What Progress Have We Made in Mitigating Racial Disparities in Stroke?

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Experts in stroke care expressed a need for significant increases in awareness of stroke risk factors and symptoms in patient communities that experience racial disparities.

The field of stroke has advanced its care approaches for these patients in the past couple decades. Despite the progress that has been made in this field, though, there is a big challenge that lingers for patients and is often the focus of conversations in the clinical setting: racial disparities in stroke care. Meaning, over the years, research has shown that patients of minority groups are at a higher risk of stroke because of inconsistencies in the care paradigm. Admist these challenges, the clinical community has strived to address these disparities in hopes of bringing more awareness of these issues for vulnerable patient populations and so they can receive the quality care that they may need.

There is an emphasis on the importance of recognizing stroke symptoms in minority communities for the patients to be given effective intervention. This means there are still many patients in these stroke populations that need to be educated on the critical steps for them to act for their own care. This responsibility not only falls on the patients to adhere to information given to them about signs of stroke and complying to treatment regimens, but also on the clinicians who are helping to guide these patients along their care journey. In recent conversations with NeurologyLive®, clinicians provided their insight on the progress that has been made over in improving awareness of stroke and reducing these racial disparities.

A Closer Look at Racial Disparities in Stroke

Santosh Murthy, MD, MPH, associate professor of neurology at Weill Cornell Medicine

Santosh Murthy, MD, MPH

Credit: NewYork-Presbyterian Doctors

In the United States, the largest racial disparity in the risk of stroke is among Black patients compared with White patients. Research shows Black patients—both men and women—between 45 and 64 years of age have a 3-fold higher risk of stroke compared with White individuals.1 Studies also show that mortality rates are high among working age adults, for example, these rates among non-Hispanic Black adults aged 35 to 64 years were 2.4 times that of their non-Hispanic White counterparts in 2019, according to a published research in Preventing Chronic Disease.2 These differences also separate women from men, at least earlier in life. For example, in a 2018 national cohort study published in JAMA Neurology, investigators observed a lower risk of stroke in women aged 45 to 64 years for both Black individuals and White individuals, a risk that became more similar for men and women aged 75 years or older, both for Black and White individuals.3 Conducted by lead author Virginia J. Howard, PhD, distinguished professor of epidemiology at The University of Alabama at Birmingham School of Public Health, and colleagues, the data show that White women were at lower stroke risk than White men between 65 and 74 years of age. Notably, though, in the same age frame, the stroke risk for Black men and women showed no difference, which the authors noted suggests that Black women lose their protection from stroke at a younger age in comparison with White women. Overall, the evidence supports the presence of racial disparities in patients who experienced stroke.

“We do know that there are racial and ethnic disparities in stroke, and in terms of intracerebral hemorrhage [ICH]. For instance, we know that Black patients have a higher incidence of intracerebral hemorrhage, and this occurs much earlier than in other patients. We will also see in that Black patients who have an ICH have an increased risk of recurrent ICH, not just that Black patients with ICH also end up having a higher risk of ischemic stroke down the road,” Santosh Murthy, MD, MPH, associate professor of neurology at Weill Cornell Medicine, told NeurologyLive. “Clearly, there are a lot of health disparities. A lot of work has gone into studying the social determinants of health, long-term risk factor control, and also including patients of Black race and Hispanic ethnicity in clinical trials and being more inclusive [in general]. I think [this] would shed a lot of light.”

An important factor that influences racial disparities in stroke involves social determinants of health, which are defined as the conditions in which patients are born, grow, work, live, and age, and the wider set of forces and systems shaping the aspects of their daily life.4 Social determinants have the ability to significantly alter the experience of a condition, such as their impact on quality of life across a patient’s lifespan. In several cases presented in research, these social inequalities that relate to health determinants have disproportionately affected historically disadvantaged racial and ethnic populations, including Black and Hispanic patient groups.5 According to a recent cross-sectional study published in JAMA Network Open,6 social determinants of health in educational attainment, poverty, language barriers, and health care professionals shortages were positively associated with stroke prevalence in New York City communities. Similarly, in study published Stroke,7 investigators observed that incremental increases in the number of social determinants of health were independently associated with higher incident stroke risk among patients younger than 75 years old, with no statistically significant effects observed in individuals who were at least 75 years of age. Thus, findings suggest that targeting patients who have multiple social determinants of health may help to reduce the risk of stroke among these vulnerable populations.

