(Stroke. 1997;28:1579-1584.)
© 1997 American Heart Association, Inc.
Articles |
Stroke Prevalence in Taiwan
Findings From the 1994 National Health Interview Survey
From the Department of Internal Medicine, College of Medicine and Institute of Public Health, College of Public Health (T.-L.C.), and National Taiwan University, Taiwan, Republic of China.
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Abstract |
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Background and Purpose Stroke has been the second leading cause of death for all ages in Taiwan since 1983. However, despite the severity of the threat, stroke prevalence in Taiwan has not yet been addressed in a nationwide survey. In this study, the stroke prevalence in Taiwan was investigated using data from the 1994 National Health Interview Survey.
Methods This nationwide survey sought to obtain a nationally representative sample of households in Taiwan by using three-stage stratified random sampling with a probability proportional to size. In the first stage, 58 townships were selected, from the 359 townships in Taiwan, according to their administrative structure and level of socioeconomic development. In the second stage, 149 basic administrative regions (tsun or li) were selected from the selected 58 townships. Finally, 3814 households were selected from the 149 selected tsuns or lis. Field interviews were carried out between October 1994 and December 1994. Follow-up interviews with families of stroke patients were made 2 years later.
Results Of the selected households 3119, or 81.8%, responded. A total of 11 925 persons were interviewed, and 71 of them were stroke patients, with a crude point prevalence rate of 5.95 per 1000. The stroke prevalence increased steadily with age, from 0.51 per 1000 in persons aged 35 to 44 years to 113.6 per 1000 in persons aged 85 years or over. There was a weak association with higher stroke prevalence for persons living in eastern Taiwan or those of lower educational level. The overall male/female prevalence ratio was 1.17. The results of follow-up interviews showed a cumulative mortality rate of 25.4% within the 2-year period and an ischemic/hemorrhagic stroke ratio of 1.33 in 35 patients whose stroke type could be validated.
Conclusions Age was the most important factor correlating to stroke prevalence. On the basis of this result, planning policies and programs for stroke prevention in Taiwan should give a higher priority to (1) aggressive primary prevention for aged people who are apparently at higher risk of stroke and (2) early reduction of stroke risk factors in younger aged people whose immediate risk of stroke is lower but would increase significantly with age.
Key Words: epidemiology • aging • stroke prevention • geography
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Introduction |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Stroke has been the second leading cause of death for persons of all ages and the leading killer for those aged 65 years or over in Taiwan since 1983.1 Although results from several epidemiological studies of stroke prevalence in Taiwan have been reported,2 3 4 5 none of them used data from a nationwide survey. Tseng's study in 1975 was conducted in a precinct of Taipei city.2 In Pan and Chen's study in 19823 and in that of Hu et al in 1986,4 the stroke prevalences were obtained from six and eight selected townships, respectively, that were representative of different regions of Taiwan. The study of Lee et al, conducted from 1990 through 1992, was a survey of four precincts selected from four major cities.5 Thus, nationally representative data on stroke prevalence in Taiwan, which is essential for planning health policies and prevention programs on stroke, are still lacking. This study investigated the nationwide stroke prevalence in Taiwan using data from the 1994 National Health Interview Survey (NHIS-1994).
