The Socioeconomic Gradient in the Incidence of Stroke

A Prospective Study in Middle-Aged Women in Sweden

Hannah Kuper, ScD; Hans-Olov Adami, MD, PhD;
Tores Theorell, MD, PhD; Elisabete Weiderpass, MD, PhD

Background and PurposeA socioeconomic gradient in stroke has been demonstrated in a variety of settings, but mostly
in men. Our purpose was to establish whether a socioeconomic gradient in stroke existed in a group of Swedish women
and whether this gradient could be explained by established stroke risk factors or psychosocial factors.
MethodsThe Womens Lifestyle and Health Cohort Study includes 49 259 women from Sweden aged 30 to 50 years at
baseline (1991 to 1992). The women completed an extensive questionnaire and were traced through linkages to national
registries until the end of 2002. Among the 47 942 women included in these analyses, there were 200 cases of incident
stroke during follow up (121 ischemic stroke, 47 hemorrhagic stroke, and 32 of unknown origin). Statistical analysis was
through the Cox proportional hazards model.
ResultsThe risk of stroke was significantly inversely related to years of education completed, our proxy for
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socioeconomic status (hazard ratio comparing lowest with highest education group2.1, 95% CI: 1.4 to 2.9, P for trend
0.001). This association was reduced after adjustment for established risk factors, although remaining significant (1.5,
1.0 to 2.2, P for trend0.04). The gradient was more pronounced for ischemic stroke (2.9, 1.8 to 4.7, P for trend
0.001) than for hemorrhagic stroke (1.4, 0.7 to 2.9, P for trend0.35). Job strain and social support were unrelated
to risk of stroke. Self-rated health was strongly related to risk of stroke mediated by established risk factors.
Psychosocial factors did not contribute toward the socioeconomic gradient in stroke.
ConclusionsThere was a strong gradient in risk of stroke by years of education, especially for ischemic stroke. Most of
the social gradient was explained by established risk factors, particularly smoking and alcohol, but not by psychosocial
factors. (Stroke. 2007;38:27-33.)
Key Words: hemorrhagic ischemic psychosocial factors socioeconomic gradient stroke

S troke is a dominant cause of mortality and morbidity

throughout the world.1 Each year, approximately 15 million
people will have a stroke, which will be fatal for 5 million people
and permanently disabling for a further 5 million.2 Stroke is a
leading cause of death and disability in Sweden, third only to
ischemic heart disease and depression/neurosis in terms of
disability-adjusted life-years lost.3 People in low socioeconomic
groups are at increased risk of stroke,4 even in egalitarian
Sweden.3 The social disparity in stroke has persisted over time,
despite the overall fall in mortality from stroke.5
Most studies that have tried to explain the basis for the
socioeconomic gradient in stroke show that it is reduced after
taking account of conventional stroke risk factors,6 11 al-
though a significant excess risk in the lower socioeconomic
classes often remains.10,1215 The persistent excess risk may
be attributable to residual confounding, because adjustment
for risk factors is usually incomplete. Psychosocial factors
such as stress at work may also play a role because they are
associated with cardiovascular disease,16 stroke risk factors,17
and socioeconomic status,18 and men with poor adaptation to
stress have an increased risk of stroke.13,19
The aim of this study is to establish whether a socioeco-
nomic gradient in stroke existed in a group of Swedish
women,20 and whether this gradient could be explained by
established stroke risk factors or psychosocial factors using
comprehensive assessment of risk factors and validated
stroke outcome measures.
Materials and Methods
Study Population
The Womens Lifestyle and Health cohort was enrolled during 1991
and 1992. A sample of 96 000 women born between 1943 and 1962
(aged 30 to 49 years) residing in the Uppsala Health Care Region
were randomly selected from the Swedish Central Population Reg-
istry at Statistics Sweden and sent a survey questionnaire.20 A total

Received June 21, 2006; final revision received September 1, 2006; accepted September 5, 2006.
From the Clinical Research Unit (H.K.), London School of Hygiene & Tropical Medicine, London, United Kingdom; the Department of Medical
Epidemiology and Biostatistics (H.-O.A., E.W.), Karolinska Institutet, Stockholm, Sweden; the Department of Epidemiology (H.-O.A.), Harvard
University, Boston, Massachusetts; The Cancer Registry of Norway (T.T.), Oslo, Norway; and the Division of Psychosocial Factors & Health, Department
of Public Health Sciences (E.W.), Karolinska Institutet, Stockholm, Sweden.
Correspondence to Hannah Kuper, ScD, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, U.K. E-mail hannah.
kuper@lshtm.ac.uk
2006 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000251805.47370.91

