Disparities in knowledge of heart attack and stroke symptoms among adult men: an analysis of behavioral risk factor surveillance survey data

Health Inequity and Time From Pediatric Stroke Onset to Arrival

BACKGROUND

Time from stroke onset to hospital arrival determines treatment and impacts outcome. Structural, socioeconomic, and environmental factors are associated with health inequity and onset-to-arrival in adult stroke. We aimed to assess the association between health inequity and onset-to-arrival in a pediatric comprehensive stroke center.

METHODS

A retrospective observational study was conducted on a consecutive cohort of children (>28 days-18 years) diagnosed with acute arterial ischemic stroke (AIS) between 2004 and 2019. Neighborhood-level material deprivation was derived from residential postal codes and used as a proxy measure for health inequity. Patients were stratified by level of neighborhood-level material deprivation, and onset-to-arrival was categorized into 3 groups: <6, 6 to 24, and >24 hours. Association between neighborhood-level material deprivation and onset-to-arrival was assessed in multivariable ordinal logistic regression analyses adjusting for sociodemographic and clinical factors.

RESULTS

Two hundred and twenty-nine children were included (61% male; median age [interquartile range] at stroke diagnosis 5.8-years [1.1-11.3]). Over the 16-year study period, there was an increase in proportion of children diagnosed with AIS living in the most deprived neighborhoods and arriving at the emergency room within 6 hours (P=0.01). Among Asian patients, a higher proportion lived in the most deprived neighborhoods (P=0.02) and level of material deprivation was associated with AIS risk factors (P=0.001).

CONCLUSIONS

Our study suggests an increase in pediatric stroke in deprived neighborhoods and certain communities, and earlier arrival times to the emergency room over time. However, whether these changes are due to an increase in incidence of childhood AIS or increased awareness and diagnosis is yet to be determined. The association between AIS risk factors and material deprivation highlights the intersectionality of clinical factors and social determinants of health. Finally, whether material deprivation impacts onset-to-arrival is likely complex and requires further examination.

Ethnic differences of the care pathway following an out-of-hospital cardiac event: A systematic review

AIM

This systematic review aimed to determine to what extent and why the care pathways for acute cardiac events in the community might differ for minoritised ethnic populations compared to non-minoritised populations. It also sought to identify the barriers and enablers that could influence variations in access to care for minoritised populations.

METHODS

A multi-database search was conducted for articles published between 1 January 2000 and 1 January 2023. A combination of MeSH terms and keywords was used. Inclusion criteria for papers were published in English, adult population, the primary health condition was an acute cardiac event, and the primary outcomes were disaggregated by ethnicity or race. A narrative review of extracted data was performed, and findings were reported according to the PRISMA 2020 guidelines.

RESULTS

Of the 3552 articles identified using the search strategy, 40 were deemed eligible for the review. Studies identified a range of variables in the care pathway that differed by ethnicity or race. These could be grouped as time to care, transportation, event related-variables, EMS interactions and symptoms. A meta-analysis was not performed due to heterogeneity across the studies.

CONCLUSION

The extent and reasons for differences in cardiac care pathways are considerable. There are several remediable barriers and enablers that require attention to achieve equitable access to care for minoritised populations.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Thrombolytic Refusal Over Telestroke

Background

Tissue plasminogen activator (tPA) refusal is 4%-6% for acute ischemic stroke (AIS) in the emergency department. Telestroke (TS) has increased the use of tPA for AIS but is accompanied by barriers in communication that can affect tPA consent. We characterized the incidence of tPA refusal in our TS network and its associated reasons.

Methods

Patients with AIS who were offered tPA within 4.5 hours from symptom onset according to American Heart Association guidelines were identified within our Lone Star Stroke Consortium Telestroke Registry from September 2015 to December 2018. We compared baseline characteristics and clinical outcomes between patients who refused tPA and patients who accepted tPA.

