Research Income inequalities and stroke mortality trends in Sao Paulo, Brazil, 1996–2011 Tiótrefis G. Fernandes1, Daniel H. Bando2, Airlane P. Alencar3, Isabela M. Benseñor4, and Paulo A. Lotufo4* Background It is not clear the relationship between stroke mortality trends and socioeconomic inequalities in low- and middle-income countries. Aims We compared differences of trends in stroke mortality by socioeconomic status in the city of Sao Paulo, Brazil. Methods We analyzed the intra-urban distribution of stroke death rates from 1996 to 2011 for persons aged 35–74 years old according to income using joinpoint regression. Results We confirmed 77 848 stroke deaths in the period, 51·4% of them among persons aged 35–74 years old. For all areas, there was parallelism between genders, and the average annual percent changes combined was −5·2 (−5·7 to −4·6) from 1996 to 2005 and −3·0 (−4·3 to −1·7) from 2005 to 2011. The full period average annual percent changes of ageadjusted rates between persons living in the high- and lowincome area were, respectively, −5·4 and −4·2 (P = 0·002) for men and −5·9 vs. −4·9 (P = 0·017) for women. Differences in the risk of stroke between the high- and low-income areas increased more than twofold in the period in both genders. Conclusions The risk of stroke death is decreasing in all regions, but the faster decline in mortality rates in the wealthiest area contributes to further greater inequalities. Key words: Brazil, social inequalities, stroke, trends mortality

Introduction Cerebrovascular diseases are one of the most important causes of death worldwide (1). Epidemiological studies report a higher risk of stroke death among people from lower socioeconomic status (SES) compared with high-income groups in Europe, the United States, and Australia (2–4). The Global Burden of Disease 2010 showed that stroke mortality rates decreased significantly in both high- and low- and middle-income countries with lower reduction in the poorest countries (1). However, few studies have analyzed the relationship between stroke mortality trends and SES in low- and middle-income regions. Brazil has one of the Correspondence: Paulo A. Lotufo*, Centre for Clinical and Epidemiological Research, Hospital Universitario USP, Av. Lineu Prestes 2565, 3° andar, São Paulo, 05508-000, Brazil. E-mail: [email protected] 1 Federal University Amazonas, Manaus, Amazonas, Brazil 2 Federal University of Alfenas, Minas Gerais, Brazil 3 Mathematics and Statistics Institute of University of São Paulo (USP), São Paulo, Brazil 4 Hospital Universitario (USP), São Paulo, Brazil Received: 30 October 2014; Accepted: 25 February 2015; Published online 4 June 2015 Conflict of interest: None declared. Funding: Conselho Nacional de Pesquisa, Brasilia, Brazil. Author’s contributions: TGF, DHB, APA, IMB, and PAL participated in the design of study, performed statistical analyses, wrote the first draft, and approved the final version of manuscript. DOI: 10.1111/ijs.12526

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highest stroke rates in America (1), and people living in the poorest places have a twofold chance of stroke death compared with affluent people (5). Although mortality rates for stroke are declining in Brazil (6), there are no information about the pace of decline according to SES as described for heart disease (7). We aimed to compare differences of stroke mortality trends from 1996 to 2011 in Sao Paulo, Brazil, according to household income.

Methods São Paulo is organized into 96 districts, classified into three areas according to the proportion of households with a family income ≤ five minimum wages (2000, Brazilian National Census). The poorest areas have a higher proportion of young, nonCaucasian, less educated inhabitants, with more premature deaths compared with the wealthiest areas (7). In São Paulo, mortality data are centralized at the Health Statistics Department, which monitors the good quality of information (