27
 28 Stroke January 2007
of 49 259 women returned a completed mailed questionnaire (re-
sponse rate 51%). Each woman is identified by a unique 10-digit
national registration number, which encodes information on date of
birth and gender.21 For the current study, we excluded 1091 women
because they did not provide information about their years of
education (the primary exposure for the study). We excluded a
further five women who had emigrated before the start of follow up
and 221 women with a history of stroke or myocardial infarction
before the start of follow up. The final study population included
47 942 women.
Exposure Classification
Educational Level
At baseline, the women completed a detailed self-administered
questionnaire. Socioeconomic status was estimated using self-
reported total years of school attendance in four categories22:
1. Seven to 9 years (primary school with at most 2 years of
additional professional education);
2. Ten to 12 years (completed secondary school or up to 5 years
of professional training);
3. Thirteen to 15 years (university bachelor degree or several
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professional training sessions); and
4. Sixteen or more years (usually corresponds to university
masters level degree or higher).
Psychosocial Characteristics
Work characteristics were measured using established questionnaires
for the central components of the job strain model, that is, job
demands (five questions), job control (six questions), and social
support at work (six questions).23 Scores for each scale were
calculated as the sum of the item scores and the population was
divided into tertiles for each characteristic based on the responses
across all the women. The few subjects missing one or two items in
a scale were assigned an average score based on the items that they
did answer, and those missing more than two items on a scale were
excluded from the analyses (419 women for job demands, 284 for
job control, 674 for social support at work). Four quadrants of job
strain (active work high demand and high control, high
strain high demand and low control, low strainlow demand
and high control, passive worklow demand and low control)
were constructed by crosstabulating job demands and job control,
both divided at the median.
Social support in general was measured using six questions. A
score was created and the women were divided into tertiles, although
351 women were excluded because they did not answer more than
two questions. Women were also asked to give a personal assessment
of their health. Health-seeking behavior was measured by enquiring
about the frequency of breast self-examination, mammography
screening, and gynecologic checkups.
Conventional Stroke Risk Factors
Participants reported on established stroke risk factors, which were:
cigarette smoking (never smoker, 5, 5 to 10, 10 pack-years),
physical activity (very low, low, normal, high, very high), alcohol
consumption (0, 1.7, 1.7 to 4.4, 4.4 g/d), body mass index
(18.5, 18.5 to 25, 25 to 30, 30 kg/m2), diabetes (yes/no), and
high blood pressure (yes/no). The women with missing data for
previous stroke (n3543), previous myocardial infarction
(n3558), diabetes (n3363), or hypertension (n2313) were
assumed not to have prevalent disease.
Follow Up and Stroke End Points
The cohort was followed up through linkages with existing nation-
wide health registers using the unique national registration number of
the women so that follow up was virtually complete with respect to
death, emigration, and stroke. Information on stroke was collected
through linkage to the National Hospital Discharge Register Inter-
national Classification of Diseases (ICD), 9th Revision from 1987 to
1996 and the 10th version thereafter. We considered cases in the
Inpatient Register with any of the following main diagnoses:
ischemic stroke (occlusion of cerebral arteries, IS) (ICD-7: 332;
ICD-8: 433 to 434; ICD-9: 434; ICD-10: I63.3 to I63.9), intracere-
bral hemorrhage (ICD-7: 331; ICD-8, 9: 431; IC-D10: I61), and
undefined stroke (ICD-7: 334; ICD-8, 9: 436; ICD-10: I64). Because
some patients might have experienced sudden death attributable to
stroke without hospitalization and recording in the Inpatient Regis-
ter, we also linked our cohort to the nationwide Causes of Death
Register. If a subject was found to have different diagnoses of stroke
within 28 days after index diagnosis, the subtype was defined by the
latest hospital discharge. We obtained information on date of death
from other diseases from the Causes of Death Register and on date
of emigration out of Sweden from the Emigration Register.
The start of follow up was defined as the date of receipt of the
returned questionnaire and person-years were calculated from the
start of follow up to the primary diagnosis of fatal or nonfatal stroke,
date of emigration or death, or the end of follow up (December 31,
2002), whichever came first. The average length of follow up was
11.2 years. In total, there were 200 events (121 ischemic, 47
hemorrhagic, and 32 of unknown origin).
Statistical Analysis
We calculated relative hazards using the Cox proportional hazards
model to assess whether years of education was associated with the
age-adjusted incidence of stroke. The association between incidence
of stroke and, in turn, general social support, self-rated health,
health-seeking behavior, and job variables (among women in full- or
part-time employment) was also modeled. We interpreted hazards
ratios as estimates of relative risk, and these were reported with 95%
CIs. We tested for trends across categories of variables by assigning
equally spaced values (eg, 1, 2, 3, or 4) to the categories and treating
the variables as continuous variables in the Cox proportional hazards
model. All analyses were adjusted for age at baseline, which was
categorized by 5-year intervals. The models were successively
adjusted for established stroke risk factors: cigarette smoking, body
mass index, alcohol consumption, self-reported diabetes, self-
reported high blood pressure, and exercise.
Ethics
The study was approved by the Data Inspection Board in Sweden and
by the regional Ethical Committee. Consent was assumed by the
return of the postal questionnaire.
Results
Of a total of 47 942 women included in the study, 19.7% had
completed less than 10 years of education, 39.1% had
completed 10 to 12 years, 32.9% had completed 13 to 15
years, and 8.4% had completed at least 16 years (Table 1).
Women were on average 40.3 years (5.8 SD) at baseline.
Longer education was associated with a lower prevalence of
stroke risk factors, including fewer pack-years of smoking,
lower average body mass index, a lower prevalence of
diabetes and hypertension, and more frequent exercise.
The incidence of all stroke was strongly related to years of
education (hazard ratio comparing the lowest with highest
level of education2.1, 95% CI1.4 to 2.9, P for trend
0.001) (Table 2). For these analyses, we combined group 3
(13 to 15 years of education) and group 4 (16 years of
education) because only 12 events occurred in the highest
education group. This association was more marked for
ischemic stroke (2.9, 1.8 to 4.7, P for trend 0.001) than for
hemorrhagic stroke (1.4, 0.7 to 2.9, P for trend0.35).
Adjustment for smoking explained some of the educational
gradient for stroke, as did adjustment for alcohol, but adjust-
ment for the other stroke risk factors had less influence on the
effect estimates. After adjusting for all stroke risk factors, the
 Kuper et al Socieconomic Gradient in Stroke in Swedish Women 29