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Materials and Methods |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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1994 National Health Interview Survey in Taiwan
The NHIS-1994 was conducted by the Institute of Public Health of National Taiwan University, under the sponsorship of the Department of Health, Executive Yuan, Republic of China. A more detailed account of this survey is presented elsewhere.6 Overall, the objective of the NHIS-1994 was to collect information about health conditions, health services utilization, and health habits of the noninstitutionalized population in Taiwan. The NHIS-1994 sought to obtain a nationally representative sample of households in Taiwan by using a three-stage stratified random sampling with a probability proportional to size. Townships were the primary sampling unit. In the first stage, all 359 townships in Taiwan were divided into 10 strata according to their administrative structure and level of socioeconomic development.7 On the basis of this stratification, 58 of these townships were selected as a representative cross section. The secondary sampling unit was tsun or li, which is the basic administrative region in a rural or urban township, respectively. In the second stage, 149 tsuns/lis from the selected townships were selected as a representative cross section. Finally, 3814 households, the final sampling unit, were selected from the 149 basic administrative regions. Field interviews were carried out by the Provincial Institute of Family Planning between October 1994 and December 1994. Of the 3814 selected households, 3119, or 81.8%, responded to the interview. All registered members of the selected households, whether regular residents or not, were interviewed. Newborns who had not been registered and all persons who had not registered but had resided in the household for more than 3 months were also included. A total of 11 925 persons were interviewed. Of these, 71 were stroke patients. The decision to enroll a stroke patient was made by a qualified public health nurse interviewer, based on a previous diagnosis of stroke that had been told to the families by a medical doctor. The basic demographic characteristics of the 11 925 subjects interviewed were very close to those of the total population in Taiwan except that in age composition the percentage for the age group of 15 to 24 years in interviewed subjects (14.7%) was slightly lower than that in the total population (17.8%).6 Most of the nonresponses were because of our failure to trace the selected families that had moved away and those family members who had registered but often stayed outside of home to work, to study, or for other reasons.
1996 Follow-up Interview
Follow-up telephone interviews with the families of the 71
stroke patients were conducted by the authors 2 years after the field
interviews. Household interviews were conducted by local public health
nurses when families could not be reached by telephone. The purposes of
the follow-up interview were (1) to ascertain the previous occurrence
of stroke and verify the type of stroke (ischemic or
hemorrhagic) and (2) to estimate the crude mortality rate during the
2-year period. Interview questions included (1) When did the stroke
occur? (2) Had the patient been admitted to a hospital at the time of
stroke onset? If yes, which hospital? (3) Was CT of the head performed
during that admission? If yes, what was the type of stroke according to
the attending doctor's interpretation of the CT? (4) How is the
patient now? Patients who had more than one stroke were requested to
give information regarding the latest stroke only. When the location of
the previous hospital admission could be obtained, available medical
records were checked to confirm the diagnosis of stroke and its
type. The individual identification numbers of patients who could not
be reached despite all efforts were checked at Registry Offices to find
out if any of them had died.
Statistical Methods
The stroke prevalence rate was estimated by age, sex,
educational status, geographic region, and level of urbanization of
residential area. The significance of the differences in prevalence
rate by educational status, geographic region, and level of
urbanization of residential area was analyzed by logistic
regression tests, with and without adjustment for age and sex. The
associations and significance of stroke and other major chronic
diseases were tested by odds ratio analysis.
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Results |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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A total of 11 925 persons (5962 men and 5963 women) completed the home interviews in the NHIS-1994. Seventy-one stroke patients were found with a crude point stroke prevalence of 5.95 per 1000. The stroke prevalence rates by age and sex are listed in Table 1
. The prevalence increased steadily with
age, from 0.51 per 1000 in persons aged 35 to 44 years to 113.6 per
1000 in persons aged 85 years or over. Men had a slightly higher
prevalence rate than women, with a male/female ratio of 1.17.
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The correlations of stroke with other major chronic diseases are listed
in Table 2. Significant associations were
found between stroke and hypertension, heart disease, and diabetes
mellitus (P<.001, P<.001, and P
<.05, respectively). There was no significant correlation between
stroke and chronic obstructive pulmonary disease or renal
disease.
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Table 3 shows the stroke prevalence by
educational status, geographic region, and level of urbanization of
residential area and their significance by logistic regression
analysis, with and without adjustment for age and sex.
Educational status was classified into three categories: "not
educated," "primary school," and "junior school or
above." The "not educated" group included those who had never
received formal education. Most of these people were old persons who
had little chance to receive formal education at childhood about 60
years or more ago when Taiwan was under Japanese rule. The "primary
school" group included those who had received a 6-year basic
educational course in a public primary school. Such an educational
course has been obligatory in Taiwan for more than 40 years. The
"junior school or above" group included those who had received
more formal education than those in the "primary school" group.
