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Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 179-183

Factors associated with stroke mortality in India

Department of Pediatrics, Safdarjung Hospital, New Delhi, India

Date of Submission10-Mar-2020
Date of Decision24-Mar-2020
Date of Acceptance26-Mar-2020
Date of Web Publication10-Jul-2020

Correspondence Address:
Dr. Manas Pratim Roy
Department of Pediatrics, Safdarjung Hospital, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_28_20

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Objectives: Stroke is one of the major causes of death and disability in India, as evident from the Global Burden of Disease Study, causing 7.3% deaths. An effort was made to correlate stroke mortality with tobacco use, alcohol use, use of clean fuel, and economic condition. Study Design: This was an ecological study. Methods: Data were taken from nationally representative reports – National Family Health Survey 4, Global Adult Tobacco Survey 2: India 2016–2017, and India: Health of the Nation's States. Spearman correlation coefficient, scatter plot, and multivariate linear regression were used for state-wise analysis. Results: Clean fuel and smokeless tobacco (SLT) were significantly associated with mortality due to stroke (r = –0.423 and 0.445, respectively). Delhi, Goa, and Tamil Nadu, states with the highest proportion of population using clean fuel, recorded less deaths due to stroke, in comparison to rest of the country. On multivariate regression, use of SLT and secondhand smoking at work were found as independent predictors for stroke mortality. Conclusion: For preventing deaths from stroke, wide use of clean fuel should be encouraged and work place should be kept free from smoking.

Keywords: India, indoor air pollution, stroke mortality, tobacco

How to cite this article:
Roy MP. Factors associated with stroke mortality in India. Curr Med Issues 2020;18:179-83

How to cite this URL:
Roy MP. Factors associated with stroke mortality in India. Curr Med Issues [serial online] 2020 [cited 2022 Aug 9];18:179-83. Available from: https://www.cmijournal.org/text.asp?2020/18/3/179/289414

  Introduction Top

Stroke, a major noncommunicable disease (NCD), is responsible for 6.17 million deaths worldwide in 2017 and emerges as a threat to public health. Globally, it is responsible for 11% deaths.[1],[2] In India, it stands as the third individual cause of death, with 7.3% deaths and a mortality rate of 53/100,000 population. Stroke also claims the fifth-most common cause of disability-adjusted life-years (DALYs) in India, with 3.67% share in 2017. Gradual changes in demography, economy, and lifestyle have propelled the disease from the 12th place in 1990 to the 5th in 2016, in terms of DALY.[2],[3]

National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke, launched in 2010, has been India's response to the uphill challenge posed by the NCDs. Under the program, there are provisions for health promotion, treatment, referral, and screening for the early diagnosis. NCD clinics are operational at district and Community Health Centre levels across the country to take care of all common NCDs including stroke. Acute cases are being managed at Cardiac Care Centre at district level.[4]

For primary prevention of stroke, the modifiable risk factors include tobacco use, heavy alcohol consumption, lack of exercise, hypertension, diabetes, diet, and blood cholesterol.[5],[6] Air pollution has also been implicated in the recent rise in the incidence of stroke.[7],[8] Among social factors, poverty has long been correlated with stroke.[9] All these factors lead to stroke and contribute to subsequent mortality. However, there is a lack of nationally representative study in the country for certain risk factors such as tobacco use and indoor air pollution.

In this perspective, the present paper aims to analyze the association of tobacco use, alcohol use, use of clean fuel, and economic condition with stroke mortality in a state-wise comparison.

  Methods Top

This was an ecological study. State-wise data were retrieved from National Family Health Survey (2015–2016) (NFHS 4) and India: Health of the Nation's States, a report by ICMR and partners.[3],[10] State/union territories (UT) was the unit for the analysis. A total of 29 states and 1 UT were considered for the article. Data on alcohol use for male and female were separately captured in NFHS 4 from the age group 15–49 years. Electricity, LPG/natural gas, and biogas were considered as clean fuels. Death rates for different states were taken from India: Health of the Nation's States. The report was prepared after consulting census, Sample Registration Survey, vital registration, national surveys, and other studies including systematic reviews. Per capita Net State Domestic Product was considered as a parameter for economic condition and expressed in INR (Indian currency). Data on this parameter for 2015–2016 were taken from Ministry of Statistics and Programme Implementation, India.[11] Data on smokeless tobacco (SLT) use, smoking, and secondhand smoking (SHS) were taken from the Global Adult Tobacco Survey 2 report where people aged 15 years or older were considered. SLT is available courtesy products like betel quid with tobacco, khaini, gutka, and pan masala with tobacco; these are all consumed by chewing. Other SLT products, such as mishri, gul, bajjar, and gudakhu, are applied to teeth and gums, while snuff is inhaled.