TABLE 1. The Association Between Years of Education and Established Stroke Risk Factors, Psychosocial
Risk Factors, and Health-Seeking Behavior
Years of Education

9 Years, 10 to 12 Years, 13 to 15 Years, 16 Years,

(n9433) (n18 734) (n15 771) (n4004) 2 P Value
Mean age in years (SD) 43.1 (5.5) 39.4 (5.7) 39.4 (5.5) 41.1 (5.5) 0.001
Established stroke risk factors
Never smoker 3078 (32.8%) 6918 (37.1%) 7390 (47.0%) 2071 (51.9%) 0.001
Smoker: 5 pack-years 1200 (12.8%) 2757 (14.8%) 2652 (16.9%) 698 (17.5%)
Smoker: 510 pack-years 1261 (13.4%) 2986 (16.0%) 2292 (14.6%) 526 (13.2%)
Smoker: 10 pack-years 3858 (41.1%) 5999 (32.2%) 3394 (21.6%) 694 (17.4%)
Mean body mass index in 24.4 (4.0) 23.6 (3.7) 23.0 (3.5) 22.8 (3.4) 0.001
kg/m2 (SD)
Mean alcohol in g/day (SD) 2.9 (4.4) 3.4 (4.4) 3.8 (4.3) 4.6 (5.2) 0.001
Diabetes (no., %) 156 (1.7%) 255 (1.4%) 181 (1.2%) 31 (0.8%) 0.001
High blood pressure (no., %) 1123 (11.9%) 1830 (9.8%) 1230 (7.8%) 247 (6.2%) 0.001
0.001
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Rating of physical activity