"Stroke care has made enormous strides, advancing in almost every aspect, from prehospital to hospital to post-hospital–discharge care. It is crucial to emphasize the message that if family members or friends observe any new onset of weakness, numbness, or difficulty speaking, they should err on the side of caution, assuming it could be a stroke, and expedite the transfer to the nearest medical care facility,” Murphy added. “Given the time sensitivity of many of these interventions, early presentation to the hospital is key to prompt diagnosis and application of these advances. Numerous trials have demonstrated the benefits of these interventions in improving functional outcomes and minimizing long-term disability. Maintaining a low threshold to take a patient to the hospital or call 9-1-1 and seeking medical attention at the earliest possible time is of utmost importance."

The Role of Awareness and Education

As evidence shows that there are racial disparities in stroke among minority populations, raising awareness on this public health concern is the first step toward making a positive impact to improve care of these patients. This issue has become a constant topic in conversations in recent years, with more awareness being brought each year thanks to awareness campaigns, additional research, and workshops that educate the experts in the field to be more informed. It is not only important for clinicians to be aware of this issue in terms of helping to spread awareness to others, but it is also essential to be applied in their own practice if they have patients who experience these health inequalities based on their background. Prior research on the awareness of stroke suggests that the understanding of the condition's early warning signs is low in high-risk groups, like patient populations who experience racial disparities. According to an analysis published in Public Health Reports, findings showed that less than 35% of poststroke patients could distinguish the complex symptom profile of a stroke and take appropriate action in an emergency.8 Thus, these vulnerable patient populations need to be more informed about stroke to act for their health through health initiatives conducted by clinics and other organizations that promote patient advocacy. Not only is there a need for these awareness campaigns for these patients, but the educational activities also would have to be targeted to them based on their differences in race, ethnicity, age, and education.

Opeolu Adeoye, MD, professor of emergency medicine at Washington University in St. Louis

Opeolu Adeoye, MD

Credit: Washington University in St. Louis

Awareness campaigns on the risk factors of stroke in minority populations could significantly lower the likelihood of stroke incidence as patients feel more empowered to take action in the case of the occurrence of the condition, when they are knowledgeable. The campaigns would address the warning signs and treatment options for stroke, which could substantially change the outcome of a stroke if patients immediately seek emergency help. In a 2011 survey on disparities in stroke awareness, investigators observed significant disparities in the recognition of cholesterol, smoking, prior stroke, and race as stroke risk factors from the responses.9 The responses also showed a significant and substantial difference in awareness of stroke signs based on the responses of Black and White patients to stroke occurrence. Similarly, findings from another survey revealed differences in the knowledge of stroke symptoms across race, ethnic, and other demographic groups.10 The responses in this survey showed that knowledge of stroke symptoms, in addition to the importance of calling 9-1-1 for a suspected stroke, was higher among women, White patients, and patients who had health insurance. Investigators observed that stroke awareness was lowest for the survey participants who were Hispanic, Black, or lived in the western region of the United States. These survey findings support the need for improved communication on the risk factors and symptoms of stroke to enhance patient outcomes.11

“We should do whatever we can in the end. We have these opportunities to promote FAST and recognition of signs and symptoms of stroke. [FAST] includes Face [drooping], Arm [weakness], Speech [difficulty], the Time to call 9-1-1, if one has any concerns about possible stroke symptoms. It's well-established that the general public doesn't have great awareness of the signs and symptoms of stroke. There's a bigger gap amongst Blacks and Hispanics in terms of the knowledge of the signs and symptoms of stroke, despite the increased burden of stroke in those communities. If there's an opportunity for us to enhance awareness of the signs and symptoms again, [we need to use] FAST, and make sure people call 9-1-1 so that they can get to the hospital to receive these proven treatments,” Opeolu Adeoye, MD, professor of emergency medicine at Washington University in St. Louis told NeurologyLive.

Intervention Approaches for Stroke Prevention

F.A.S.T. Warning Signs

  • F = Face Drooping 
    • Does 1 side of the face droop or is it numb? Ask the person to smile. Is the person's smile uneven?
  • A = Arm Weakness
    • Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?
  • S = Speech Difficulty
    • Is speech slurred? Is the person having difficulty forming speech?
  • T = Time to call 9-1-1
    • A stroke is an emergency. Every minute counts. Call 9-1-1 immediately. Note the time when any of the symptoms first appear.
REFERENCE
American Stroke Association. Stroke Symptoms. Accessed February 27, 2024. https://www.stroke.org/en/about-stroke/stroke-symptoms

