The Contribution of School Quality to Stroke and Cardiovascular Disease Risk in the U.S. Stroke Belt

Background Stroke and cardiovascular disease (CVD) are important risk factors for later life dementia. In the United States the geographical distribution of high stroke risk, known as the U.S. Stroke Belt, is an important contributor to race and SES-based gradients in not only CVD but dementia as well 1. In this study we examine the impact that schools have on stroke risk and CVD. We hypothesize that school characteristics will mitigate the effects of attending high school in a Stroke Belt state. Method: We use the High School and Beyond study, a longitudinal dataset of individuals who were in high school in 1980. The most recent wave of data collection occurred in 2020/2021. We perform competing risk regressions to predict the hazard of dying from stroke and CVD controlling for going to high school in a Stroke Belt state, background characteristics, school quality, and individual education characteristics. We also predict the odds that surviving respondents had coronary heart disease or a stroke by 2021. Missing information on an individual level was multiply imputed and survey weights were used in all analyses. Result High schools in the Stroke Belt had significantly lower average SES and students had lower achievement scores on average. Going to high school in a Stroke Belt state was associated with a higher hazard of early mortality due to cardio-and cerebrovascular causes. Stroke Belt origin was also associated with higher odds of stroke diagnosis in midlife. These associations were partially accounted for by variation in background characteristics, especially parental education. Measures of school academic press were associated with cardio-and cerebrovascular disease mortality and heart disease diagnosis, net of covariates. Conclusion The findings of this study indicate that going to high school in the Stroke Belt is associated with higher risks of CVD and stroke. School quality seems to additionally affect individual risk, not explain the Stroke Belt risk