Very low 585 (6.5%) 761 (4.3%) 508 (3.4%) 137 (3.5%)
Low 827 (9.1%) 1799 (10.1%) 1700 (11.3%) 561 (14.5%)
Normal 6055 (66.7%) 10 939 (61.5%) 8340 (55.5%) 1999 (51.5%)
High 1015 (11.2%) 2871 (16.1%) 3009 (20.0%) 826 (21.3%)
Very high 591 (6.5%) 1425 (8.0%) 1472 (9.8%) 359 (9.3%)
Psychosocial factors
Self-rated health
High 3202 (34.3%) 7941 (42.7%) 7942 (50.6%) 2039 (51.2%) 0.001
Medium 5437 (58.2%) 9959 (53.5%) 7327 (46.7%) 1797 (45.1%)
Low 699 (7.5%) 718 (3.9%) 416 (2.7%) 148 (3.7%)
Mean job demands* (SD) 2.4 (0.6) 2.4 (0.5) 2.5 (0.5) 2.7 (0.6) 0.001
Mean job control* (SD) 2.8 (0.5) 2.9 (0.5) 3.2 (0.5) 3.4 (0.4) 0.001
Mean social support at work* (SD) 1.7 (0.5) 1.7 (0.5) 1.7 (0.5) 1.8 (0.5) 0.001
Mean social support (SD) 2.5 (0.7) 2.6 (0.7) 2.7 (0.7) 2.8 (0.7) 0.001
Health-seeking behavior
Low 3372 (36.3%) 9410 (50.8%) 7966 (51.1%) 1807 (45.6%)
Medium 2767 (29.8%) 5272 (28.5%) 4456 (28.6%) 1166 (29.4%)
High 3155 (34.0%) 3852 (20.8%) 3172 (20.3%) 987 (24.9%) 0.001
*Restricted to the sample of 35 471 women in full-time (n19 533) or part-time (n15 938) employment.

association between education and all stroke (1.5, 1.0 to 2.2,
P for trend0.04) and ischemic stroke (2.2, 1.3 to 3.7, P for
trend0.003) was weakened, although it remained statisti-
cally significant.
The analyses for work characteristics were restricted to the
35 471 women in full-time (n19 533) or part-time
(n15 938) employment. The educational gradient in risk of
stroke was still apparent after the sample was restricted to
women in full- and part-time employment (hazard ratio
comparing the lowest with the highest education group2.2,
1.4 to 3.3, P for trend 0.001) (Table 3). The gradient
remained more pronounced for ischemic stroke (2.7, 1.6 to
4.6, P for trend 0.001) than for hemorrhagic stroke (1.9, 0.8
to 4.3, P for trend0.16). Adjustment for the psychosocial
factors individually, or together, did not explain the educa-
tional gradient in all stroke (2.2, 1.4 to 3.5, P for trend
0.001), ischemic stroke (2.5, 1.4 to 4.6, P for trend0.002),
or hemorrhagic stroke (1.7, 0.7 to 4.2, P for trend0.26).
Job control, job demands, job strain, and social support at
work were essentially unrelated to risk of all stroke or
hemorrhagic stroke during follow up (Table 4). There was a
borderline significant increased risk of ischemic stroke
among women who had low job control (hazard ratio for low
versus high job control1.4, 0.9 to 2.4, P for trend0.08) or
high job strain (hazard ratio for high versus low job
strain1.6, 0.9 to 3.0). Ischemic stroke was not associated
with job demands or social support at work.
Self-rated health was strongly associated with risk of all
stroke (hazard ratio low versus high self-rated health3.4,
2.1 to 5.6, P for trend 0.001) and ischemic stroke (4.5, 2.4
to 8.4, P for trend 0.001), but not hemorrhagic stroke (1.2,
0.3 to 5.1, P for trend0.27) (Table 5). Most of the excess
risk of stroke among women with low self-rated health
disappeared after adjustment for stroke risk factors, although
the associations for all stroke and ischemic stroke remained
 30 Stroke January 2007

TABLE 2. Adjusted Hazard Ratios (and 95% CIs) for the Association Between Years of Education and Incidence of Fatal/Nonfatal
Stroke Serially Adjusted for Established Stroke Risk Factors
Age and Age, Hypertension,
No. of Women Age and Body Mass Age and and Age and
Education Group (events) Age-Adjusted Smoking-Adjusted Index-Adjusted Alcohol-Adjusted Diabetes-Adjusted Exercise-Adjusted Fully Adjusted

