Stroke, Multi-Ethnicity and Gender
Stroke is the second leading cause of death and the leading cause of disability worldwide. In terms of health care costs, stroke and heart disease carry the global burden, close to $100 billion annually. Among the different populations of the world, stroke is also shown to impact certain ethnic groups more severely than others. Hispanic-Americans, African-Americans, and other African men and women throughout the world, for example, experience more strokes, more debilitating strokes, and more deaths from stroke than Caucasians. While stroke mortality has been on decline for the past thirty years, stroke mortality among Hispanic-Americans and African-Americans remains at least twice as high as that among Caucasian-Americans. Socioeconomic conditions alone are insufficient to explain this vast disparity in ethnic mortality rates for stroke. More research is needed to understand the inconsistent impact of stroke among different ethnic populations, including further study of the healthcare accessibility and utilization, and physiological disparities among different ethnic groups.
Incidence of Stroke in African-Americans and Hispanic-Americans
In the small number of multi-ethnic cohort studies available, stroke incidence has been consistently higher in African-Americans and Hispanic-Americans than in Caucasian-Americans. For example, the Northern Manhattan Stroke Study (NOMASS), a ten-year National Institute of Health-sponsored epidemiological study, has demonstrated that African-Americans have a 2.4 times, and Hispanic-Americans a 2 times, annual rate for stroke as Caucasian-Americans living in the same community. Stroke also affects African-Americans and Hispanic-Americans at younger ages than in most other American ethnic groups. Although stroke directly poses a major public health problem among these two ethnic-minority populations, the nature, outcome, and medical care of stroke among these groups remain vastly understudied. The database for stroke studies in the United States has largely depended on Caucasian subjects; stroke data from other ethnic-minority groups in the United States, such as from Asian-Americans and Native-Americans, remains basically unavailable.
Risk Factors for Stroke in African-Americans and Hispanic-Americans
A number of firmly established risk factors for stroke commonly appear among African-American and Hispanic-American men and women, including elevated blood pressure, diabetes, and smoking. Advanced age generally contributes to stroke risk. Lipid (e.g. fats) profiles do not vary substantially among ethnic groups, except in African-American women, whose pronounced lipid profiles may increase stroke risk. African-Americans and Hispanic-Americans should seek prevention and management of hypertension and diabetes, as well as cessation from smoking, in order to control their risk for stroke. More research on stroke among these ethnic-minority groups is needed to gain a better understanding of and to develop strategies for reducing their high-risk status.
Risk Socioeconomic Factors and Access To Healthcare
Social, cultural, and economic factors contribute to the impact of stroke on African-Americans and Hispanic-Americans. Healthcare remains disparate among ethnic groups in the United States. Since African- American and Hispanic-American stroke victims are more frequently uninsured or underinsured, their access to medical care and to adequate medical care is more limited. African-American and Hispanic-American stroke victims receive fewer high-cost medical procedures and surgeries. This disparity in utilization may derive from patient refusal of procedures, varying levels of trust in the medical care system, and various disease types that may rule out certain procedures.
Insufficient healthcare coverage may potentially impair accurate diagnosis of specific stroke types among these ethnic-minority groups. African-Americans, for instance, suffer a greater incidence of stroke due to bleeding in the brain or atherosclerosis of the arteries in the brain. While a precise stroke diagnosis largely depends on the presence of symptoms, it may also require other diagnostic and imaging tests that may be underutilized among minority patients.
Limited data on the hospital course of ethnic-minority stroke patients may also suggest their limited use of rehabilitation services. African-American and Hispanic-American stroke patients show prolonged hospital stay and more deaths. Although this limited data permits no firm conclusions, it suggests poorer rehabilitation and in-hospital prognosis for stroke patients among these groups. Fuller analyses of heathcare databases, including Medicare and HMO databases, would help to address the disparity in healthcare utilization among ethnic groups.
Stroke In Women
Stroke is the second leading cause of death among women worldwide, after coronary heart disease. Although many think of stroke as a disease of older men, over half of all strokes and 60% of all stroke-related deaths occur in women, and over a quarter of female stroke victims in a given year are under the age of 65. Stroke kills more women than the number who die from breast cancer and AIDS combined.
Notwithstanding these mortality rates, stroke survival potentially bears grave disabilities. Today, more than two million American women live with the consequences of stroke. When examined seven years after a nonfatal stroke, thirty-one percent of female stroke survivors will need help caring for themselves, twenty percent will need help walking, and seventy-one percent will have an impaired ability to work. As high as sixteen percent of female survivors will have to be institutionalized.
Stroke, however, occurs in women at an older age than in men. This delay is related in part to the effects of the estrogen hormone and in part to other physiological differences between male and female bodies. Studies have shown inconsistent effects of hormone replacement therapy on stroke occurrence and outcome, suggesting that the impact of gender on stroke is not confined to the hormonal differences between men and women.
Available data also indicates disparities in health among women of various ethnic backgrounds. For example, whereas heart disease and cancer are the leading causes of death among all American women, cancer is the leading cause of death among Asian women, and cardiovascular disease, among African-American, Hispanic, and Caucasian women in the United States. African-American and Hispanic-American women have a two- to three-fold risk for stroke as Caucasian-American women. Despite these differences and until recently in the United States, clinical research (that has included women, at all) has focused on middleclass, Caucasian women. As the percentage of minority groups in the U.S. population continues to rise, more research is needed on the disparate health profiles among disparate groups of women, including women of different racial, cultural, and ethnic origins, women with disabilities, women living in urban and rural localities.
The aging and rapid growth of Hispanic, African-American, and Asian populations in the U.S. has further potential to increase ethnic disparities in stroke occurrence, deaths, and disability. A fuller understanding of how gender, cultural, ethnic, and socioeconomic differences may influence the causes, diagnoses, progression, treatment, and rehabilitation of stroke is critical.
Disparities in healthcare accessibility and utilization among gender and ethnic groups require further examination. Outreach programs in stroke prevention targeting high-risk minority groups need further development and mobilization. By seeking to fund medical research and to promote public awareness about stroke in women of all cultural and ethnic backgrounds, The Goddess Fund is committed to eliminating the impact of stroke from the lives of women in all populations.
Click here to download a PDF file of our Multi-ethnicity brochure.