A Prospective Comparative Study of Health Inequalities and the Epidemiology of Stroke in French Guiana and Dijon, France

Abstract

BackgroundIn French Guiana poverty is widespread and specialized care is lacking. We aimed to compare strokes between precarious and non-precarious patients within French Guiana and to compare the epidemiology of ischemic strokes and their outcomes between French Guiana and mainland France.MethodsA multicenter prospective cohort examined the influence of social inequalities on stroke characteristics. Consecutive patients aged > 18 years admitted for an acute ischemic stroke, confirmed by neuroimaging were eligible. Exclusion criteria were a history of symptomatic stroke, presence of other short-term life-threatening diseases and inability to contact patients by telephone during follow-up. Social deprivation was measured using the EPICES score, which is based on a multidimensional questionnaire.ResultsOverall, 652 patients with ischemic stroke were included. The patients in French Guiana were 7 years younger, were more frequently male, of sub-Saharan ancestry, they had a low level of education, and were more often precarious (67.7%) than the patients included in Dijon (39.2%). The origin of the ischemic stroke was predominantly lacunar for patients included in French Guiana and cardioembolic for patients included in Dijon, with greater severity for patients included in Dijon. The proportion of patients with known pre-stroke hypertension, diabetes, or a history of Transient Ischemic Accident was greater in French Guiana than in Dijon. In contrast, hypercholesterolemia, atrial fibrillation, and history of Myocardial Infarction were more frequently found in patients included in Dijon than in patients included in French Guiana. Fibrinolysis was less frequent in French Guiana than in Dijon, 24% of patients arriving early enough receiving thrombolysis in French Guiana vs. 45% in Dijon, P < 0.0001. However, after adjustment for patient characteristics, the effect of the center on the use of fibrinolysis disappeared. When comparing precarious and non-precarious patients within French Guiana, the main difference was the younger age and the lower mortality of precarious patients—notably immigrants.ConclusionPrecariousness was widespread in French Guiana. Within French Guiana, despite a younger age among foreigners than French patients, the risk factors, mechanisms, and outcomes were homogenous across socioeconomic strata. The observed differences between the two contrasted French territories suggested that, beyond health inequalities, the epidemiology of cardiovascular risk factors may differ between French Guiana and mainland France.

The Epidemiologic Transition in French Guiana: Secular Trends and Setbacks, and Comparisons with Continental France and South American Countries

“…In French Guiana, over half of the population lives under the poverty level. It is well known that, for infectious or non-communicable diseases, the most deprived patients consult later, with more severe presentations at a younger age [4,[25][26][27]. For breast cancer survival, for instance, we have shown that crude survival was lower than in mainland France but that, when only considering French-Guiana-born women, there was no longer any difference with mainland France.…”

Contrasted life trajectories: reconstituting the main population exposomes in French Guiana

“…Despite the youthfulness of the population in French Guiana (median age 23 years), arterial hypertension is a major problem, notably among women ( 73 ). Thus, hypertension constitutes the major risk factor associated with strokes, myocardial infarction, and end-stage renal disease ( 65 , 74 , 75 ). Lipid abnormalities are common, but a recent study of Lpa among people with diabetes showed that Lipoprotein (a) (Lp(a)) concentrations, in contrast with mainland France, did not have the same prognostic value, suggesting that lipoprotein polymorphisms make it difficult to compare their prognostic values between populations with different ancestries ( 76 ).…”

Complex Sex Differences in Life Expectancy in French Guiana

“…The proportion of obese (body mass index > 30 kg/m 2 ) was greater among French Guianese women (23%) than in women in mainland France (12%) and French Guianese men (13% versus 12% in mainland France) [ 18 ]. Being overweight/obese in French Guiana was significantly associated with precariousness, being an immigrant, and having a mismatch between body image and obesity [ 14 ]. Although in French Guiana, women consulted more frequently than males in the past year (85% versus 71%), they were also significantly more likely to have renounced care for both financial reasons and lack of time [ 11 ].…”

“…However, for prolonged diseases, such as diabetes or HIV, once persons are in care, the universal health system in French Guiana actually levels prognoses and erases the differences that are observed before patients are taken care of by the system [ 13 ]. We hypothesized that, in the complex context of French Guiana, different vulnerabilities and different risk factors between genders [ 14 ] may lead to complex differences in health outcomes, mortality, and life expectancy. Our aim was, thus, to compare male and female mortality and life expectancy, to compare it between French Guiana and mainland France, and to look at temporal trends and the main specific causes of death in order to identify actionable singularities.…”