Results

Among the 1,242 patients who qualified for tPA and were offered treatment, 8% refused tPA. Female and non-Hispanic Black patients and patients with a prior history of stroke were more likely to decline tPA. Patients who refused tPA presented with a lower NIHSS and were associated with a final diagnosis of stroke mimic (odds ratio [OR] 0.23; 95% confidence interval [CI] 0.15-0.36). Good outcome (90-day modified Rankin Scale 0-2) was the same among patients who received tPA and those who refused (OR 0.80; 95% CI 0.42-1.54). The most common reasons for refusal were rapidly improving and mild/nondisabling symptoms and concern for potential side effects.

Conclusion

tPA refusal over TS is comparable to previously reported rates; there was no difference in outcomes among patients who received tPA compared with those who refused. Sex and racial differences associated with an increased tPA refusal warrant further investigation in efforts to achieve equity/parity in tPA decisions.

Health Literacy in Korean Adults and Korean American Immigrants: Implications for Achieving Health Equity

Health literacy is necessary to understand health information and make appropriate decisions regarding one's health. This study aims to investigate (1) the health literacy level of Korean citizens and Korean American (KA) immigrants in the United States and (2) factors that influence health literacy across three age groups. A quota sampling method was used to collect cross-sectional survey data from 404 Korean participants and 404 KA immigrants. Andersen's behavioral model was used as the theoretical framework for this study. Overall, Korean participants had a higher mean score on health literacy than did the KA immigrants. Only one of predisposing and enabling factors were significant variables influencing health literacy in KA immigrants, while several predisposing, enabling and need factors were significantly associated with health literacy in Korean adults. Our findings indicate that both countries need to have a community-based health literacy educational program that is tailored to each age group.

Cardiac symptom attribution and knowledge of the symptoms of acute myocardial infarction: a systematic review

BACKGROUND

Since the knowledge of the symptoms of acute myocardial infarction (AMI) may reduce the decision time for patients to seek help in case of an AMI, we aimed to summarize evidence on the knowledge of the AMI symptoms and the symptom attribution in case of an acute coronary syndrome (ACS).

METHODS

Therefore, we systematically searched the databases PubMed, CINAHL, Embase, and Cochrane Library for relevant studies published between January 1, 2008 and 2019 (last search August 1, 2019).

RESULTS

A total of 86 studies were included, with a composite sample size of 354,497 participants. The weighted mean of the knowledge scores for the symptoms of AMI of 14,420 participants from the general population, was 42.1% (when maximum score was considered 100%) and 69.5% for 7642 cardiac patients. There was a substantially better level of knowledge for six symptoms ('chest pain or discomfort', 'shortness of breath', 'pain or discomfort in arms or shoulders', 'feeling weak, lightheaded, or faint', 'pain or discomfort in the jaw, neck, or back', and 'sweating') (49.8-88.5%) compared to the four less obvious/atypical symptoms 'stomach or abdominal discomfort', 'nausea or vomiting', 'headache', and 'feeling of anxiety' (8.7-36.7%). Only 45.1% of 14,843 patients, who experienced ACS, have correctly attributed their symptoms to a cardiac cause.

CONCLUSION

In conclusion, we found a moderate to good knowledge of "classic" and insufficient knowledge of less obvious symptoms of AMI. This might suggest that increasing knowledge about less obvious symptoms of AMI could be beneficial. It appears also important to address cardiac attribution of symptoms.

Knowledge of heart attack and stroke symptoms among US Native American Adults: a cross-sectional population-based study analyzing a multi-year BRFSS database

Background

Heart disease and stroke are among the leading causes of death in Native Americans. Knowledge of heart attack and stroke symptomology are essential for prompt identification of symptoms and for appropriate action in seeking care. Knowledge of heart attack and stroke symptoms among US Native American adults was this study’s focus.

Methods

Multivariate techniques were used to analyze national surveillance data. Native American adults comprised the study population. Low heart attack and stroke knowledge score was the dependent variable.

Results

Logistic regression analysis yielded that Native American adults with low heart attack and stroke composite knowledge scores were more likely to be: older, less educated, poorer, uninsured, a rural resident, male, without a primary health care provider, and lacking a recent medical checkup.

Conclusions

The identified characteristics of Native American adults with heart attack and stroke knowledge deficits or disparities should guide educational initiatives by health care providers focusing on improving such knowledge.

