Socioeconomic disparities in stroke rates and outcome: pooled analysis of stroke incidence studies in Australia and New Zealand

Emma L Heeley, Jade W Wei, Kristie Carter, Md Shaheenul Islam, Amanda G Thrift, Graeme J Hankey, Alan Cass and Craig S Anderson
Med J Aust 2011; 195 (1): 10-14.


Objective: To assess the influence of area-level socioeconomic status (SES) on incidence and case-fatality rates for stroke.

Design, setting and participants: Analysis of pooled data for 3077 patients with incident stroke from three population-based studies in Perth, Melbourne, and Auckland between 1995 and 2003.

Main outcome measures: Incidence and 12-month case-fatality rates for stroke.

Results: Annual age-standardised stroke incidence rates ranged from 77 per 100 000 person-years (95% CI, 72–83) in the least deprived areas to 131 per 100 000 person-years (95% CI, 120–141) in the most deprived areas (rate ratio, 1.70; 95% CI, 1.47–1.95; P < 0.001). The population attributable risk of stroke was 19% (95% CI, 12%–27%) for those living in the most deprived areas compared with the least deprived areas. Compared with people in the least deprived areas, those in the most deprived areas tended to be younger (mean age, 68 v 77 years; P < 0.001), had more comorbidities such as hypertension (58% v 51%; P < 0.001) and diabetes (22% v 12%; P < 0.001), and were more likely to smoke (23% v 8%; P < 0.001). After adjustment for age, area-level SES was not associated with 12-month case-fatality rate.

Conclusions: Our analysis provides evidence that people living in areas that are relatively more deprived in socioeconomic terms experience higher rates of stroke. This may be explained by a higher prevalence of risk factors among these populations, such as hypertension, diabetes and cigarette smoking. Effective preventive measures in the more deprived areas of the community could substantially reduce rates of stroke.

  • Emma L Heeley1,2
  • Jade W Wei1,2
  • Kristie Carter3
  • Md Shaheenul Islam4
  • Amanda G Thrift5,6
  • Graeme J Hankey7,8
  • Alan Cass1,2
  • Craig S Anderson1,2

  • 1 The George Institute for Global Health, Sydney, NSW.
  • 2 Sydney Medical School, University of Sydney and Royal Prince Alfred Hospital, Sydney, NSW.
  • 3 Department of Public Health, University of Otago, Wellington, New Zealand.
  • 4 Emergency Medicine, Sydney West Area Health Service, Sydney, NSW.
  • 5 Department of Medicine, Monash University, Melbourne, VIC.
  • 6 Stroke Epidemiology, Baker IDI Heart and Diabetes Institute, Melbourne, VIC.
  • 7 Royal Perth Hospital, Perth, WA.
  • 8 School of Medicine and Pharmacology, University of Western Australia, Perth, WA.



We are grateful for the contribution and inspiration of the late Professor Konrad Jamrozik to this work, and for advice from Professor Mark Woodward.

The Heart Foundation of Australia provided a research grant-in-aid to assist in the pooling and analysis of the data, but had no input into the design, performance, analysis or reporting of the study, and did not see the manuscript before final acceptance for publication. Craig Anderson and Alan Cass received salary support from The George Institute for Global Health and as a Senior Principal Research Fellow of the National Health and Medical Research Council (NHMRC). Jade Wei was supported by an Australian Postgraduate Award. Amanda Thrift was supported by a Senior Research Fellowship from the NHMRC.

Competing interests:

None identified.