All stroke 47 942 (200) 47 774 (199) 46 102 (191) 47 942 (200) 47 942 (200) 45 779 (198) 44 034 (189)
(events)
1 (lowest) 9433 (73) 2.1 (1.4 to 2.9) 1.8 (1.2 to 2.6) 2.0 (1.4 to 2.9) 1.8 (1.3 to 2.6) 1.9 (1.3 to 2.7) 2.0 (1.4 to 2.9) 1.5 (1.0 to 2.2)
2 18 734 (73) 1.5 (1.0 to 2.1) 1.4 (1.0 to 1.9) 1.4 (1.0 to 2.0) 1.4 (1.0 to 2.0) 1.4 (1.0 to 2.0) 1.5 (1.0 to 2.1) 1.2 (0.9 to 1.8)
3/4 (highest) 19 775 (54) 1.0 1.0 1.0 1.0 1.0 1.0 1.0
P for trend 0.001 0.002 0.0002 0.001 0.001 0.001 0.04
Ischemic stroke 47 863 (121) 47 695 (120) 46 026 (115) 47 863 (121) 47 863 (121) 45 701 (120) 43 959 (114)
(events)
1 (lowest) 9409 (49) 2.9 (1.8 to 4.7) 2.5 (1.5 to 4.0) 3.1 (1.9 to 5.1) 2.6 (1.6 to 4.3) 2.7 (1.6 to 4.3) 2.8 (1.7 to 4.6) 2.2 (1.3 to 3.7)
2 18 707 (46) 1.9 (1.2 to 3.1) 1.7 (1.1 to 2.8) 1.9 (1.2 to 3.2) 1.8 (1.1 to 3.0) 1.8 (1.1 to 2.9) 1.9 (1.1 to 3.0) 1.6 (1.0 to 2.7)
3/4 (highest) 19 747 (26) 1.0 1.0 1.0 1.0 1.0 1.0 1.0
P for trend 0.001 0.001 0.001 0.001 0.001 0.001 0.003
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Hemorrhagic 47 789 (47) 47 622 (47) 45 955 (44) 47 789 (47) 47 789 (47) 45 627 (46) 43 888 (43)
stroke (events)
1 (lowest) 9375 (15) 1.4 (0.7 to 2.9) 1.3 (0.6 to 2.7) 1.2 (0.6 to 2.6) 1.3 (0.6 to 2.6) 1.3 (0.7 to 2.8) 1.5 (0.7 to 3.2) 1.1 (0.5 to 2.4)
2 18 677 (16) 1.1 (0.5 to 2.2) 1.0 (0.5 to 2.1) 1.0 (0.5 to 2.0) 1.1 (0.5 to 2.1) 1.1 (0.5 to 2.1) 1.2 (0.6 to 2.4) 1.0 (0.5 to 2.0)
3/4 (highest) 19 737 (16) 1.0 1.0 1.0 1.0 1.0 1.0 1.0
P for trend 0.35 0.47 0.62 0.55 0.43 0.26 0.87

statistically significant. Low social support was associated
with risk of all stroke (hazard ratio for low versus high social
support1.6, 1.1 to 2.2, P for trend0.006), ischemic stroke
(1.5, 1.0 to 2.4, P for trend0.05), and hemorrhagic stroke
(2.0, 1.0 to 4.1, P for trend0.05), although most of the
excess risk was explained by adjustment for stroke risk
factors. Low health-seeking behaviors were inversely related
to the risk of stroke, and this was independent of stroke risk
factors.
Discussion
In this large prospective study, we found a strong inverse
association between educational attainment and stroke among
middle-aged Swedish women. The gradient was particularly

TABLE 3. Adjusted Hazard Ratios (and 95% CIs) for the Association Between Years of Education and Incidence of Fatal/Nonfatal
Stroke in Full- or Part-Time Workers Serially Adjusted for Psychosocial Risk Factors
No. of Women Age and Job Age and Job Age and Social Age and Total Age and
(events) Age-Adjusted Demands Control Support at Work Social Support Self-Rated Health Fully Adjusted

