Original Article| Volume 23, ISSUE 6, P1529-1536, July 2014

The Influence of Neighborhood Unemployment on Mortality after Stroke


      Few studies have investigated the impact of neighborhood characteristics on mortality after stroke. Aim of our study was to analyze the influence of district unemployment as indicator of neighborhood socioeconomic status (SES-NH) on poststroke mortality, and to compare these results with the mortality in the underlying general population.


      Our analyses involve 2 prospective cohort studies from the city of Dortmund, Germany. In the Dortmund Stroke Register (DOST), consecutive stroke patients (N = 1883) were recruited from acute care hospitals. In the Dortmund Health Study (DHS), a random general population sample was drawn (n = 2291; response rate 66.9%). Vital status was ascertained in the city's registration office and information on district unemployment was obtained from the city's statistical office. We performed multilevel survival analyses to examine the association between district unemployment and mortality.


      The association between neighborhood unemployment and mortality was weak and not statistically significant in the stroke cohort. Only stroke patients exposed to the highest district unemployment (fourth quartile) had slightly higher mortality risks. In the general population sample, higher district unemployment was significantly associated with higher mortality following a social gradient. After adjustment for education, health-related behavior and morbidity was made the strength of this association decreased.


      The impact of SES-NH on mortality was different for stroke patients and the general population. Differences in the association between SES-NH and mortality may be partly explained by disease-related characteristics of the stroke cohort such as homogeneous lifestyles, similar morbidity profiles, medical factors, and old age.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ward A.
        • Payne K.A.
        • Caro J.J.
        • et al.
        Care needs and economic consequences after acute ischemic stroke: the Erlangen stroke project.
        Eur J Neurol. 2005; 12: 264-267
        • Heuschmann P.U.
        • Busse O.
        • Wagner M.
        • et al.
        Frequency and care of stroke in Germany.
        Akt Neurol. 2010; 37: 333-340
        • Wang Y.
        • Rudd A.G.
        • Wolfe C.D.A.
        Trends and survival between ethnic groups after stroke: the South London Stroke Register.
        Stroke. 2013; 44: 380-387
        • Wolfe C.D.A.
        • Rudd A.G.
        • Howard R.
        • et al.
        Incidence and case fatality rates of stroke subtypes in a multiethnic population: the South London Stroke Register.
        J Neurol Neurosurg Psychiatry. 2002; 72: 211-216
        • Wolfe C.D.A.
        • Smeeton N.C.
        • Coshall C.
        • et al.
        Survival differences after stroke in a multiethnic population: follow-up study with the South London Stroke Register.
        BMJ. 2005; 33: 431
        • Arrich J.
        • Lalouschek W.
        • Mullner M.
        Influence of socioeconomic status on mortality after stroke: retrospective cohort study.
        Stroke. 2005; 36: 310-314
        • Li C.
        • Hedblad B.
        • Rosvall M.
        • et al.
        Stroke incidence, recurrence, and case-fatality in relation to socioeconomic position: a population-based study of middle-aged Swedish men and women.
        Stroke. 2008; 39: 2191-2196
        • Lofmark U.
        • Hammarstrom A.
        Education-related differences in case fatality among elderly with stroke.
        Neuroepidemiology. 2008; 31: 21-27
        • Grube M.M.
        • Koennecke H.-C.
        • Walter G.
        • et al.
        Association between socioeconomic status and functional impairments 3 months after ischemic stroke.
        Stroke. 2012; 43: 3325-3330
        • Anderson R.T.
        • Sorlie P.
        • Backlund E.
        • et al.
        Mortality effects of community socioeconomic status.
        Epidemiology. 1997; 8: 42-47
        • Ecob R.
        • Jones K.
        Mortality variations in England and Wales between types of place: an analysis of the ONS longitudinal study. Office of National Statistics.
        Soc Sci Med. 1998; 47: 2055-2066
        • Sloggett A.
        • Joshi H.
        Deprivation indicators as predictors of life events 1981-1992 based on the UK ONS longitudinal study.
        J Epidemiol Community Health. 1998; 52: 228-233
        • Waitzman N.J.
        • Smith K.R.
        Phantom of the area: poverty-area residence and mortality in the United States.
        Am J Public Health. 1998; 88: 973-976
        • Yen I.H.
        • Kaplan G.A.
        Neighborhood social environment and risk of death: multilevel evidence from the Alameda county study.