Variation and Disparities in Awareness of Myocardial Infarction Symptoms Among Adults in the United States

IMPORTANCE

Prompt recognition of myocardial infarction symptoms is critical for timely access to lifesaving emergency cardiac care. However, patients with myocardial infarction continue to have a delayed presentation to the hospital.

OBJECTIVE

To understand the variation and disparities in awareness of myocardial infarction symptoms among adults in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the 2017 National Health Interview Survey among adult residents of the United States, assessing awareness of the 5 following common myocardial infarction symptoms among different sociodemographic subgroups: (1) chest pain or discomfort, (2) shortness of breath, (3) pain or discomfort in arms or shoulders, (4) feeling weak, lightheaded, or faint, and (5) jaw, neck, or back pain. The response to a perceived myocardial infarction (ie, calling emergency medical services vs other) was also assessed.

MAIN OUTCOMES AND MEASURES

Prevalence and characteristics of individuals who were unaware of myocardial infarction symptoms and/or chose not to call emergency medical services in response to these symptoms.

RESULTS

Among 25 271 individuals (13 820 women [51.6%; 95% CI, 50.8%-52.4%]; 17 910 non-Hispanic white individuals [69.9%; 95% CI, 68.2%-71.6%]; and 21 826 individuals [82.7%; 95% CI, 81.5%-83.8%] born in the United States), 23 383 (91.8%; 95% CI, 91.0%-92.6%) considered chest pain or discomfort a symptom of myocardial infarction; 22 158 (87.0%; 95% CI, 86.1%-87.8%) considered shortness of breath a symptom; 22 064 (85.7%; 95% CI, 84.8%-86.5%) considered pain or discomfort in arm a symptom; 19 760 (77.0%; 95% CI, 76.1%-77.9%) considered feeling weak, lightheaded, or faint a symptom; and 16 567 (62.6%; 95% CI, 61.6%-63.7%) considered jaw, neck, or back pain a symptom. Overall, 14 075 adults (53.0%; 95% CI, 51.9%-54.1%) were aware of all 5 symptoms, whereas 4698 (20.3%; 95% CI, 19.4%-21.3%) were not aware of the 3 most common symptoms and 1295 (5.8%; 95% CI, 5.2%-6.4%) were not aware of any symptoms. Not being aware of any symptoms was associated with male sex (odds ratio [OR], 1.23; 95% CI, 1.05-1.44; P = .01), Hispanic ethnicity (OR, 1.89; 95% CI, 1.47-2.43; P < .001), not having been born in the United States (OR, 1.85; 95% CI, 1.47-2.33; P < .001), and having a lower education level (OR, 1.31; 95% CI, 1.09-1.58; P = .004). Among 294 non-Hispanic black or Hispanic individuals who were not born in the United States, belonged to the low-income or lowest-income subgroup, were uninsured, and had a lower education level, 61 (17.9%; 95% CI, 13.3%-23.6%) were not aware of any symptoms. This group had 6-fold higher odds of not being aware of any symptoms (OR, 6.34; 95% CI, 3.92-10.26; P < .001) compared with individuals without these characteristics. Overall, 1130 individuals (4.5%; 95% CI, 4.0%-5.0%) chose a different response than calling emergency medical services in response to a myocardial infarction.

CONCLUSIONS AND RELEVANCE

Many adults in the United States remain unaware of the symptoms of and appropriate response to a myocardial infarction. In this study, several sociodemographic subgroups were associated with a higher risk of not being aware. They may benefit the most from targeted public health initiatives.

Knowledge and Poor Understanding Factors of Stroke and Heart Attack Symptoms

OBJECTIVES

Adequate awareness of cardiovascular disease (CVD) may help in its prevention and control. Therefore, we evaluated knowledge among the general population of stroke and heart attack symptoms and determined the factors associated with poor understanding of CVD.

METHODS

This cross-sectional study included 228,240 adults (102,408 males, 125,832 females) who participated in the 2017 Korean Community Health Survey. Data on sociodemographic characteristics and cognizance of the warning signs of CVD events (stroke and heart attack) were examined. Logistic regression analysis was used to investigate factors associated with poor understanding of CVD.