All stroke 35 471 (149) 35 471 (149) 35 471 (149) 34 960 (146) 35 336 (149) 35 291 (148) 34 666 (145)
(events)
1 (lowest) 6406 (53) 2.2 (1.4 to 3.3) 2.2 (1.4 to 3.2) 2.4 (1.5 to 3.7) 2.2 (1.4 to 3.3) 2.1 (1.4 to 3.1) 2.1 (1.4 to 3.2) 2.2 (1.4 to 3.5)
2 13 769 (52) 1.4 (0.9 to 2.0) 1.4 (0.9 to 2.0) 1.5 (1.0 to 2.2) 1.3 (0.9 to 2.0) 1.3 (0.9 to 2.0) 1.4 (0.9 to 2.0) 1.4 (0.9 to 2.1)
3/4 (highest) 15 296 (44) 1.0 1.0 1.0 1.0 1.0 1.0 1.0
P for trend 0.001 0.001 0.001 0.001 0.001 0.001 0.001
Ischemic 35 413 (91) 35 413 (91) 35 413 (91) 34 902 (88) 35 278 (91) 35 233 (90) 34 608 (87)
stroke (events)
1 (lowest) 6388 (35) 2.7 (1.6 to 4.6) 2.7 (1.6 to 4.6) 2.6 (1.5 to 4.6) 2.7 (1.6 to 4.6) 2.6 (1.5 to 4.5) 2.6 (1.5 to 4.5) 2.5 (1.4 to 4.6)
2 13 750 (33) 1.6 (1.0 to 2.8) 1.6 (1.0 to 2.8) 1.6 (0.9 to 2.9) 1.6 (0.9 to 2.7) 1.6 (0.9 to 2.7) 1.7 (1.0 to 2.8) 1.6 (0.9 to 2.8)
3/4 (highest) 15 275 (23) 1.0 1.0 1.0 1.0 1.0 1.0 1.0
P for trend 0.001 0.001 0.001 0.001 0.001 0.001 0.002
Hemorrhagic 35 356 (34) 35 356 (34) 35 356 (34) 34 848 (34) 35 221 (34) 35 177 (34) 34 555 (34)
stroke (events)
1 (lowest) 6365 (12) 1.9 (0.8 to 4.3) 1.9 (0.8 to 4.3) 1.9 (0.8 to 4.8) 1.9 (0.8 to 4.3) 1.7 (0.7 to 3.8) 1.8 (0.8 to 4.1) 1.7 (0.7 to 4.2)
2 13 727 (10) 1.0 (0.4 to 2.2) 1.0 (0.4 to 2.2) 1.0 (0.4 to 2.4) 1.0 (0.4 to 2.2) 0.9 (0.4 to 2.1) 0.9 (0.4 to 2.2) 0.9 (0.4 to 2.3)
3/4 (highest) 15 264 (12) 1.0 1.0 1.0 1.0 1.0 1.0 1.0
P for trend 0.16 0.17 0.16 0.16 0.26 0.20 0.26
 Kuper et al Socieconomic Gradient in Stroke in Swedish Women 31

TABLE 4. Adjusted Hazard Ratios (and 95% CIs) for the Association Between Baseline Job Control, Job
Demands, and Job Strain and Incidence of Fatal/Nonfatal Stroke in Full- and Part-Time Workers
All Stroke Ischemic Stroke Hemorrhagic Stroke

Age-Adjusted Age-Adjusted Age-Adjusted

No. (n35 471 and No. (n35 413 and No. (n35 356 and
(events) events149) (events) events91) (events) events34)
Job control*
1 (lowest) 13 328 (65) 1.0 (0.7 to 1.5) 13 308 (45) 1.4 (0.9 to 2.4) 13 278 (15) 1.1 (0.5 to 2.4)
2 12 807 (40) 0.7 (0.4 to 1.0) 12 791 (24) 0.8 (0.4 to 1.4) 12 776 (9) 0.7 (0.3 to 1.6)
3 (highest) 9336 (44) 1.0 9314 (22) 1.0 9302 (10) 1.0
P for trend 0.61 0.08 0.76

Job demands
1 (lowest) 12 838 (59) 1.0 12 815 (36) 1.0 12 793 (14) 1.0
2 10 189 (39) 0.8 (0.6 to 1.3) 10 174 (24) 0.8 (0.5 to 1.4) 10 158 (8) 0.7 (0.3 to 1.7)
3 (highest) 12 444 (51) 0.9 (0.6 to 1.3) 12 424 (31) 0.9 (0.5 to 1.4) 12 405 (12) 0.9 (0.4 to 1.9)
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P for trend 0.52 0.61 0.73

Job strain
Low 8127 (34) 1.0 8110 (17) 1.0 8101 (8) 1.0
Strain 7749 (39) 1.2 (0.8 to 1.9) 7736 (26) 1.6 (0.9 to 3.0) 7719 (9) 1.2 (0.5 to 3.1)
Active 9818 (38) 0.9 (0.6 to 1.5) 9802 (22) 1.1 (0.6 to 2.0) 9788 (8) 0.8 (0.3 to 2.2)
Passive 9777 (38) 0.9 (0.6 to 1.5) 9765 (26) 1.3 (0.7 to 2.4) 9748 (9) 0.9 (0.4 to 2.5)

Work social support

1 (lowest) 10 955 (42) 0.9 (0.6 to 1.4) 10 936 (23) 0.8 (0.5 to 1.3) 10 923 (10) 1.1 (0.5 to 2.7)
2 10 297 (49) 1.2 (0.8 to 1.7) 10 277 (29) 1.1 (0.6 to 1.7) 10 261 (13) 1.6 (0.7 to 3.5)
3 (highest) 13 708 (55) 1.0 13 689 (36) 1.0 13 664 (11) 1.0
P for trend 0.84 0.42 0.75

*Job control is defined as control over skill use, time allocation, and organizational decisions; job demands is defined as the need
to work quickly and hard.

