Structural racism and racial disparities in stroke mortality in the United States, 2021

Objectives: To understand place-based drivers of racial disparities in stroke mortality in the United States by investigating the relationship between county-level measures of structural racism and racial disparities in stroke mortality. Methods: We constructed an additive structural racism score from census-based indicators of racial disproportionality (income, poverty, unemployment, home ownership, education, health insurance) and residential segregation (evenness, isolation), as well as county-level jail incarceration data from the Vera Institute of Justice. We utilized age-standardized, spatially smoothed stroke death rates in 2021 for Black and White adults aged 35-64 years in the United States. We fit linear regression models, both unadjusted and adjusted for overall county-level conditions, and assessed interaction between structural racism and gender. Results: Among 935 included counties, median structural racism score was 13.29 (range: 2.83-32.43). In unadjusted models, a 1-unit increase in structural racism was associated with 0.37 (95% CI 0.26, 0.46) additional stroke deaths per 100,000 Black residents compared to White residents of a county. Adjusted results were similar. This association was stronger among men (0.67 [95% CI 0.50, 0.83]) than women (0.35 [95% CI 0.19, 0.51]) (P = 0.003). Conclusions: Structural racism may drive racial disparities in stroke mortality, particularly among men.