RESULTS

The stroke and heart attack warning signs that were identified least often by respondents were "sudden poor vision in one or both eyes" (66.1%) and "pain or discomfort in the arm or shoulder" (53.8%). Of the subjects, 19.0% had low CVD knowledge scores (less than 4 out of 10) with males having lower scores than females. In the multivariate analysis, poor understanding of CVD warning signs was significantly associated with older age, male gender, lower education level, lack of regular exercise, unmarried status, unemployment, poor economic status, poor health behaviors (high salt diet, no health screening), poor psychological status (high stress, self-perceived poor health status), and the presence of hypertension or dyslipidemia.

CONCLUSIONS

Specialized interventions, including those based on public education, should focus on groups with less knowledge of CVD.

Association between diabetes-specific health literacy and health-related quality of life among elderly individuals with pre-diabetes in rural Hunan Province, China: a cross-sectional study

OBJECTIVES

To examine the association between diabetes-specific health literacy (DSHL) and health-related quality of life (HRQoL) among elderly individuals with pre-diabetes in rural China.

DESIGN, SETTING AND PARTICIPANTS

This cross-sectional study included 434 elderly individuals with pre-diabetes from 42 villages in rural China.

MAIN OUTCOME MEASURES

HRQoL was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey. DSHL was measured by a validated questionnaire in China. Differences in HRQoL between groups with and without high DSHL were tested by multivariate analysis of covariance (MANCOVA).

RESULTS

The prevalence of pre-diabetes was 21.5%. The average age of participants (n=434) was 69.4±6.4 years, and 58.5% were female. Bivariate analysis showed that those with high DSHL had increases of 2.9 points in the physical health component score and 4.4 points in the mental health component score (MCS) compared with those without. After adjustment for potential confounders, a significant MANCOVA model (Wilks' λ=0.974, F=5.63, p=0.004) indicated that individuals with pre-diabetes who had high DSHL reported higher MCS (M_diff=3.5, 95% CI 1.8 to 6.3, effect size=0.38). This remained significant across subscales: general health (p=0.028), vitality (p=0.014), social functioning (p=0.017) and mental health (p=0.005).

CONCLUSIONS

Low DSHL was associated with worsening HRQoL among elderly individuals with pre-diabetes in rural China, particularly in the mental health components.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-15007033.

Persistence of socioeconomic inequalities in the knowledge of cardiovascular risk factors five years after coronary angiography

BACKGROUND

Cardiovascular diseases are important causes of death, morbidity, and years of potential life lost in most developed countries.

AIMS

The purpose of this study was to assess trends in knowledge of cardiovascular risk factors among patients five years after coronary angiography and to investigate the impact of educational level on knowledge level.

METHODS

The study included 1289 of 4391 patients admitted for cardiac events in 2008/2009 at the National Institute for Cardiac Surgery and Interventional Cardiology, Luxembourg. A follow-up study was conducted by post five years later (2013/2014). Data were obtained from 1837 of the contacted patients (with 548 reported deaths) (response rate=42%). Logistic regression models were used to evaluate the association between educational level and knowledge of cardiovascular risk factors. Educational level was used as a surrogate for socioeconomic status.

RESULTS

In total, 39.9% of patients could list at least three risk factors in 2013/2014, a much higher percentage than the 8.5% observed during the initial survey. In both sexes, knowledge of cardiovascular risk factors increased between 2008/2009 and 2013/2014. Patients with higher educational levels were more likely (odds ratio=2.33, 95% confidence interval: 1.63-3.34) to cite at least three risk factors than patients with lower education levels.

CONCLUSION

Knowledge level was associated with educational level, and improved for all educational groups five years after coronary angiography. Educational differences in knowledge persisted, but the gaps decreased. Improving knowledge of cardiovascular risk factors among patients with cardiovascular disease will help increase awareness and promote lifestyle changes.

Racial disparities in refusal of stroke thrombolysis in Chicago

OBJECTIVE

To evaluate race differences in tissue plasminogen activator (tPA) refusal among eligible patients with acute ischemic stroke (AIS) in Chicago.

METHODS

Using the Get With The Guidelines-Stroke registry data from 15 primary stroke centers between January 2013 and June 2015, we performed a retrospective analysis of patients with AIS presenting to the emergency department within 4.5 hours from symptom onset. Patient or proxy refusal was captured as a reason for nonadministration of tPA to eligible patients in the registry. We assessed whether tPA refusal differed by race using logistic regression.

