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Subjective Social Status and Outcomes After Stroke: A Prospective Cohort Study
Doo Young Kim1,2,3,4, E Alison Holman5,6, Steven C Cramer3,4
1Department of Rehabilitation Medicine, International St. Mary's Hospital, Catholic Kwandong University, Incheon, Republic of Korea (D.Y.K.).
Background:
Subjective social status (SSS) represents self-perceived social position and may affect poststroke recovery. Despite impacting various medical outcomes, SSS remains understudied in stroke. We hypothesized that higher SSS is associated with better stroke recovery at 3- and 12 months poststroke.
Methods:
In this prospective cohort study, patients were enrolled between October 2016 and February 2020. We examined associations between 3-month SSS score and clinician-reported, performance, and patient-reported outcomes at 3- and 12-month assessments. Ordinal multivariable regression analysis evaluated 3-month SSS score as a predictor of 12-month modified Rankin Scale score.
Results:
The 494 participants had a median age of 63.5 years; 200 (41%) were female, and median (interquartile range) acute National Institutes of Health Stroke Scale score was 4 (2-8). Scores on SSS showed no meaningful associations with performance outcomes and some associations with clinician-reported outcomes (eg, 3-month modified Rankin Scale: ρ, -0.12 [95% CI, -0.21 to -0.03], false discovery rate-adjusted P=0.017; 12-month modified Rankin Scale: ρ12mo, -0.18 [95% CI, -0.27 to -0.09], false discovery rate-adjusted P=0.001). Conversely, higher SSS showed strong, consistent correlations with patient-reported outcomes, including less psychological distress and higher Stroke Impact Scale-Activities of Daily Living (ρ3mo, 0.18 [95% CI, 0.09-0.26]; ρ12mo, 0.17 [95% CI, 0.07-0.26]; all false discovery rate-adjusted P<0.05). Item-level analyses of Stroke Impact Scale-Activities of Daily Living revealed that SSS remained most strongly and consistently linked to complex Stroke Impact Scale-Activities of Daily Living motor tasks over time. In ordinal multivariable regression adjusted for age, sex, stroke subtype, initial severity, and the selected objective socioeconomic status proxies (eg, educational attainment, employment, and marital status), 3-month SSS score significantly predicted 12-month modified Rankin Scale score (β, 0.14 [95% CI, 0.02-0.26]; P=0.014).
Conclusions:
In patients with predominantly mild stroke, 3-month SSS score may serve as a significant social determinant of health that is associated with long-term functional recovery, a relationship closely linked with psychological distress. SSS scores at 3 months poststroke may identify vulnerable patients, enabling development, validation, and targeted application of interventions that optimize stroke recovery.