Stroke care is rife with inequities, and fixing them will require more research into issues such as structural racism and other "upstream" social factors that affect where people live, learn, work and play, a new report says.
The report, a scientific statement from the American Heart Association, summarizes research on ways to address racial and ethnic disparities in stroke treatment. It published Monday in the journal Stroke.
The report's authors found that few stroke studies addressed racist policies, such as residential segregation. They also looked at issues such as food availability, economic stability, education quality and access to health insurance.
Such factors – known as social determinants of health – affect stroke incidence, care and outcomes, the report said. But most studies the report reviewed looked at patient-level factors, such as lifestyle, health literacy and whether people take medication properly.
"There are enormous inequities in stroke care, which lead to significant gaps in functional outcomes after stroke for people from historically disenfranchised racial and ethnic groups, including Black, Hispanic and Indigenous peoples," Dr. Amytis Towfighi of the University of Southern California said in a news release. She served as chair of the statement's writing group.
For example, speedy treatment is an essential part of reducing the lasting effects of a stroke caused by a blood clot – the most common type of stroke. Medication to dissolve the clot usually must be administered within three hours after symptoms begin. A procedure to remove a clot may be an option for some people up to 24 hours after stroke symptoms start.
But, Towfighi said, people from historically disenfranchised populations are less likely to get to an emergency room within the time window for treatment. And not all people experiencing a stroke have rapid access to the treatments.
Although Black people are more likely to participate in post-stroke rehabilitation programs, research indicates they are more likely to fare poorly, she said. "In addition, there are persistent racial and ethnic inequities in post-stroke risk factor control, and studies specifically addressing these inequities have not found the optimal method to mitigate the disparities."
Towfighi said that while research has historically focused on describing such inequities, "it is critical to develop and test" ways to address them.
Previous studies indicate that careful attention to stroke preparedness among patients, caregivers and emergency medical personnel may reduce inequities in getting people prompt treatment. However, the statement said, insufficient attention has been paid to post-stroke rehabilitation, recovery and social reintegration. That includes information such as assessing the effect of improved sidewalks and access to physical, occupational and speech therapy.
Towfighi said solutions will require health care professionals to "think outside the 'stroke box.' Sustainable, effective interventions to address inequities will likely require collaboration with patients, their communities, policymakers and other sectors."
The report also said that historically disenfranchised populations are vastly underrepresented in stroke clinical trials, which contributes to the lack of understanding and reduces the generalizability of research findings – exacerbating inequities and leading to worse outcomes.
Bernadette Boden-Albala of the University of California, Irvine, who served as vice chair of the writing group, said it's critical that those populations "participate in research so that researchers may collaborate in addressing the communities' needs and concerns."
The report acknowledges that racial and ethnic identity are complex and that race is a social construct, rather than a biological one.
"In our review, we used the race and ethnicity categories typically supported by governmental research funding agencies that drive how data are collected," Boden-Albala said. "However, we are cognizant that these categories are inadequate to describe the nuances of lived experiences and to fully illuminate inequities that are entrenched in societal structures, including health care."