pronounced for ischemic stroke. Most of the educational
gradient was explained by established stroke risk factors,
particularly smoking and alcohol, whereas psychosocial fac-
tors did not contribute toward the gradient.
The social gradient in stroke could be driven by varia-
tion in stroke risk factors, health-seeking behaviors, or
psychosocial risk factors by social stratus. Most of the
studies that tried to explain the basis for the socioeconomic
gradient in stroke have shown that the gradient is reduced
after taking account of conventional stroke risk factors,6 11
although a significant excess risk remained in the lower
socioeconomic classes.10,1215 The results from the current
study support this finding and are consistent with a recent
study that showed a strong association between educa-
tional level and healthy lifestyle in women.24 Health-
seeking behavior and psychosocial factors could not ex-
plain the educational gradient in stroke. The evidence
suggests that the social gradient in stroke was largely
driven by conventional stroke risk factors. The stronger
social gradient in ischemic stroke than in hemorrhagic
stroke (consistent with the findings of other studies)10
would support this finding, because ischemic stroke is
related to conventional stroke risk factors, whereas hem-
orrhagic stroke is more often caused by structural abnor-
malities. Any excess risk in the lower socioeconomic
groups that persists after adjusting for risk factors may be
attributable to residual confounding or unmeasured con-
founding, because risk factors were only measured through
self-report and at one point in time.
Few studies have investigated psychosocial factors as a
cause of stroke or as mediators of the socioeconomic gradient
in stroke,11 and no previous cohort studies have investigated
the association between work stress and stroke. The results of
the present study do not support the existence of an associa-
tion between work stress and overall risk of stroke, although
the association between low job control and job strain and
ischemic stroke approached statistical significance. We found
some association between risk of stroke and social support,
although this was largely explained by established stroke risk
factors. Self-rated health consistently predicts overall mortal-
ity,25 because it may capture subtle symptoms of subclinical
disease, and so the association between self-rated health and
stroke may be attributable to incomplete control for baseline
health status.
 32 Stroke January 2007

TABLE 5. Adjusted Hazard Ratios (and 95% CIs) for the Association Between Self-Rated Health and Social Support and Incidence of
Fatal/Nonfatal Stroke
All Stroke Ischemic Stroke Hemorrhagic Stroke

No. of Age and Age and Age and

Women Stroke Risk Stroke Risk Stroke Risk
(events) Age-Adjusted Factors-Adjusted Age-Adjusted Factors-Adjusted Age-Adjusted Factors-Adjusted

Self-rated 47 625 (199) 43 791 (188) 47 546 (120) 43 716 (113) 47 473 (47) 43 646 (43)
health*
1 (highest) 21 124 (60) 1.0 1.0 21 095 (31) 1.0 1.0 21 080 (16) 1.0 1.0
2 24 520 (117) 1.6 (1.2 to 2.2) 1.3 (1.0 to 1.9) 24 477 (74) 2.0 (1.3 to 3.1) 1.6 (1.0 to 2.6) 24 432 (29) 1.5 (0.8 to 2.8) 1.5 (0.8 to 2.9)
3 (lowest) 1981 (22) 3.4 (2.1 to 5.6) 1.7 (1.0 to 3.0) 1974 (15) 4.5 (2.4 to 8.4) 2.4 (1.2 to 4.8) 1961 (2) 1.2 (0.3 to 5.1) 0.5 (0.1 to 4.2)
P for trend 0.001 0.03 0.001 0.007 0.27 0.61

Social 47 591 (197) 43 782 (186) 47 513 (119) 43 708 (112) 47 440 (46) 43 638 (42)
support
1 (lowest) 15 178 (82) 1.6 (1.1 to 2.2) 1.3 (0.9 to 1.8) 15 143 (47) 1.5 (1.0 to 2.4) 1.3 (0.8 to 2.0) 15 117 (21) 2.0 (1.0 to 4.1) 1.6 (0.8 to 3.4)
2 15 783 (56) 1.0 (0.7 to 1.5) 0.9 (0.7 to 1.4) 15 764 (37) 1.2 (0.7 to 1.8) 1.1 (0.7 to 1.7) 15 740 (13) 1.2 (0.5 to 2.6) 1.1 (0.5 to 2.4)
3 (highest) 16 630 (59) 1.0 1.0 16 606 (35) 1.0 1.0 16 583 (12) 1.0 1.0
P for trend 0.006 0.15 0.05 0.30 0.05 0.18
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Health-seeking 47 382 (197) 43 582 (186) 47 304 (119) 43 508 (112) 47 232 (47) 43 439 (43)
behavior
1 (lowest) 22 555 (57) 0.6 (0.4 to 0.9) 0.6 (0.4 to 0.9) 22 531 (33) 0.6 (0.3 to 0.9) 0.5 (0.3 to 0.9) 22 511 (13) 0.7 (0.3 to 1.5) 0.6 (0.3 to 1.4)
2 13 661 (54) 0.7 (0.5 to 1.0) 0.7 (0.5 to 1.0) 13 640 (33) 0.7 (0.4 to 1.0) 0.6 (0.4 to 1.0) 13 622 (15) 0.9 (0.4 to 1.8) 0.9 (0.4 to 1.8)
3 (highest) 11 166 (86) 1.0 1.0 11 133 (53) 1.0 1.0 11 099 (19) 1.0 1.0
P for trend 0.01 0.004 0.02 0.008 0.35 0.24
*Self-rated health was assessed by the women through a personal assessment of their health (very good, good, poor, very poor); social support is measured by
the structure and function of social support.

