SynthesisInternational journal of stroke : official journal of the International Stroke Society2026
A systematic review of causal pathways of socioeconomic inequalities in stroke.
Synthesis in International journal of stroke : official journal of the International Stroke Society, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
1 citing paper in PubMed.
Corrections and comments
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Authors and funding
15 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundSocioeconomic status (SES), often measured by education, income, occupation, or area-level deprivation, impacts stroke incidence and outcomes, yet the underlying mechanisms remain unclear. This review synthesizes causal analyses quantifying drivers of these inequalities.
methodsWe conducted a systematic review (PROSPERO CRD42024554285) and reported following the PRISMA-2020 guidelines. Observational studies applying causal mediation analysis between SES and stroke risk, disability, or mortality were included from PubMed, Embase, Scopus, and Google Scholar. SES indicators, outcomes, mediators, and decompositions into natural direct effect (NDE) and natural indirect effect (NIE) were extracted. Risk of bias and certainty of evidence were assessed using ROBINS-E and GRADE. A narrative synthesis was undertaken, and findings were illustrated in causal diagrams.
resultsOf 12,034 records, 19 studies (15 in high-income countries) were included. Lower SES increased stroke incidence through hypertension (NIE 14-21% of the total effect, moderate certainty), although one study restricted to women reported smaller effects (2-4%). Smoking (6-19.9%, very low certainty). At 3 months post-stroke, the combined outcome of death or disability was higher due to severe strokes (38.5% for ischemic, 57-94% for hemorrhagic, moderate certainty). One study found that hypertension, atrial fibrillation, and smoking together mediated 28.5% of the SES effect on stroke severity (low certainty). Reduced access to thrombolysis and stroke units mediated 2.7% of 3-month disability/mortality (very low certainty), while greater distance to specialized centers explained 48% of inequalities in thrombectomy access (low certainty). Long-term mortality (⩾6 months) was mediated by comorbidities (18%) and healthcare coverage (24-55%), both with low certainty.
conclusionsHypertension, smoking, and differential stroke severity at presentation are the main pathways through which low SES increases stroke risk and causes worse outcomes. Targeting these may reduce inequalities, though evidence from low-income settings and emerging mediators (e.g. early-life SES, environmental exposures, care quality) is lacking.
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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the Socratic graph.