Statement Highlights:
- In a review of the latest research, few stroke studies addressed racist policies, such as residential segregation, or social determinants of health, such as neighborhood deprivation, walkability or security; food availability; economic stability; education quality; or employment and health insurance, all of which play a role in stroke incidence, care and outcomes.
- The statement summarizes research on interventions to address racial and ethnic disparities in stroke care and outcomes.
- Additional research is needed to determine which types of structural or “upstream” interventions may help to reduce inequities in stroke care.
Newswise — DALLAS, May 15, 2023 — According to a recent statement by the American Heart Association, we haven't studied the main reasons behind health disparities related to stroke, such as racism and the conditions of the communities where people live, learn, work, and have fun. The statement, published in the scientific journal Stroke, reviews the latest research on unequal stroke care and outcomes among different racial and ethnic groups. It also points out what we don't know yet and suggests areas for further research.
Dr. Amytis Towfighi, the chair of the group that wrote the scientific statement, explains that there are big differences in how stroke care is provided, resulting in significant disparities in the recovery outcomes for people from marginalized racial and ethnic backgrounds, like Black, Hispanic, and Indigenous individuals. While previous research has mainly described these disparities, it is crucial to now focus on creating and testing interventions to tackle these issues.
Historically marginalized communities are more likely to be affected by stroke, but we don't fully understand why this is the case. One reason is that these communities are significantly underrepresented in clinical trials focused on stroke. This lack of representation leads to limited knowledge and makes it difficult to apply research findings to these communities. As a result, the existing inequities continue to worsen, resulting in poorer outcomes for individuals in these communities. The statement emphasizes the need for more inclusive research to address this issue.
In order to minimize the long-term impact of a stroke caused by a blood clot (which is the most common type), it is important to administer medication to dissolve the clot within three hours of the onset of symptoms. In some cases, this window can be extended to four-and-a-half hours. Additionally, for certain individuals, removing the clot through a mechanical procedure known as endovascular therapy may be a safe option up to 24 hours after the stroke symptoms appear. Unfortunately, not everyone who experiences a stroke has prompt access to these treatments, which can be a barrier to receiving the necessary medical interventions in a timely manner.
Dr. Towfighi explains that time is crucial when it comes to treating stroke, but individuals from historically marginalized communities are less likely to reach the emergency room within the critical time window for immediate intervention. Furthermore, research indicates that although Black people are more likely to participate in post-stroke rehabilitation programs, they still tend to have poorer functional outcomes. Additionally, racial and ethnic disparities persist when it comes to controlling risk factors after a stroke, and studies addressing these disparities have not yet identified the best approach to reduce these inequities.
The authors of the review point out that most of the studies they examined focused on individual factors that affect stroke outcomes, such as a person's understanding of health information, preparedness for stroke, adherence to medication, and lifestyle choices. However, very few studies investigated broader factors that contribute to stroke disparities, such as structural racism (including discriminatory policies that led to segregated communities) or social determinants of health, which include aspects like community resources, economic stability, access to healthcare, housing conditions, neighborhood safety, availability of nutritious food, quality of education, and employment opportunities. The authors highlight the need for more research to explore these upstream factors and their impact on stroke inequities.
The statement emphasizes that addressing the impact of systemic racism requires taking upstream actions. This involves implementing policy changes, implementing interventions targeted at specific locations, and actively involving healthcare systems that primarily serve historically marginalized populations and their communities. It's important to understand the barriers that exist and work together collaboratively to develop solutions that can effectively overcome these barriers. By doing so, we can make progress in reducing the disparities caused by systemic racism.
A 2020 American Heart Association presidential advisory, “Call to Action: Structural Racism as a Fundamental Driver of Health Disparities,” declared structural racism as a major cause for poor health and premature death from heart disease and stroke for many and detailed the Association’s immediate and ongoing actions to accelerate social equity in health care and outcomes for all people.