Residential areas were categorized into either city, urban township, or
rural township based on the following definitions: (1) City was defined
as a preexisting administrative unit with a population 
150 000; (2)
urban township was defined as a preexisting administrative unit with a
population <150 000 with high population density and high
socioeconomic status; (3) rural townships had a population <150 000
with low population density and low socioeconomic status.7
There was no significant difference in prevalence rate by level of
urbanization of residential area. Persons of lower educational level or
persons who were living in eastern Taiwan had a significantly higher
prevalence rate before age and sex adjustment. After adjustment for age
and sex, the differences became insignificant except for a borderline
significantly higher prevalence rate in eastern Taiwan
(P=.067).
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The results of 2-year follow-up interviews with the families of the 71 stroke patients in the survey population were as follows. (1) Two-year mortality rate: Of the 65 stroke patients whose families could be reached, 16 patients had died. For the other 6 patients whose families could not be reached, most often because of having moved away, we checked patients' individual identification numbers at Registry Offices and found that 2 had died. Results indicated a 2-year mortality rate of 25.4% (18/71 cases) in the 71 stroke patients in the population of the 1994 field survey. The crude monthly mortality rate was 1.06% (18 persons/71 persons/24 months), with a crude annual mortality rate of 12.7% (1.06%x12 months). Most of the stroke patients who had died were 70 years of age or older in 1994 (14 cases, 77.8% of all deaths). The mortality rates for those stroke patients less than 65 years of age, 65 to 69 years, and 70 years of age or older in 1994 were 9.09% (2/22 cases), 12.5% (2/16 cases), and 42.4% (14/33 cases), respectively. Many families of the deceased subjects did not want to talk about the cause of death or other details concerning the death of subjects. Therefore, we were unable to determine exactly when or why these patients died. (2) Ascertainment of previous stroke by family's interview: Ascertainment of previous stroke was based on a previous stroke diagnosis made by the attending doctor who cared for the patient in the acute stage of stroke. Among the 65 patients whose families we were able to reach, 2 families refused follow-up interviews because the patient had died. One patient was suspected to have suffered a stroke based on persistent bilateral limb weakness. Four other patients were told they had suffered minor strokes by attending doctors at outpatient clinics on the basis of neurological signs and symptoms. The families of these 4 patients were not sure of the stroke diagnosis because the patients' symptoms had improved and they were free from neurological sequelae after a period of treatment. The remaining 58 families confirmed a previous occurrence of stroke. (3) Validation of previous stroke and its type versus available medical records: Of the 65 families that we were able to reach, 2 families of the deceased patients refused to provide the names of hospitals where the patients had been admitted. Another 11 families could not remember the names of the hospitals or clinics where the stroke diagnoses were made, either because the patients had suffered the stroke quite a long time ago (mean duration, 8.0 years) and/or because they had never been admitted to a hospital and had received treatment only at outpatient clinics. Of the remaining 52 patients whose admitting hospitals could be determined, previous medical records of 12 patients had been deleted or were not available because the stroke had occurred many years ago (mean duration, 7.2 years) and follow-up had not been performed for more than 2 years. As a result, the occurrence of stroke could be confirmed by medical records in only 40 of 71 patients (56.3%). When 5 patients whose current medical records showed a diagnosis of stroke but did not specify its type were excluded, the stroke type could be validated, based on previous head CT reports, in only 35 of 71 patients (49.3%). Among these patients, 20 had ischemic stroke and 15 had hemorrhagic stroke, with an ischemic/hemorrhagic ratio of 1.33.
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Discussion |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Because the NHIS-1994 surveyed only the noninstitutionalized population, and a certain percentage of stroke survivors reside in either nursing homes or other chronic nursing facilities, the crude point stroke prevalence of 5.95 per 1000 in the study is probably underestimated. However, The impact of this factor may be unremarkable in Taiwan. It was reported that in 1992 most disabled elderly in Taiwan (92.5%) were cared for at home by families or a caregiver.8 Only 3.0% of these people resided in chronic nursing institutions, and another 4.5% was cared for in hospitals. When our analysis hypothetically considered these figures, the actual point stroke prevalence approached 5.95/0.925 or 6.43 per 1000.