        Am J Epidemiol. 1999; 149: 898-907
        • Clark C.J.
        • Guo H.F.
        • Lunos S.
        • et al.
        Neighborhood cohesion is associated with reduced risk of stroke mortality.
        Stroke. 2011; 42: 1212-1217
        • Finkelstein M.M.
        • Jerrett M.
        • Sears M.R.
        Environmental inequality and circulatory disease mortality gradients.
        J Epidemiol Community Health. 2005; 59: 481-487
        • Hu Z.
        • Liebens J.
        • Rao K.R.
        Linking stroke mortality with air pollution, income, and greenness in northwest Florida: an ecological geographical study.
        Int J Health Geogr. 2008; 7: 20
        • Pedigo A.
        • Aldrich T.
        • Odoi A.
        Neighborhood disparities in stroke and myocardial infarction mortality: a GIS and spatial scan statistics approach.
        BMC Public Health. 2011; 11: 644
        • Grimaud O.
        • Leray E.
        • Lalloue B.
        • et al.
        Inverse association between socio-economic status and post stroke mortality, an analysis of the Dijon stroke registry taking account of place of care.
        Cerebrovasc Dis. 2013; 35: 140
        • Brown A.F.
        • Liang L.J.
        • Vassar S.D.
        • et al.
        Neighborhood socioeconomic disadvantage and mortality after stroke.
        Neurology. 2013; 80: 520-527
        • Kapral M.K.
        • Wang H.
        • Mamdani M.
        • Tu J.V.
        Effect of socioeconomic status on treatment and mortality after stroke.
        Stroke. 2002; 33: 268-273
        • Maheswaran R.
        • Pearson T.
        • Smeeton N.C.
        • et al.
        Impact of outdoor air pollution on survival after stroke: population-based cohort study.
        Stroke. 2010; 41: 869-877
        • Diederichs C.
        • Mühlenbruch K.
        • Lincke H.O.
        • et al.
        Predictors of dependency on nursing care after stroke: results from the Dortmund and Münster stroke registry.
        Dtsch Arztebl Int. 2011; 108: 592-599
        • Minnerup J.
        • Wersching H.
        • Ringelstein E.B.
        • et al.
        Impact of the extended thrombolysis time window on the proportion of recombinant tissue-type plasminogen activator-treated stroke patients and on door-to-needle time.
        Stroke. 2011; 42: 2838-2843
        • Vennemann M.M.
        • Hummel T.
        • Berger K.
        The association between smoking and smell and taste impairment in the general population.
        J Neurol. 2008; 255: 1121-1126
        • Dragano N.
        • Bobak M.
        • Wege N.
        • et al.
        Neighbourhood socioeconomic status and cardiovascular risk factors: a multilevel analysis of nine cities in the Czech Republic and Germany.
        BMC Public Health. 2007; 7: 255
        • Dragano N.
        • Hoffmann B.
        • Stang A.
        • et al.
        Subclinical coronary atherosclerosis and neighbourhood deprivation in an urban region.
        Eur J Epidemiol. 2009; 24: 25-35
        • Naimi A.I.
        • Paquet C.
        • Gauvin L.
        • Daniel M.
        Associations between area-level unemployment, body mass index, and risk factors for cardiovascular disease in an urban area.
        Int J Environ Res Public Health. 2009; 6: 3082-3096
        • Campbell D.A.
        • Radford J.M.C.
        • Burton P.
        Unemployment rates: an alternative to the Jarman index?.
        BMJ. 1991; 303: 750-755
        • Aslanyan S.
        • Weir C.J.
        • Lees K.R.
        • et al.
        Effect of area-based deprivation on the severity, subtype, and outcome of ischemic stroke.
        Stroke. 2003; 34: 2623-2629
        • Weir N.U.
        • Gunkel A.
        • McDowall M.
        • Dennis M.S.
        Study of the relationship between social deprivation and outcome after stroke.
        Stroke. 2005; 36: 815-819
        • Peltonen M.
        • Rosén M.
        • Lundberg V.
        • Asplund K.
        Social patterning of myocardial infarction and stroke in Sweden: incidence and survival.
        Am J Epidemiol. 2000; 151: 283-292
        • Wong K.Y.K.
        • Wong S.Y.S.
        • Fraser H.W.
        • et al.
        Effect of social deprivation on mortality and the duration of hospital stay after a stroke.
        Cerebrovasc Dis. 2006; 22: 251-257
        • Ngeh J.
        • Hackshaw A.
        • Gupta S.
        The relationship between socioeconomic deprivation, atypical respiratory infections and survival outcomes in elderly stroke and medical patients.
        Cerebrovasc Dis. 2007; 24: 546-547
        • Macintyre S.
        • Ellaway A.
        Neighborhoods and health: an overview.
        in: Kawachi I. Berkman L.F. Neighborhoods and health. Oxford: University Press, 2003: 20-42