Black History Month in Neurology: Addressing the Roots of Stroke Disparities

Black Americans continue to experience a disproportionate burden of stroke, with persistent disparities in incidence, recurrence, and long-term outcomes despite major advances in prevention and acute treatment. As the field of neurology continues to refine evidence-based care, attention to the structural and social drivers of health remains central to closing these gaps.

During Black History Month, clinicians and researchers across neuroscience reflect not only on progress made, but on the enduring systems that shape inequities in brain health. Few leaders embody this intersection of clinical excellence and equity-focused innovation more than Anjail Sharrief, MD, Professor of Neurology and Director of Stroke Prevention for the Institute of Stroke and Cerebrovascular Disease at UTHealth Houston.

Sharrief, who founded the Stroke Transitions Education and Prevention (STEP) Clinical Program in 2014, has dedicated her career to addressing health disparities in stroke survivors while mentoring the next generation of neuroscientists. In this conversation with NeurologyLive, she shares her perspective on the roots of stroke inequities, system-level solutions, and the role of mentorship in advancing equitable brain health.

Black communities continue to face disproportionate stroke burden. During Black History Month, what do you think clinicians should reflect on regarding the roots of these inequities?

Anjail Sharrief, MD: Higher rates of stroke in Black Americans have been reported for over 100 years. Despite decades of advances in stroke care that have improved outcomes for all Americans, these disparities in risk and outcomes persist. During Black History Month, it is important to first recognize and acknowledge the outstanding work of many researchers who have highlighted disparities across the continuum of stroke care and elevated the importance of understanding the roots of these inequities.

Many of these inequities are related to non-medical drivers of health that act across the continuum of stroke care, from primordial prevention through secondary and tertiary prevention. These inequities are rooted in differences in access to and quality of care, access to education, economic stability and opportunity, and neighborhood and community factors that have persisted through the Jim Crow era, segregation, and systems of racial inequality whose remnants remain today.

At the same time, while acknowledging these underlying factors, it is crucial for clinicians and investigators to focus on developing strategies and systems to mitigate disparities in stroke care and outcomes. In the Stroke Transitions Education and Prevention Program, we take a holistic approach to improving care for all stroke survivors while also working intentionally to decrease disparities in care and outcomes.

In developing the STEP (Stroke Transitions Education and Prevention) program, what equity-related challenges did you identify in patient education and follow-up care, and how did you address them?

Over the past 10 years, the STEP Program has developed as a learning health system in which patient and community engagement, research and quality improvement, mentoring and education, and team-based learning are integrated to support continuous learning and improve person-centered outcomes. The program was initially focused on improving risk factor control after stroke, but it quickly became apparent that non-medical drivers of health were as, if not more, important than medication management and traditional medical risk factors in shaping patient outcomes.

We identified several equity-related challenges in patient education and follow-up care. Economic instability is often compounded after stroke, with loss of income contributing to food insecurity, housing instability, and cost-related medication non-adherence. These factors directly affect risk factor control and stroke recurrence. Educational attainment among patients and care partners influences health literacy, digital health literacy, the ability to retain educational information, and the maintenance of risk factor control. Educational attainment combined with post-stroke cognitive impairment further contributes to disparities in outcomes.

Access to post-stroke care is another critical factor. A large proportion of our population is underinsured or uninsured, and many patients live in areas with limited access to neurological care. In response, the STEP Program works closely with our hospital partners to ensure that every patient discharged from our Comprehensive Stroke Center has guaranteed follow-up in our clinic, regardless of ability to pay. We offer both in-person and telehealth visits, include a clinical social worker to help patients navigate access challenges and apply for insurance, and have developed a comprehensive resource guide for providers to better support patient needs.

Through this approach, we aim not only to improve education and follow-up, but to build systems that reduce inequities in post-stroke outcomes.

Given your public health training, how do you integrate data on structural determinants — such as neighborhood resources or access barriers — into individualized stroke risk assessment in clinical practice?

My training in public health focused on epidemiology and the social and behavioral sciences. The social and behavioral sciences training has had a tremendous influence on the STEP program and my research career. It emphasized program planning and development for health behavior change and made me keenly aware of system-, community-, interpersonal-, and individual-level factors that influence health behaviors and outcomes. This understanding is critically important for health equity work.

In clinical practice, this training shapes how I think about stroke risk. I do not view risk as limited to blood pressure, diabetes, or cholesterol levels alone. I consider the social context in which a patient is managing these conditions, including neighborhood resources, access to healthy food, transportation, insurance coverage, digital access, and caregiving support. These factors influence not only risk of stroke, but the likelihood of sustained risk factor control after stroke.

In the STEP program, multilevel barriers to stroke care are considered from the time of hospital admission through outpatient follow-up. Within our learning health system, we continuously integrate data and collaborate across disciplines to address these factors as they arise. In the outpatient clinic, we address literacy challenges by ensuring that educational materials are written at the 8th grade reading level and available in English and Spanish. We provide blood pressure monitors for patients who cannot afford them and offer education on home monitoring. We screen all patients for health-related social needs such as food insecurity, transportation barriers, and insurance challenges. This allows us to provide social risk-informed care and to refer patients to our clinical social worker to support their needs.

In this approch, social factors are not viewed as background context, but as central components of individualized stroke risk assessment and management.

What mentorship practices have you found most impactful in encouraging trainees from under-represented backgrounds to pursue academic neurology?

There are five key practices I have utilized to support trainees from under-represented backgrounds in pursuing academic neurology. I use these same practices to support all trainees in considering and addressing disparities and inequities, whether they ultimately pursue academic neurology or another discipline. Over time, these practices have evolved and include 1) modeling, 2) inclusion, 3) experiential learning, 4) support for peer mentoring, and 5) individualized mentoring.

First, modeling matters. I have learned that my genuine excitement for research and clinical innovation inspires similar curiosity in others. I try to model this by continuously asking questions, demonstrating creativity and optimism despite barriers, openly sharing both failures and successes, and encouraging trainees to learn from all experiences.

Inclusion is central to my mentoring approach. Our team welcomes trainees at all levels and from all disciplines. I work intentionally to create an environment where ideas are valued and where everyone has opportunities to contribute and lead projects. Importantly, patients and care partners are included in all aspects of our work, from research design to community engagement and dissemination. This strengthens the learning environment and ensures that our work remains centered on those most affected. Mentees learn not only scientific rigor, but also humility and partnership.

Experiential learning is another critical component. Fellows, residents, medical students, and others who rotate through the STEP clinic are exposed to an approach to care that intentionally addresses disparities. They are invited to participate in research projects and join our group meetings. Many have gone on to develop their own research and clinical programs at other institutions or to incorporate equity-focused work into their teaching and clinical missions. I also invite mentees to community outreach events so they can engage directly with communities, understand real-world challenges, and see how patient and community engagement strengthens research and care.

As our mentoring group has expanded to more than 150 individuals, smaller peer mentorship communities have naturally developed. Trainees at similar stages support one another, collaborate on projects, and share challenges. This peer structure has become an important source of encouragement and accountability.

Finally, I have learned that mentorship must be individualized. Different mentees have different needs, and expectations must be set and revisited over time. Some benefit from monthly one-on-one meetings, while others connect at different intervals. My role may shift from project mentor to career mentor to more personal guidance depending on the stage and situation. I strive to be available, to advocate for them, and to support them through both success and setbacks.

I see mentoring as the most important contribution I can make to academic medicine. My greatest impact will not be through my individual accomplishments, but through the broader impact of those I have the privilege to mentor.