RESULTS

Among 704 tPA-eligible patients with AIS, tPA was administered to 86.2% (black race, 82.5% vs nonblack race, 89.5%; p < 0.001). Fifty-three (7.5%) tPA refusals were documented. Refusal was more common in black vs nonblack patients (10.6% vs 4.8%; p = 0.004). In multivariable analysis, the following were associated with tPA refusal: black race (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] 1.3-4.6), self-pay status (adjusted OR 3.23, 95% CI 1.2-8.71), prior stroke (adjusted OR 2.11, 95% CI 1.14-3.90), age (adjusted OR 1.04, 95% CI 1.02-1.07), and NIH Stroke Scale score (adjusted OR 0.94, 95% CI 0.90-0.99).

CONCLUSIONS

Among tPA-eligible patients with AIS in Chicago, over 7% refused tPA. Refusal was more common in black patients and accounted for the apparent lower rates of tPA use in black vs nonblack patients. Further research is needed to understand barriers to consent and overcome race-ethnic disparities in tPA treatment for AIS.

Community-Level Measures of Stroke Knowledge among Children: Findings from Hip Hop Stroke

BACKGROUND

Community-level determinants of stroke knowledge among children are unknown but could meaningfully impact public stroke education campaigns. We explored for associations between community- and school-level quality measures relative to baseline stroke knowledge among children participating in the Hip Hop Stroke program.

METHODS

Baseline stroke knowledge assessments were performed in 2839 fourth-, fifth-, and sixth-grade students (ages 9-11 years) from November 2005 to April 2014. Knowledge was assessed relative to school performance grade (SPG, graded A-F; a school-level measure determined by the New York City [NYC] Department of Education) and economic need index (ENI, range: 0-2; a community-level, within-school measure of subsidized housing and meals with higher scores indicating more socioeconomic distress).

RESULTS

Schools studied included those with SPG = B (n = 196), SPG = C (n = 1590), and SPG = D (n = 1053) and mean ENI = .85 (standard deviation: .23). A composite assessment of knowledge, including 4 stroke symptoms (blurred vision, facial droop, sudden headache, and slurred speech), was conducted consistently since 2006. Overall, students correctly identified a mean of 1.74 stroke symptoms (95% confidence interval: 1.70-1.79; possible range: 0-4, expected value of chance response alone or no knowledge = 2). For quartiles of ENI, mean knowledge scores are as follows: ENI_Q1 = 2.00, ENI_Q2 = 2.09, ENI_Q3 = 1.46, and ENI_Q4 = 1.56 (ENI_Q3 and ENI_Q4 versus ENI_Q1, P < .001). For SPG, SPG = B schools: 2.09, SPG = C: 1.83, and SPG = D: 1.56 (SPG = C and SPG = D versus SPG = B schools, P ≤ .05).

CONCLUSIONS

Children's stroke knowledge was lowest in NYC communities with greater economic need and lower school performance. These findings could guide stroke education campaign implementation strategies.

A cross-sectional study of the effect of health literacy on diabetes prevention and control among elderly individuals with prediabetes in rural China

OBJECTIVES

This study was designed to examine the effect of health literacy on diabetes prevention and control and risk factors for low diabetes health literacy among elderly individuals with prediabetes in rural areas in China.

DESIGN SETTING AND PARTICIPATES

A cross-sectional survey was conducted among elderly individuals in rural communities in Yiyang City in China. Multi-staged cluster random sampling was used to select 42 areas and 434 individuals with prediabetes who were interviewed using a questionnaire on diabetes health literacy in China.

MAIN OUTCOME MEASURES

Participants were asked for general information (age, gender, marital status, history of hyperglycaemia, family history of diabetes mellitus, presence of other diseases and level of education). Binary logistic regression analysis was used to identify risk factors for poor health literacy concerning diabetes prevention and control among elderly subjects with prediabetes.