Targeted interventions help to reduce stroke risk factors, increase awareness of symptoms of stroke and improve access to care for stroke, as these types of interventions show promise for overall reduction of racial and ethnic disparities in stroke mortality. According to a previous study published in Stroke,12 an educational intervention on stroke awareness increased the number of patients arriving at the emergency department within 3 hours of stroke symptom onset, including in racial/ethnic minorities. Another intervention that consisted of a 3-hour multimedia stroke literacy session, patients in economically disadvantaged minorities had increased stroke preparedness with sustained effects at 3-month follow-up.13 Another example of a successful intervention occurred in a classroom instruction where pediatric patients, in a community of Mexican Americans and non-Hispanic White Americans, had increased knowledge of stroke pathophysiology, symptoms, and what to do when witnessing a stroke.14 Additionally, stroke education given to patients in a Black beauty shop improved their knowledge of stroke warning signs and calling 9-1-1 at 6 weeks, and sustained their improvement in knowledge for 5 months, according to data from a single-arm trial.15 These examples of stroke awareness interventions provide evidence show that these types of interventions can be effective at increasing awareness of stroke symptoms in both Black and Hispanic populations.16

A key recommendation for the future in improving strategies with stroke awareness is having more representation in clinical trials assessing different types of stroke interventions to reduce racial disparities and enhance care for patients—and these populations are growing. According to a population report on the United States, researchers predict that Hispanic patients will make up 29% of the total population, and Black patients or multi-race will make up nearly 18% of the total population by 2060.17 Outside of the United States, recruitment of patients for trials from other parts of the world is important to further address racial/ethnic disparities in stroke prevention and treatment. Researchers also emphasize the importance of recruiting patients among minority patients in nontraditional settings and utilizing mobile health technology to meet the patients’ needs.16 One example from an randomized controlled trial is a vascular risk factor management program delivered through a smartphone-based electronic decision support system to rural patients in China and India, which improved self-reported antihypertensive medication use at 1-year of follow-up.18 In another randomized controlled trial, findings revealed the feasibility of assessing a mobile health technology intervention and recruitment of patients with uncontrolled hypertension from emergency departments.19 Thus, more trials investigating interventions for stroke to improve access and quality of care for minority patients at risk of stroke are needed.16

Anne W. Alexandrov PhD, RN, CCRN, ANVP-BC, NVRN-BC, FAAN, professor of nursing and neurology at the University of Tennessee Health Science Center

Anne W. Alexandrov PhD, RN, CCRN, ANVP-BC, NVRN-BC, FAAN

Credit: University of Tennessee Health Science Center

“Stroke is a leading cause of death and disability, and while perhaps the US is in a slightly more favorable position with where it sits overall, compared with other forms of illness that are tied to death in most of the world, it is the second or the third leading cause of death. I think the unfortunate thing about stroke is that many times, patients and family members and bystanders remain unaware of stroke symptoms. Understanding stroke and how patients can present, with each presenting so very differently, is extremely important. I think that that is probably the most important message to get across: rapidly identify stroke in time to get patients quickly to a certified stroke center,” Anne W. Alexandrov PhD, RN, CCRN, ANVP-BC, NVRN-BC, FAAN, professor of nursing and neurology at the University of Tennessee Health Science Center told NeurologyLive.

Conclusion

Experts in stroke have offered that there is a great need for increased awareness of stroke risk factors and symptoms in patient communities that experience racial disparities. Acknowledging these disparities is one of the first steps in improving care for patients. The next after that is having more education presented to patients, not only in the general public, but to those who may be at a higher risk of stroke than others. These educational promotions of stroke warning signs can include workshops presented at conferences where patients and clinicians are present, and other initiatives could be conducted through social media campaigns with infographics targeted to the at risk community. Another way to improve knowledge of stroke disparities in minority groups is conducting more inclusive clinical trials that have a diverse patient population. In essence, the goal of these campaigns is to reach the targeted audience, patients and clinicians who may not be aware of the racial disparities in stroke care, to hopefully offer strategies to address it in clinical practice.

