Lauren Peruski, DO
Levine DA, Duncan PW, Nguyen-Huynh MN, Ogedegbe OG. Interventions Targeting Racial/Ethnic Disparities in Stroke Prevention and Treatment. Stroke. 2020;51:3425–3432.*
Racial/ethnic disparities in health care have been clearly documented and result from unequal treatment. This occurs as a result of biased populations and healthcare systems in the literature that fail to translate to the real-life circumstances and the diverse world that we live in today. If there existed racial/ethnic equality in medicine, an estimated 700,000 deaths may have been avoided. The authors of this article understand the magnitude of this inequality and have eloquently summarized selected interventions aimed at reducing racial/ethnic disparities in stroke prevention and treatment.
Hypertension is one of the most common, and deadly, identified vascular risk factors. It is also one of the top contributors to racial/ethnic disparities in health. Black individuals tend to develop hypertension at an earlier age and have a more severe course of illness than White individuals. Similarly, Hispanic patients are more likely to have worse blood pressure control than White patients. Fortunately, there have been interventions that have been effective in improving control of blood pressure in under-represented racial and ethnic populations. One of the most successful interventions took place in barbershops. In Black male barbershop customers with uncontrolled hypertension, the combination of health promotion by barbers, alongside medication management in the barbershop by specialty-trained pharmacists, resulted in decreased blood pressure at 6 and 12 months. The combination of a barber with a pharmacist appeared to have a more substantial effect than the barber promoting health alone. The pairing of medical professionals with similarly prominent, respected, and trusted members of under-represented racial and ethnic communities may be a way to approach health promotion moving forward.
Less is More
Some interventions have focused on reducing multiple risk factors at once. For example, diet, blood pressure, and physical activity. Thus far, these interventions aimed at reducing multiple vascular risk factors tend to have modest effects on one risk factor, but are not successful overall. Moreover, trials examining secondary stroke prevention in under-represented populations have been less successful than those targeting primary stroke prevention. In the future, we may continue to improve upon a single risk factor at a time and apply the strategies that have been helpful in primary prevention to secondary prevention.
Randomized controlled trials have shown that interventions can be effective at increasing awareness of stroke symptoms in Black and Hispanic populations. This was initially studied when researchers noted that Black patients were more likely than White patients to delay in presenting to the hospital after stroke onset. Similarly, to the previously described hypertension interventions, stroke education was most effective when it was presented within the community. For example, stroke education provided by beauticians improved knowledge of stroke warning signs and calling 911, with the effect sustained for at least five months. Likewise, there was a retention of knowledge in middle school children who were educated on stroke physiology, symptoms, and what to do for witnessed stroke.
The Bigger Picture
At a systemic level, Black and Hispanic individuals in the United States have worse access to care and are more likely to present to low-quality hospitals with worse clinical outcomes. In the outpatient setting, under-represented racial and ethnic groups have greater difficulty accessing specialist care. One way that access to care for stroke prevention and treatment was effective was through the Affordable Care Act and Medicaid expansion. Results from observational studies suggest that these changes decreased cost-related nonadherence to medication and reduced racial/ethnic disparities in insurance coverage.
Meet Patients Where They Are
The article ends with one of my favorite messages, “meet patients where they are.” As providers, we need to be educated not only about science, but about these very real disparities in healthcare that exist today. We need provider training that addresses the recognition of implicit racial/ethnic biases that may be contributing to this problem. We need to recruit under-represented racial and ethnic patients in our clinical trials. We need to think outside the box by getting into the community and educating the public in schools, churches, and barbershops — not only in the office. We need to keep these issues in the forefront of our minds while voting this election season. These issues cannot wait — because history repeats itself, and over the next decade, we can save over 700,000 lives by making sure each patient is given fair, equal, and affordable treatment.
*This article is part of a Focused Updates series of articles on topics related to health equity published in the November 2020 issue of Stroke.