Prior studies have highlighted the significance of focusing on stroke preparedness among patients, caregivers, and emergency medical personnel to address inequities in promptly getting individuals with suspected stroke to the emergency room for timely treatment. However, there hasn't been enough emphasis on reducing disparities in post-stroke rehabilitation, recovery, and social reintegration. This includes assessing the effects of neighborhood or city-level interventions, such as enhancing sidewalks and ensuring access to physical, occupational, and speech therapy. The statement underscores the need to pay greater attention to these areas to address inequities and improve outcomes for stroke survivors.
The statement recognizes that racial and ethnic identity are multifaceted and that race itself is a social construct rather than a biological fact. Moreover, it acknowledges that research has often oversimplified or mischaracterized racial classifications. For instance, in the United States, ethnicity has been broadly categorized as Hispanic or non-Hispanic, which overlooks the diversity of ethnic backgrounds within these groups. Additionally, Native Hawaiians and Pacific Islanders are often grouped together with Asian Americans, disregarding the distinct impact of stroke on Indigenous communities. The statement highlights the importance of acknowledging these complexities and improving the accuracy and inclusivity of racial and ethnic classifications in research on stroke disparities.
Bernadette Boden-Albala, vice chair of the writing group for the statement, acknowledges that in their review, they utilized the race and ethnicity categories commonly used and supported by government research funding agencies, which influence how data is collected. However, they recognize that these categories are insufficient in capturing the complexities of individual experiences and fully exposing the entrenched inequities rooted in societal structures, including healthcare. This acknowledgment highlights the limitations of existing categorizations and the need for more nuanced approaches to understand and address health inequities effectively.
Further research is needed across the stroke continuum of care to tackle racial and ethnic inequities in stroke care and improve outcomes.
Boden-Albala emphasizes the importance of historically marginalized communities actively participating in research. By doing so, researchers can collaborate with these communities to address their specific needs and concerns effectively. There are various opportunities for involvement, such as working with community stakeholder groups and organizations to advocate for partnerships with hospitals, academic medical centers, local colleges, and universities. Additionally, joining community advisory boards and volunteering with organizations like the American Heart Association can provide avenues for engagement and influence in shaping research efforts to better serve these communities.
Towfighi adds that healthcare professionals need to expand their perspectives and think beyond conventional approaches when addressing stroke disparities. Creating sustainable and effective interventions to tackle these inequities will likely require collaboration with patients, their communities, policy makers, and various sectors outside of the healthcare system. By working together and involving multiple stakeholders, we can develop comprehensive solutions that address the complex factors contributing to stroke inequities and promote long-lasting positive change.
This scientific statement was developed by a dedicated writing group composed of volunteers representing various councils within the American Heart Association. These councils include the Stroke Council, the Council on Cardiovascular and Stroke Nursing, the Council on Cardiovascular Radiology and Intervention, the Council on Clinical Cardiology, the Council on Hypertension, the Council on the Kidney in Cardiovascular Disease, and the Council on Peripheral Vascular Disease. The statement represents the collective expertise and efforts of these councils in addressing stroke-related issues and advancing knowledge in the field.
American Heart Association scientific statements serve an important purpose by raising awareness and providing valuable information about cardiovascular diseases and stroke. They help individuals and healthcare professionals make well-informed decisions regarding healthcare. These statements summarize the existing knowledge on a particular topic and highlight areas that require further research. It's important to note that while scientific statements inform the development of guidelines, they themselves do not make specific treatment recommendations. Instead, the official clinical practice recommendations for healthcare providers are provided by the American Heart Association guidelines. These guidelines are evidence-based and provide guidance on the best practices for managing and treating cardiovascular diseases and stroke.
Other co-authors are Salvador Cruz-Flores, M.D, M.P.H.; Nada El Husseini, M.D., M.H.Sc., FAHA; Charles A. Odonkor, M.D., M.A.; Bruce Ovbiagele, M.D., M.Sc., M.A.S., M.B.A.; Ralph L. Sacco, M.D., FAHA; Lesli E. Skolarus, M.D., M.S.; and Amanda G. Thrift, Ph.D., FAHA. Authors’ disclosures are listed in the manuscript.
The Association receives funding primarily from individuals. Foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers, and the Association’s overall financial information are available here.
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