Older people are known to have a higher stroke prevalence rate than
younger adults,9 10 11 12 13 probably simply because they have more
frequent and prominent cerebral
atherosclerosis.14 15 In the present
study, a steady increase of stroke prevalence rate with age, up to 85
years of age and older, was found. Table 4 shows a comparison of age- and
sex-specific prevalence rates from this study and four previous studies
in Taiwan.2 3 4 5 These studies differed significantly in
study area, target population, and case-sampling method (Table 5). Thus, their findings might reflect
different situations, have different meanings, and not be comparable.
However, taken together, these data give a good overview of the real
stroke prevalence in Taiwan. Comparison of these Taiwan-based studies
(Table 4) revealed several interesting points: (1) For all ages, the
crude point prevalence rate in the present study in 1994 (5.95 per
1000) was much greater compared with that of Tseng's 1975
study2 (3.87 per 1000). However, when the data from large
cities were taken into account (Table 3
) in the present study, the
prevalence rate was 4.61 per 1000. This prevalence rate is only
slightly higher than the 3.87 per 1000 of Tseng's study,2
which was conducted in a precinct of Taipei city, the capital of the
Republic of China. (2) The prevalence rate for the population aged 65
years or over in the present study (50.8 per 1000) was close to
that of Tseng's study2 (57.1 per 1000) and also to that
of the study of Lee et al5 (59.6 per 1000). (3) The steady
increase in prevalence rate from persons 35 to 44 years of age up to
those 85 years of age or older in the present study differed from
the results of the study of Hu et al4 in 1986, which
showed less of an increase in the prevalence rate between the ages of
55 and 84 years and a slight fall after age 85 years. Our result was
also different from that of a 1986 study in the Kuthar Valley of
Kashmir, India, which showed a peak stroke prevalence rate from age 50
to 59 years13 but was consistent with the results
of the study of Lee et al in large cities from 1990 to 1992 and several
studies in more developed countries, including the United States,
Denmark, Finland, and Japan.9 10 11 12 The reason for the slight
fall in stroke prevalence rate among the advanced elderly in less
developed areas, such as India and Taiwan in 1986, is unclear. A
possible explanation may be that in less developed areas, old people,
who often have complex health problems, bear a higher case fatality
rate from stroke because of the lack of available modern medical
facilities and intensive medical care. The resultant lower number of
stroke survivors might be responsible for the lower stroke prevalence
rate in the more advanced ages.
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In the present study, the overall male/female prevalence ratio (1.2 for all ages, 1.3 for those aged 65 years or older, and 1.2 for those aged 35 years or older) was lower than those of other studies (1.7 for all ages, 1.7 for those aged 65 years or older in Tseng's study,2 1.4 for those aged 65 years or older in that of Lee et al,5 and 1.7 for those aged 36 years or older in that of Hu et al4 ). The reason for the lower male/female prevalence ratio in the present study is not known.
