Racial Disparities in Stroke Burden Mediated by Social Determinants of Health: A National Population-Based Investigation

Abstract

Despite advancements in stroke prevention, its burden remains substantial, with social determinants of health (SDoH) increasingly recognized as potentially modifiable contributors to stroke risk and mortality. Utilizing nationally representative data from the U.S. National Health and Nutrition Examination Survey (NHANES, 1999-2018) and the China Health and Retirement Longitudinal Study (CHARLS, 2011-2012), associations between SDoH composites (economic stability, education, healthcare access, neighborhood environment, social context) and stroke outcomes were evaluated. Weighted logistic regression and Cox regression models assessed stroke prevalence and mortality, adjusting for covariates. Mediation analyses quantified SDoH contributions to racial disparities. In NHANES, adverse SDoH indices significantly predicted stroke prevalence and mortality. Key independent SDoH stroke predictors included unemployment, food insecurity, and housing instability. Non-Hispanic Black individuals aged 40 to 79 exhibited 1.23% to 3.86% higher absolute stroke risk than White counterparts. Mediation analyses identified home ownership as the primary mediator of Black-White disparities. CHARLS validation confirmed consistent SDoH-stroke associations. Asian populations demonstrated the lowest mortality risks. Stroke outcomes demonstrate dose-dependent escalation with increasing SDoH indices, wherein racial disparities in stroke prevalence and mortality between Black and White populations are predominantly mediated by housing instability.