Gender difference of geographic distribution of the stroke incidence affected by socioeconomic, clinical and urban-rural factors: an ecological study based on data from the Brest stroke registry in France

Abstract

Background: Mapping the spatial distribution of disease occurrence is a strategy to identify contextual factors that could be useful for public health policies. The purpose of this ecological study was to examine to which extent the socioeconomic deprivation and the urbanization level can explain gender difference of geographic distribution in stroke incidence in Pays de Brest, France between 2008 and 2013.

Methods: Stroke cases aged 60 years or more were extracted from the Brest stroke registry and combined at the census block level. Contextual socioeconomic, demographic, and geographic variables at the census block level come from the 2013 national census. We used spatial and non-spatial regression models to study the geographic correlation between socioeconomic deprivation, degree or urbanization and stroke incidence. We generated maps using spatial geographically weighted models, after longitude and latitude smoothing and adjustment for covariates.

Results: Stroke incidence was comparable in women and men (6.26 ± 3.5 vs 6.91 ± 3.3 per 1000 inhabitants-year, respectively). Results showed different patterns of the distribution of stroke risk and its association with deprivation or urbanisation across gender. For women, stroke incidence was spatially homogeneous over the entire study area, but was associated with deprivation level in urban census blocks: age adjusted risk ratio of high versus low deprivation = 1.24, [95%CI 1.04-1.46]. For men, three geographic clusters were identified. One located in the northern rural and deprived census blocks with a 9-14% increase in the risk of stroke. Two others clusters located in the south-eastern (mostly urban part) and south-western (suburban and rural part) with low deprivation level and associated with higher risk of stroke incidence between (3 and 8%) and (8.5 and 19%) respectively. There were no differences in profile of cardiovascular risk factors, stroke type and stroke severity between clusters, or when comparing clusters cases to the rest of the study population.

Conclusions: Understanding whether and how neighborhood and patient's characteristics influence stroke risk may be useful for both epidemiological research and healthcare service planning.

Keywords: Incidence, geographically weighted regression (GWR), spatial variations; Socioeconomic factors; Stroke; Urban rural.

Fig. 1

Description of the four deprivation & urban-rural index classes and their geographic distribution in the Pays de Brest administrative region, France. Maps were created by the authors using ArcGIS software

Fig. 2

Age-standardized stroke incidence risk per 1000 inhabitants-year, in men and women living in the different census blocks of the Pays de Brest administrative region, France. Maps were created by the authors using ArcGIS software

Fig. 3

Spatial distribution of the deprivation level (FDep index) in the different census blocks within the Pays de Brest administrative region, France. The map was created by the authors using ArcGIS software

Fig. 4

Clusters of higher risk of stroke incidence and deprivation map using GWR models. Negative deprivation scores indicate progressively higher deprivation levels, thus stroke incidence rate is negatively associated with high deprivation levels (negative scores) in Cluster 1 and positively associated with low deprivation levels (positive scores) in Clusters 2 and 3. The map was created by the authors using ArcGIS software