There were some limitations to the study. Only half of the
women who were contacted agreed to participate in the study,
and this may have introduced the possibility of a selection
bias. However, a validation exercise from the Norwegian part
of the cohort indicated that the cohort participants were
representative of the general population,26 reducing the po-
tential for bias. The exposure variables were only measured at
baseline, which may have resulted in residual confounding of
the association between education and stroke. This would not
have had an important effect for education, our main expo-
sure variable, because this is unlikely to change among
women after the age of 30. The misclassification of the
psychosocial variables is expected to be nondifferential with
respect to outcome and so this could have led to an underes-
timation of effects.27 We were not able to measure access to
health care in this study, although we used a proxy measure
for health-seeking behavior, and in Sweden, everyone has
free access to high-quality medical services. Some potentially
important stroke risk factors were not measured in the study
such as childhood socioeconomic conditions, cholesterol and
fibrinogen levels, migraine with aura, atrial fibrillation, drug
use, and cerebrovascular disorders; and these unmeasured
confounders may have contributed toward explanation of the
social gradient in stroke. There were relatively few cases of
hemorrhagic stroke, and this could limit interpretation of the
data and result in wide confidence intervals in the adjusted
models.
There were also strengths. This study simultaneously
assessed the role of conventional stroke risk factors and
psychosocial risk factors in explaining the socioeconomic
gradient in stroke and also investigated the effect of job strain
on stroke in women. We used validated outcomes to measure
incident stroke among women who were disease-free at
baseline and measured job strain through standardized ques-
tionnaires. Disease end points were obtained through the
In-Patient Register and Mortality Register, which allowed
complete follow up of the cohort. This study was large and
had extended follow up, and the women in the cohort were
likely to be representative of the general population.26
Stroke is a dominant cause of morbidity and mortality
throughout the world.1,2 The social gradient in stroke offers us
an insight into prevention of stroke because we can aim for
the incidence in the lowest social strata to approach that of the
highest social strata. The study results indicate that in this
cohort of women aged 30 to 50 at baseline, most of the social
gradient is attributable to established risk factors, particularly
smoking and alcohol. Because socioeconomic status may be
a good proxy to identify individuals at increased risk for
stroke, a health promotion campaign targeting lower educa-
tional groups may reduce the population incidence of stroke,
although other correlates of low education need further
investigation.
Summary
In this cohort of middle-aged Swedish women, followed on
average for more than 11 years, we found a strong gradient in
risk of stroke by education level. Most of this gradient was
explained by established conventional risk factors, but not by
job characteristics, other psychosocial variables, or health-
seeking behavior.
Acknowledgments
The authors thank all the women who contributed to this study.
 Kuper et al Socieconomic Gradient in Stroke in Swedish Women
Sources of Funding
In Sweden, the survey was supported by the Swedish Council for
Planning and Co-ordination of Research, Swedish Cancer Society,
STINT (The Swedish Foundation for International Cooperation in
Research and Higher Education) Organon, Pharmacia, Medical
Products Agency and Schering-Plough. The travel costs for Hannah
Kuper and Elisabete Weiderpass were supported by a joint program
grant from the Royal Society.
Disclosures
None.
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 The Socioeconomic Gradient in the Incidence of Stroke: A Prospective Study in
Middle-Aged Women in Sweden
Hannah Kuper, Hans-Olov Adami, Tres Theorell and Elisabete Weiderpass
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Stroke. 2007;38:27-33; originally published online November 30, 2006;

doi: 10.1161/01.STR.0000251805.47370.91
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Copyright 2006 American Heart Association, Inc. All rights reserved.
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