Educational level differences in the primary and secondary prevention of stroke

China bears the largest stroke burden of any country (Wu et al., 2019). According to the Global Burden of Disease statistics estimates, there were 3.94 million new cases of stroke in China in 2019, and the age-standardized prevalence of stroke increased by 13.2% from 1990 to 2019. (Ma et al., 2021) Although age-standardized morbidity and mortality rates decreased over the same period, the absolute numbers and crude rate of stroke burden still increased from 1990 to 2019. Effective prevention remains the best way of reducing the burden of stroke (Feigin et al., 2016; Pandian et al., 2018): primary prevention can greatly reduce the risk of stroke (Larsson et al., 2015), and secondary prevention can reduce the risk of recurrent stroke by up to 80% (Diener and Hankey, 2020). However, stroke is the second leading cause of death among 32 diseases and conditions (Lancet, 2018), and the burden of stroke are expected to increase steadily with population ageing in China (Feigin et al., 2015), Stroke prevention and control remain daunting tasks in China.

A person's health status has been suggested to be related to their education level. The knowledge, attitude, and practices model considers that knowledge is the basis for behavioural change, and only when people acquire knowledge and gradually form beliefs can they adopt positive attitudes and change their behaviors (Haron et al., 2020). Studies have revealed educational inequalities in the control of risk factors for cardiovascular disease, such as blood pressure (BP) (Ose et al., 2014), smoking (Veronesi et al., 2017), drinking (Oshio and Kan, 2019), and the body mass index (BMI) (Bruthans et al., 2016). For example, education is the most important factor in controlling BP and diabetes (Liu et al., 2011). However, educational level differences in the primary and secondary prevention of stroke have not been studied in China.

Herein, we estimated educational level differences in the primary and secondary prevention of stroke using data from the China Kadoorie Biobank (CKB) survey. The CKB survey was a nationally representative large prospective cohort study with a large sample size, geographic diversity, highly complete data collection, and stringent follow-up systems. Understanding educational differences in the primary and secondary prevention of stroke will be helpful in providing a reference for the improvement of stroke prevention strategies in China.

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