**3.4 Gender effect in the risk of stroke in individuals with unfavourable levels of PSF**

The risk of stroke was higher among men with HAL, HR = 4.43 (95% CI:2.8– 6.9), rather than among women, HR = 3.5. In the multivariate model, the risk of stroke was lower for men than for women. Adverse changes in marital status (divorce or death of a spouse), as well as age over 54 years, were associated with an increase in the risk of stroke (3.8–5.8 times higher) in men, but not women.

Stroke is the fourth leading cause of death in the female population [32]. Recent studies indicate an independent influence of anxiety in stroke risk [33, 34]. This confirms the results obtained earlier [35]. The overall risk of stroke according to the meta-analysis, which included 950 thousand participants, was 1.24. It is reported that individuals with more severe anxiety may have a higher risk [36]. In multivariate models, a higher risk of stroke was observed among men, people with low education attainment, and those living out of wedlock [32], as well as in our study. Our study confirms the need to consider the social gradient in terms of the effect of PSF on the risk of CVD in the general population.

Depression increased the risk of stroke more strongly in men (by 5.8 times) than in women (HR = 4.6). However, including social and demographic variables in the model increased the risk of stroke in women 8.5 times. At the same time, the combination of age over 54 years with depression increased the risk of stroke (6.9 times in women, and 3.1 times in men). Depression in widowed men with primary education increased the risk more than 8 times. A tendency toward increased risk was observed in men with D in low-skilled jobs.

A meta-analysis of more than 17 cohort studies found a 1.34-fold increase in the risk of stroke among people with depression [37], which again confirms our results [30]. In this analysis, the differences in risk among men and women were not so significant (HR = 1.49 and 1.35), which may be explained by a shift in the evaluation due to differences between studies, since some studies were performed among the male population [38]. Yet individual studies show a significantly higher risk of stroke in women than in men [39]. In addition, the influence of age is also significant, increasing the effect of depression in the group of people under 65 years (**Figure 3**) [39].

Vital exhaustion increased the risk of stroke equally in men and women in both the simple and multivariate models, although the inclusion of social and demographic characteristics reduced the risk value; it remained high: 2.6 times higher in men and 2.53 times higher in women in the multivariate model. The age of 55– 64 years was significant in the development of stroke, increasing the risk in men 2.4 times, in women 2.9 times. Marital status and educational attainment were associated with stroke risk only in men, but not in women. Being divorced and having an *Sex Differences in Long-Term Trends of Psychosocial Factors and Gender Effect on Risk… DOI: http://dx.doi.org/10.5772/intechopen.99767*

#### **Figure 3.**

*Gender differences in risk of stroke incidence in a cohort aged 25–64 years with anxiety traits, depression, vital exhaustion, hostility and low social support. Abbreviations: CI- confidence interval; ICC – Index of close contacts; SNI – Social network index.*

elementary level of education increased the risk of stroke in the cohort of men by 3.8–4.8 times. The tendency toward risk is also observed among widows.

Gender differences in stroke risk were also studied in the Copenhagen City Heart Study. The researchers found that women with high levels of VE had a 2.27 fold risk of stroke, which was slightly reduced in a multivariate analysis. Yet no association was found with stroke in men with VE. A longer cohort study might have levelled the gender difference in this longitudinal study: it estimated 6–9 years in this study [40].

Hostility in men has a negative association with stroke risk (HR = 0.29, 95% CI:0.1–0.7). Divorce, primary education, and the age of 55–64 are associated with a 3.2–4.6-fold increase in the risk of stroke. The maximum risk values were observed among pensioners (HR = 14.5) in comparison with executives. There was no association with stroke in women with hostility during the 16-year follow-up period.

The low level of close contacts increased the risk of stroke to the same degree in men and women – 3.5 times. But a poor social network (low SNI) was more important for men, increasing the risk of stroke 3.4 times, and for women 2.3 times. Adding social parameters and age to the analysis reduced the risk value in men with low ICC to HR = 2 (95% CI:1.27–3.61), while the risk of stroke increased 4.13-fold in women. Only women with higher education and a favourable level of close contact were resistant to the risk of stroke. In men, only primary education was associated with a twofold risk of stroke. Moreover, being a divorced or widowed blue-collar was associated with an increased risk of stroke in men but not women. However, age over 54 was critically important in the risk of stroke in both sexes, but with a greater magnitude among women (HR = 5.19; p < 0.05).

In contrast to the simple model, in the multivariate Cox model, SNI increased the risk of stroke in the same way in men and women (2.2 times). As in the case of low ICC, any level of education attainment, apart from higher education, increased the risk of stroke in women; while in men, only primary education was significant, in case of poor social ties. Women aged 55–64 were 2 times more likely than men of the same age group to have a stroke. Yet occupational status, as well as marital status, were statistically significant only in men. Being a blue-collar worker and having the status of a divorced or a widower, combined with a low SNI, increased the risk of stroke 4.8–6.9 times. Literary sources show that the socially isolated, i.e., deprived of social contacts and not participating in social activities, lonely or not satisfied with the quality of their social contacts, have a 30% higher risk of CHD, stroke and early mortality [41]. Such studies only add to the significance of the influence of the social gradient described in our previous works [42].