RESULTS

The median health literacy score for diabetes prevention and prediabetes control was 10.0 (IQR 7.0-13.0). The level of diabetes health literacy among men was lower than among women (OR 2.831, 95% CI 1.818 to 4.408), and lower among respondents with 1-6 years of education than among those with 6 years or more of education (OR 14.274, 95% CI 5.927 to 34.375). Those with less than 1 year of education had the lowest literacy (OR 31.148, 95% CI 11.661 to 83.204). The level of diabetes health literacy among elderly individuals with prediabetes but no history of hyperglycaemia was lower than among those with a history of hyperglycaemia (OR 2.676, 95% CI 1.101 to 6.504).

CONCLUSIONS

Health literacy concerning diabetes prevention and control among elderly individuals with prediabetes was very low in rural China. Appropriate health education for elderly individuals with low educational levels should be incorporated into diabetes prevention efforts.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-15007033; Results.

Stroke Knowledge in African Americans: A Narrative Review

OBJECTIVE

The purpose of this review is to evaluate the state of knowledge in regard to stroke literacy in African Americans. This topic is important for assessing the specific gaps in stroke knowledge for this population, as well as to evaluate the methodology that has been used to assess stroke literacy.

METHODS

This narrative review includes studies that evaluated and reported stroke knowledge in African Americans and were published between January 2000 and October 2015.

RESULTS

Our review revealed that disparities may exist in recognition of headache and visual symptoms, knowledge of the organ in which stroke occurs, and identification of tobacco use as a risk factor. Stress may be perceived as a more important risk factor among African Americans than among White Americans. The literature does not suggest disparities in knowledge of the appropriate action to take for stroke.

CONCLUSIONS

Racial disparities may exist for specific domains of stroke knowledge. Future studies should explore specific gaps in knowledge to be addressed in stroke prevention interventions for African Americans. Standardization of methods is needed to aid comparisons across populations. The relationship between stroke knowledge and clinical outcomes also needs to be evaluated.

The correlates of chronic disease-related health literacy and its components among men: a systematic review

Background

Chronic diseases drive the burden of disease in many societies, particularly among men. Lifestyle behaviours are strongly associated with chronic disease development, and in a number of countries men tend to engage in more risky behaviours, and have lower health knowledge and attention to prevention, than women. This study investigated the correlates of men’s health literacy and its components about major lifestyle-related diseases, namely ischaemic heart disease and type 2 diabetes mellitus, to gain evidence to guide the development of policy and programs to improve men’s health.

Methods

A systematic review was undertaken of observational studies that investigated men’s health literacy and its components related to ischaemic heart disease or type 2 diabetes mellitus, and their associated risk factors. The Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycINFO, Embase and the Cochrane Library databases were searched for articles published since 2003. The strength of the evidence was rated using the GRADE approach.

Results

After screening and review of 504 articles, the search elicited nine studies for inclusion: only one study examined health literacy (nutrition literacy). The majority of included studies focused on only one component of health literacy, namely knowledge (n = 7) and personal skills (confidence) (n = 1). Twenty correlates were identified, primarily relating to the knowledge component, with the strength of the evidence for only one correlate, education, graded as being of moderate quality. The evidence for all other correlates was graded as being of low quality.

Conclusions

The limited body of research identified may have resulted from a lack of consensus about the definition of health literacy, and a concordant set of validated health literacy measures. Despite these limitations, broadening the search to include components of health literacy has identified that several factors are associated with men’s knowledge and awareness of ischaemic heart disease and type 2 diabetes mellitus that will assist in the development of men’s health promotion strategies. However, addressing the broader knowledge gaps and controversy in the health literacy field will deliver policy and program benefits to address these major contributors to the burden of disease among men.

Stroke Outreach in an Inner City Market: A Platform for Identifying African American Males for Stroke Prevention Interventions

BACKGROUND

There are significant racial disparities in stroke incidence and mortality. Health fairs and outreach programs can be used to increase stroke literacy, but they often fail to reach those at highest risk, including African American males.

METHODS

We conducted a stroke outreach and screening program at an inner city market in order to attract a high-risk group for a stroke education intervention. A modified Framingham risk tool was used to estimate stroke risk and a 10-item quiz was developed to assess stroke literacy among 80 participants. We report results of the demographic and stroke risk analyses and stroke knowledge assessment.