Informed written consent was not obtained because the study was a retrospective analysis of anonymous data. The correlation was tested between the death rate of stroke and other variables. Spearman correlation coefficient and scatter plot were used. Multivariate regression was used for finding the predictors for stroke mortality. P <0.05 was taken as statistically significant. PASW for Windows software (version 19.0; SPSS Inc., Chicago, Il, USA) was used.

The study complied with the Declaration of Helsinki (1964) and approval from the Ethical Committee was not sought as the study deals with anonymous database.

  Results Top

Certain states like West Bengal, Odisha, Tripura, Assam, and Chhattisgarh recorded higher death rate than rest of the country. Northeast states recorded highest tobacco use rates, both among males and females. Mizoram, with 80.4% males and 59.2% females using tobacco, causes a great concern over the prevention of not only stroke but also NCDs. Delhi, Goa, and Tamil Nadu put other states behind, in terms of use of clean fuel. Economic disparity was great among states, as evident by Goa scoring ten times than Bihar, in terms of per capita NSDP.

The use of SLT was significantly related to stroke mortality (r = 0.445, P = 0.014), but no relationship could be found between stroke and smoking. SHS at home and work was not statistically related to stroke deaths.

Alcohol use in males and females was weakly related to stroke mortality (r = 0.109 and 0.027, respectively). However, the use of clean fuel was moderately associated with mortality rate due to stroke and the relation was statistically significant (r = –0.423, P = 0.020) [Figure 1]. Economic condition was also negatively associated with stroke mortality (r = –0.342, P = 0.064) [Figure 2].
Figure 1: Use of clean fuel and stroke mortality in India.

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Figure 2: Per capita National State Domestic Product and stroke mortality in India.

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On multivariate regression, the use of SLT (B = 1.277, P = 0.011) and SHS at work (B = 1.060, P = 0.040) showed statistically significance [Table 1].
Table 1: Multivariate analysis for stroke mortality in India

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  Discussion Top

In the present article, data from different sources were considered together on stroke mortality and associated demographic factors. While the nature of data collection differs from one to another, the quality may also vary. Still, considering the fact that no effort has been made earlier to analyze nationally representative data in this regard, the article stands unique.

The national death rate from stroke was 53/100,000 population in 2016. Interestingly, most of the states with high death rates were situated in the Eastern part of India. While it is fact that being neighbors, the states share certain characteristics such as diet, culture, weather, economic status; it is beyond the scope of the present article to find any single cause for high death rate from stroke, a feature that differentiate the Eastern part from the rest of the country.

States with the highest prevalence of tobacco use among males (Mizoram and Meghalaya) did not record high death rate due to stroke. In fact, Mizoram recorded lowest cause-specific death rate, suggesting role of other factors in determining fatality. For females, however, two states, namely Tripura and Manipur, share a high prevalence of tobacco use and high death rate due to stroke. Gender-wise death rate would have presented a clearer picture in this regard. Current smoking has earlier been associated with 2.5 times higher mortality from stroke.[12] In comparison to never smokers, the risk is higher for both male and female.[13] It may be noted that the prevalence of tobacco use in India (44%) is more than smoking prevalence in the US (15%) in males.[14] Although the trend is decreasing, it still remains as a matter of concern.

The effect of SLT on stroke has been established earlier.[15],[16] The present article finds its result on the same track. Although tobacco concentration varies among different products, such studies differentiating the role of different products in precipitating stroke are not very common. Easy availability, less cost, and less regulation due to household production are some reasons for a wide popularity of SLT in the country. A meta-analysis found SLT causing more frequent strokes in Southeast Asia.[17] There is a need of further exploration for developing better understanding about the role of SLT in precipitating stroke mortality.

