Association Between Cumulative Social Determinants of Health and Mortality Among Stroke Survivors

Social determinants of health (SDoH) are well-established contributors to health disparities. Whether cumulative SDoH burden is associated with long-term mortality among stroke survivors remains poorly understood.

We extracted data of 1,404 stroke survivors from the National Health and Nutrition Examination Survey 1999-2018. Cumulative SDoH burden was calculated incorporating eight individual SDoH indicators across multiple domains: employment status, poverty-income ratio (PIR), food security, education level, healthcare access, health insurance, housing status, and marital status. Survey-weighted Cox proportional hazards models were used to evaluate the associations of individual SDoH indicators and cumulative SDoH burden with all-cause, cardiovascular disease (CVD) and non-CVD mortality outcomes.

During a median follow-up of 72 months, 604 deaths were documented, including 237 CVD deaths and 367 non-CVD deaths. Among the eight SDoH indicators, being unemployed, having lower PIR and having government insurance only or being uninsured were significantly associated with all-cause mortality. Looking at cause-specific mortality, having lower PIR was significantly associated with CVD mortality, whereas being unemployed was significantly associated with non-CVD mortality. The risk of mortality from all-cause (p for trend <0.001), CVD (p for trend =0.026) and non-CVD (p for trend <0.001) increased with the increasing SDoH burden.

In this nationally representative cohort of stroke survivors, increasing cumulative SDoH burden was significantly associated with higher risks of mortality.