  • 1. World Health Organization. The top ten causes of death. (Fact sheet no. 310; updated Oct 2008.) (accessed Oct 2010).
  • 2. Cesaroni G, Agabiti N, Forastiere F, et al. Socioeconomic differences in stroke incidence and prognosis under a universal healthcare system. Stroke 2009; 40: 2812-2819.
  • 3. Li C, Hedblad B, Rosvall M, et al. Stroke incidence, recurrence, and case-fatality in relation to socioeconomic position: a population-based study of middle-aged Swedish men and women. Stroke 2008; 39: 2191-2196.
  • 4. Arrich J, Lalouschek W, Mullner M. Influence of socioeconomic status on mortality after stroke: retrospective cohort study. Stroke 2005; 36: 310-314.
  • 5. Thrift AG, Dewey HM, Sturm JW, et al. Greater incidence of both fatal and nonfatal strokes in disadvantaged areas: the Northeast Melbourne Stroke Incidence Study. Stroke 2006; 37: 877-882.
  • 6. Brown P, Guy M, Broad J. Individual socio-economic status, community socio-economic status and stroke in New Zealand: a case control study. Soc Sci Med 2005; 61: 1174-1188.
  • 7. Sudlow CL, Warlow CP. Comparing stroke incidence worldwide: what makes studies comparable? Stroke 1996; 27: 550-558.
  • 8. Anderson CS, Carter KN, Hackett ML, et al; on behalf of the Auckland Regional Community Stroke (ARCOS) Study Group. Trends in stroke incidence in Auckland, New Zealand, during 1981 to 2003. Stroke 2005; 36: 2087-2093.
  • 9. Islam MS, Anderson CS, Hankey GJ, et al. Trends in incidence and outcome of stroke in Perth, Western Australia during 1989 to 2001: the Perth Community Stroke Study. Stroke 2008; 39: 776-782.
  • 10. Thrift AG, Dewey HM, Macdonell RA, et al. Stroke incidence on the east coast of Australia: the North East Melbourne Stroke Incidence Study (NEMESIS). Stroke 2000; 31: 2087-2092.
  • 11. Adhikari P. Socio-economic indexes for areas: introduction, use and future directions [research paper]. Canberra: Australian Bureau of Statistics, 2006. (ABS Cat. No. 1351.0.55.015.)
  • 12. Salmond C, Crampton P. NZDep2001 index of deprivation user’s manual. Wellington: Department of Public Health, Wellington School of Medicine and Health Sciences, 2002.$file/phi-users-manual.pdf (accessed Jun 2010).
  • 13. Ahmad O, Boschi-Pinto C, Lopez A, et al. Age standardization of rates: a new WHO standard. Geneva: World Health Organization, 2001.
  • 14. Berry G, Armitage P. Mid-P confidence intervals: a brief review. The Statistician 1995; 44: 417-423.
  • 15. Australian Bureau of Statistics. Health risk factors, Australia, 2001. Canberra: ABS, 2003. (ABS Cat. No. 4812.0.) c00834efa/c43f50c58a9a0aedca2570eb008398 cc!OpenDocument (accessed Oct 2010).
  • 16. New Zealand Ministry of Health. A portrait of health. Key results of the 2006/07 New Zealand Health Survey. Wellington: NZMoH, 2008.
  • 17. Johnston SC, Mendis S, Mathers CD. Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling. Lancet Neurol 2009; 8: 345-354.
  • 18. Di Carlo A, Lamassa M, Baldereschi M, et al. Sex differences in the clinical presentation, resource use, and 3-month outcome of acute stroke in Europe: data from a multicenter multinational hospital-based registry. Stroke 2003; 34: 1114-1119.
  • 19. Reeves M, Bhatt A, Jajou P, et al. Sex differences in the use of intravenous rt-PA thrombolysis treatment for acute ischemic stroke: a meta-analysis. Stroke 2009; 40: 1743-1749.
  • 20. Oh MS, Yu KH, Roh JK, et al. Gender differences in the mortality and outcome of stroke patients in Korea. Cerebrovasc Dis 2009; 28: 427-434.
  • 21. Olsen TS, Dehlendorff C, Andersen KK. Sex-related time-dependent variations in post-stroke survival — evidence of a female stroke survival advantage. Neuroepidemiology 2007; 29: 218-225.
  • 22. Ayala C, Croft JB, Greenlund KJ, et al. Sex differences in US mortality rates for stroke and stroke subtypes by race/ethnicity and age, 1995-1998. Stroke 2002; 33: 1197-1201.
  • 23. Vogt TM, Mullooly JP, Ernst D, et al. Social networks as predictors of ischemic heart disease, cancer, stroke and hypertension: incidence, survival and mortality. J Clin Epidemiol 1992; 45: 659-666.
  • 24. Galobardes B, Lynch JW, Davey Smith G. Childhood socioeconomic circumstances and cause-specific mortality in adulthood: systematic review and interpretation. Epidemiol Rev 2004; 26: 7-21.
  • 25. Gillum RF, Mussolino ME. Education, poverty, and stroke incidence in whites and blacks: the NHANES I Epidemiologic Follow-up Study. J Clin Epidemiol 2003; 56: 188-195.


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Responses are now closed for this article.