SHS exposure is another known risk factor for stroke.[18] The risk of developing stroke may be less when this exposure is minimum, but what happens at higher frequency is a matter for further research.[19] Basically, a preventable risk factor, SHS, has been an important part of the WHO Framework Convention on Tobacco Control.[20] In general, countries with higher prevalence of smoking among males puts females as common victim of SHS.[21] One study claimed dose–response relationship between stroke and SHS.[22] In India, the Cigarette and Other Tobacco Products Act, 2003, regulates sell of all types of tobacco and penalizes smoking at public places. With poor compliance to the act reported in the literature, the role of awareness in strengthening the fight against tobacco is probably pivotal.[23]

States with higher use of alcohol (Arunachal Pradesh, Telengana, and Sikkim) except Chhattisgarh do not have high mortality due to stroke. The present article could not find a convincing relation between this two. Still, there are other studies to validate the claimed relation.[24],[25] In fact, one meta-analysis suggested that light-to-moderate alcohol consumption reduces the risk for ischemic stroke, but heavy drinking increases the risk for all types of stroke. Considering the controversial role of alcohol in stroke and ischemic heart disease, there should be adequate deliberation and brain storming before large-scale implementation.[25] Some states like Bihar have already prohibited the use of alcohol. Other states with higher consumption (like Arunachal Pradesh) need to address the issue with focus on future benefits, in terms of stroke mortality.

The use of clean fuel has long been underestimated contributor for the causation of NCDs, including stroke. The present study, however, found a significant association between stroke death and clean fuel. One study from the US has underscored the role of air pollution in stroke mortality.[26] It may be noted the states providing clean fuel to its population in the highest proportion (Delhi, Goa, and Tamil Nadu) recorded less deaths due to stroke. In fact, it could well be considered as a part of primary prevention of stroke mortality. The government is encouraging Ujjwala scheme to provide clean fuel to the poor population. In the long run, it may prove successful in reducing the occurrence of stroke and subsequent deaths. With few states in the Eastern part of the country (Bihar, Jharkhand, and Odisha) still being able to reach <20% of population with clean fuel, it remains as a future task for reducing mortality from stroke.

Economic condition is another factor determining death in NCDs. The cost of the acute care in pertaining to interventions like computed tomography scan, intensive care and thrombolysis, transport, need of physiotherapy, and longterm nature of the treatment contribute to higher out-of-pocket expenditure in stroke patients and subsequent mortality. It may be mentioned that the cost of recombinant tissue plasminogen activator, the drug required for thrombolysis in stroke, is Rs. 75,000/-(USD 1562).[9] In the present article, economically affluent states like Delhi and Sikkim recorded much less fatality than the national average. The weaker nature of the Eastern states, in terms of economic condition, may be an important factor depriving the patients, the costly initial care indicated in stroke. The fact that economic condition decides the utilization of golden hour for stroke could be substantiated by a previous study finding that 49% of patients used their own car for reaching hospital, while only 12% of patients availed ambulance.[27] It is evident that economy plays a decisive role in making the latest medical innovations to the common people. Accessibility of emergency transport by ambulances during golden hours and availability of costly drugs at the emergency department may prove beneficial in reducing deaths due to this fatal disease. Few states are implementing “hub and spoke model” to reduce the time gap between the attack of stroke and initial intervention.[28] Such effort would go a long way in ensuring high-end intervention at the peripheral areas.

On the other hand, for long, NCDs were considered as diseases affecting mainly rich ones.[29] With a clear role of nutrition in precipitating NCDs, poor population has also been identified as common victim of chronic diseases.[30] Prospective studies should explore the relation between poverty, diet, and stroke mortality in future.

Ecological nature and use of secondary data from different sources are the setbacks the present study suffers from. Lack of quantifying alcohol intake or tobacco use is another deficiency. The focus was on mortality, not on the occurrence of stroke. It might happen that the pattern of stroke incidence is different from its mortality across the country. There is a possibility of underreporting on alcohol consumption by females. The result could be different if any other parameters on socio-demographic condition were taken into account. Still, a paucity of large-scale data and national comparison makes the present article different from all previous researches on this topic. It is a matter of concern that the contribution of stroke in DALY in the country has changed from 2% in 1990 to 3.5% in 2016, whereas the US has documented a reduction in stroke in the past few decades.[3],[31] As several factors are responsible for precipitating the mortality in stroke, a prospective study may bring better clarifications of all probable associations found in the present study. In addition, for a country like India where the number of skilled neurologists is heavily outnumbered by the huge patient burden, this study rightly brings down focus on prevention level, which is rather not very common in stroke related literature on the Indian population.

  Conclusion Top

To summarize, the use of clean fuel emerges as a vital population-based strategy in reducing stroke mortality when compared to tobacco use or economy. With few states still performing poorly in providing clean fuel to the larger part of their population, focus should be needed in building momentum for wider distribution of clean fuel and securing continuous use by the community, as a strategy for reducing stroke mortality.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1]

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