There have been only a few previous reports of an association between
lower educational level and higher stroke prevalence.16 In
the present study, this association was present but weak. It
was significant by crude logistic regression analysis but
became insignificant after adjustment for age and sex (Table 3). Since
sex did not significantly affect stroke prevalence in this study, this
association appears to be mainly caused by a difference in age
composition among populations of different educational levels. However,
excluding the factor of age, an inverse correlation between educational
level and stroke prevalence might really exist. Several studies have
provided indirect evidence to support this viewpoint, including a
higher incidence of carotid atherosclerosis in persons
of lower educational level17 18 and a higher stroke
mortality in less-educated populations.19 20 21 One
explanation may be that less-educated people are probably less aware of
the importance of disease prevention.22 Another reason may
be that lifestyle is very likely different in persons of different
educational levels,22 23 24 which may affect the rate of
disease occurrence.24 Thus, persons with lower educational
levels may have more at-risk health habits and
behaviors25 26 and thus be more prone to stroke. It is
interesting that Wong and Donnan also found such an inverse
correlation, although not statistically significant, between
educational level and stroke mortality rate in the Hong Kong
population, but at the same time found a significant positive
correlation between educational level and mortality rate from
ischemic heart disease.27 Their results imply that
educational status has different impacts on different kinds of diseases
and that different mechanisms and pathophysiologies are involved in the
development of stroke and ischemic heart disease. These
differences are very likely inherent in lifestyle characteristics,
which might be greatly affected by educational
level.23 24
Eastern Taiwan contains only two large rural counties and is less developed than other regions of Taiwan. The reason for the higher stroke prevalence in this region is difficult to determine. If only the factor of medical service availability is considered, stroke prevalence in less-developed regions should be higher since the lack of availability of medical care28 for treatable stroke risk factors should result in a higher stroke incidence. On the other hand, the lower availability of emergent and general medical care for stroke patients in less-developed regions might result in a higher case fatality rate in both acute and chronic stroke patients. This higher case fatality rate would reduce the number of stroke survivors and result in a lower prevalence rate. Under these assumptions, the geographic pattern of stroke incidence and mortality might be affected by changes in type and quality of locally available medical care,29 and the stroke prevalence in less-developed regions might increase obviously soon after the development of improved medical care systems, especially when these systems provide local emergent care for stroke patients. Therefore, we speculate that the high stroke prevalence rate in eastern Taiwan in 1994 may have been due in part to a rapid expansion of local medical services in this region. For example, Tzu-Chi Hospital, a large and modern facility, opened in 1986 and has greatly improved emergent and general medical care services for stroke patients in its service area.
According to Chang and Chen's study,30 the decline of
mortality rate from hemorrhagic stroke after 1974 in Taiwan was
persistently greater than that of ischemic stroke. This was
probably because of the effect of the intensive hypertension control
programs that have been conducted in Taiwan since the mid-1970s.
Therefore, in theory, the ischemic/hemorrhagic stroke incidence
ratio, and thus the prevalence ratio, should have increased gradually
after 1974, assuming that the difference in case fatality rates between
ischemic and hemorrhagic stroke did not change much during that
period. In the present study, of the 35 patients whose stroke type
could be confirmed by previous head CT reports, the
ischemic/hemorrhagic stroke prevalence ratios were 1.33 (20/15
cases) for all ages, 1.33 (20/15 cases) for those aged 35 years or
older, and 1.71 (12/7 cases) for those aged 65 years or older. The
latter two values were much lower than the 3.67 reported by Hu et
al4 for those aged 36 years or older in 1986 and
the 5.50 reported by Lee et al5 for those aged
65 years or older from 1990 to 1992, respectively. Such a
decrease in the ischemic/hemorrhagic prevalence ratio with time
is in conflict with the results of Chang and Chen's
study.30 One possible explanation is the methodological
differences between studies (Table 5). Another possible reason may be
the small sample size used in this study.
In conclusion, the NHIS-1994 revealed a crude stroke point prevalence of 5.95 per 1000 for all ages in Taiwan. Older age was the most important factor associated with higher stroke prevalence. Living in eastern Taiwan or having a lower educational level was weakly associated with a higher prevalence rate. These results suggest that planning policies and programs for stroke prevention in Taiwan should give higher priority to (1) aggressive primary prevention for aged persons who are apparently at higher risk of stroke occurrence and (2) early alteration and reduction of stroke risk factors in younger aged persons whose immediate risk of stroke is lower but would increase significantly with age. Intensive health education should be considered a major means of achieving these goals.
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Acknowledgments |
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This study was supported by a research grant from the Department of Health, Executive Yuan, Republic of China. We want to thank Liu Jung-Hua for her kind assistance in statistical analysis.
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Footnotes |
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Reprint requests to Z.S. Huang, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Rd, Taipei, Taiwan, ROC.
Received December 11, 1996; revision received May 19, 1997; accepted May 19, 1997.
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