REFERENCES
1. Rosamond WD, Folsom AR, Chambless LE, et al. Stroke incidence and survival among middle-aged adults: 9-year follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort. Stroke. 1999;30(4):736-743. doi:10.1161/01.str.30.4.736
2. Flynn A, Vaughan AS, Casper M. Differences in Geographic Patterns of Absolute and Relative Black-White Disparities in Stroke Mortality in the United States. Prev Chronic Dis. 2022;19:E63. Published 2022 Oct 6. doi:10.5888/pcd19.220081
3. Howard VJ, Madsen TE, Kleindorfer DO, et al. Sex and Race Differences in the Association of Incident Ischemic Stroke With Risk Factors. JAMA Neurol. 2019;76(2):179-186. doi:10.1001/jamaneurol.2018.3862
4. Healthy people 2020: Social determinants. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed February 21, 2024.
5. Skolarus LE, Sharrief A, Gardener H, Jenkins C, Boden-Albala B. Considerations in Addressing Social Determinants of Health to Reduce Racial/Ethnic Disparities in Stroke Outcomes in the United States. Stroke. 2020;51(11):3433-3439. doi:10.1161/STROKEAHA.120.030426
6. Jadow BM, Hu L, Zou J, et al. Historical Redlining, Social Determinants of Health, and Stroke Prevalence in Communities in New York City. JAMA Netw Open. 2023;6(4):e235875. Published 2023 Apr 3. doi:10.1001/jamanetworkopen.2023.5875
7. Reshetnyak E, Ntamatungiro M, Pinheiro LC, et al. Impact of Multiple Social Determinants of Health on Incident Stroke. Stroke. 2020;51(8):2445-2453. doi:10.1161/STROKEAHA.120.028530
8. Ellis C, Egede LE. Ethnic disparities in stroke recognition in individuals with prior stroke. Public Health Rep. 2008;123(4):514-522. doi:10.1177/003335490812300413
9. Alkadry MG, Bhandari R, Wilson CS, Blessett B. Racial disparities in stroke awareness: African Americans and Caucasians. J Health Hum Serv Adm. 2011;33(4):462-490.
10. Ojike N, Ravenell J, Seixas A, et al. Racial Disparity in Stroke Awareness in the US: An Analysis of the 2014 National Health Interview Survey. J Neurol Neurophysiol. 2016;7(2):365. doi:10.4172/2155-9562.1000365
11. Mital R, Bayne J, Rodriguez F, Ovbiagele B, Bhatt DL, Albert MA. Race and Ethnicity Considerations in Patients With Coronary Artery Disease and Stroke: JACC Focus Seminar 3/9. J Am Coll Cardiol. 2021;78(24):2483-2492. doi:10.1016/j.jacc.2021.05.051
12. Boden-Albala B, Stillman J, Roberts ET, et al. Comparison of Acute Stroke Preparedness Strategies to Decrease Emergency Department Arrival Time in a Multiethnic Cohort: The Stroke Warning Information and Faster Treatment Study. Stroke. 2015;46(7):1806-1812. doi:10.1161/STROKEAHA.114.008502
13. Williams O, Leighton-Herrmann Quinn E, Teresi J, et al. Improving Community Stroke Preparedness in the HHS (Hip-Hop Stroke) Randomized Clinical Trial. Stroke. 2018;49(4):972-979. doi:10.1161/STROKEAHA.117.019861
14. Morgenstern LB, Gonzales NR, Maddox KE, et al. A randomized, controlled trial to teach middle school children to recognize stroke and call 911: the kids identifying and defeating stroke project. Stroke. 2007;38(11):2972-2978. doi:10.1161/STROKEAHA.107.490078
15. Kleindorfer D, Miller R, Sailor-Smith S, Moomaw CJ, Khoury J, Frankel M. The challenges of community-based research: the beauty shop stroke education project. Stroke. 2008;39(8):2331-2335. doi:10.1161/STROKEAHA.107.508812
16. Levine DA, Duncan PW, Nguyen-Huynh MN, Ogedegbe OG. Interventions Targeting Racial/Ethnic Disparities in Stroke Prevention and Treatment. Stroke. 2020;51(11):3425-3432. doi:10.1161/STROKEAHA.120.030427
17. Colby SL, Ortman JM. Projections of the size and composition of the U.S. population: 2014 to 2060.2015. Accessed February 24, 2024.
https://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf
18. Tian M, Ajay VS, Dunzhu D, et al. A Cluster-Randomized, Controlled Trial of a Simplified Multifaceted Management Program for Individuals at High Cardiovascular Risk (SimCard Trial) in Rural Tibet, China, and Haryana, India. Circulation. 2015;132(9):815-824. doi:10.1161/CIRCULATIONAHA.115.015373
19. Meurer WJ, Dome M, Brown D, et al. Feasibility of Emergency Department-initiated, Mobile Health Blood Pressure Intervention: An Exploratory, Randomized Clinical Trial. Acad Emerg Med. 2019;26(5):517-527. doi:10.1111/acem.13691
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