard to structural determinants of health (Figure), several recent studies focused on the impact of immigration on stroke risk and care. Studies utilizing administrative data in Canada found that stroke incidence followed a J-shaped curve between the proportion of life spent in Canada and stroke incidence and disability; it was the highest among immigrants who had either immigrated at an early age or immigrated recently 7 ; and that the attributable cost of stroke among immigrants was significantly higher than among nonimmigrants. 8 Registry data in Denmark suggested that immigrants had greater prehospital delays compared with their nonimmigrant counterparts. 9 Furthermore, immigrants were less likely to receive acute reperfusion therapies even when adjusting for time to presentation and had lower odds of stroke unit admission, dysphagia screening, and early rehabil...