Subjective Social Status and Outcomes After Stroke: A Prospective Cohort Study
Abstract
Background: Subjective social status (SSS) represents self-perceived social position and may affect post-stroke recovery. Despite impacting various medical outcomes, SSS remains understudied in stroke. We hypothesized that higher SSS is associated with better stroke recovery at 3-month and 12-month post-stroke. Methods: In this prospective cohort study, patients were enrolled between October 2016 and February 2020. We examined associations between 3-month SSS score and clinician-reported (ClinROs), performance (PerfOs), and patient-reported outcomes (PROs) at 3- and 12-month assessments. Ordinal multivariable regression analysis evaluated 3-month SSS score as a predictor of 12-month mRS score. Results: The 494 participants had median age=63.5, 200 (41%) female, and median [IQR] acute NIHSS=4 [2-8]. Scores on SSS showed no meaningful associations with PerfOs and some associations with ClinROs (e.g., 3-month mRS: ρ=−0.12, 95% CI [−0.21, −0.03], False Discovery Rate (FDR)-adjusted p=0.017; 12-month mRS: ρ12mo=−0.18, 95% CI [−0.27, −0.09], FDR-adjusted p=0.001). Conversely, higher SSS showed strong consistent correlations with PROs, including less psychological distress and higher Stroke Impact Scale-Activities of Daily Living (SIS-ADL) (ρ3mo=0.18, 95% CI: [0.09, 0.26]; ρ12mo=0.17, 95% CI: [0.07, 0.26]; all FDR-adjusted p<0.05). Item-level analyses of SIS-ADL revealed SSS remained most strongly and consistently linked to complex SIS-ADL motor tasks over time. In ordinal multivariable regression adjusted for age, sex, stroke subtype, initial severity, and the selected objective SES proxies (e.g., educational attainment, employment, and marital status), 3-month SSS score significantly predicted 12-month mRS score (β=0.14, 95% CI [0.02, 0.26]; p=0.014). Conclusions: In patients with predominantly mild stroke, 3-month SSS score may serve as a significant social determinant of health that is associated with long-term functional recovery, a relationship closely linked with psychological distress. SSS scores at 3-month post-stroke may identify vulnerable patients, enabling development, validation, and targeted application of interventions that optimize stroke recovery.