RESULTS

The program attracted a majority male (70%) and African American (95%) group of participants. Self-reported hypertension (57.5%), tobacco use (40%), and diabetes (23.8%) were prevalent. Knowledge of stroke warning signs, risk factors, and appropriate action to take for stroke symptoms was not poor when compared to the literature.

CONCLUSION

Stroke outreach and screening in an inner city public market may be an effective way to target a high-risk population for stroke prevention interventions. Stroke risk among participants was high despite adequate stroke knowledge.

Use of oral anticoagulants in African-American and Caucasian patients with atrial fibrillation: is there a treatment disparity?

Atrial fibrillation (AF) is a very common cardiac arrhythmia, and its prevalence is increasing along with aging in the developed world. This review discusses racial differences in the epidemiology and treatment of AF between African-American and Caucasian patients. Additionally, the effect of race on warfarin and novel oral anticoagulant use is discussed, as well as the role that physicians and patients play in achieving optimal treatment outcomes. Despite having a lower prevalence of AF compared with Caucasians, African-Americans suffer disproportionately from stroke and its sequelae. The possible reasons for this paradox include poorer access to health care, lower health literacy, and a higher prevalence of other stroke-risk factors among African-Americans. Consequently, it is important for providers to evaluate the effects of race, health literacy, access to health care, and cultural barriers on the use of anticoagulation in the management of AF. Warfarin-dose requirements vary across racial groups, with African-American patients requiring a higher dose than Caucasians to maintain a therapeutic international normalized ratio; the novel oral anticoagulants (dabigatran, rivaroxaban, and apixaban) seem to differ in this regard, although data are currently limited. Minority racial groups are not proportionally represented in either real-world studies or clinical trials, but as more information becomes available and other social issues are addressed, the treatment disparities between African-American and Caucasian patients should decrease.

Knowledge of heart attack and stroke symptomology: a cross-sectional comparison of rural and non-rural US adults

Background

Understanding the signs and symptoms of heart attacks and strokes are important not only in saving lives, but also in preserving quality of life. Findings from recent research have yielded that the prevalence of cardiovascular disease risk factors are higher in rural populations, suggesting that adults living in rural locales may be at higher risk for heart attack and/or stroke. Knowledge of heart attack and stroke symptomology as well as calling 911 for a suspected heart attack or stroke are essential first steps in seeking care. This study sought to examine the knowledge of heart attack and stroke symptoms among rural adults in comparison to non-rural adults living in the U.S.

Methods

Using multivariate techniques, a cross-sectional analysis of an amalgamated multi-year Behavioral Risk Factor Surveillance Survey (BRFSS) database was performed. The dependent variable for this analysis was low heart attack and stroke knowledge score. The covariates for the analysis were: age, sex, race/ethnicity, annual household income, attained education, health insurance status, having a health care provider (HCP), timing of last routine medical check-up, medical care deferment because of cost, self-defined health status and geographic locale.

Results

The weighted n for this study overall was 103,262,115 U.S. adults > =18 years of age. Approximately 22.0% of these respondents were U.S. adults living in rural locales. Logistic regression analysis revealed that those U.S. adults who had low composite heart attack and stroke knowledge scores were more likely to be rural (OR = 1.218 95%CI 1.216-1.219) rather than non-rural residents. Furthermore, those with low scores were more likely to be: male (OR = 1.353 95%CI 1.352-1.354), >65 years of age (OR = 1.369 95%CI 1.368-1.371), African American (OR = 1.892 95%CI 1.889-1.894), not educated beyond high school (OR = 1.400 955CI 1.399-1.402), uninsured (OR = 1.308 95%CI 1.3-6-1.310), without a HCP (OR = 1.216 95%CI 1.215-1.218), and living in a household with an annual income of < $50,000 (OR = 1.429 95%CI 1.428-1.431).

Conclusions

Analysis identified clear disparities between the knowledge levels U.S. adults have regarding heart attack and stroke symptoms. These disparities should guide educational endeavors focusing on improving knowledge of heart attack and stroke symptoms.

Public knowledge of the symptoms of myocardial infarction: a street survey in Birmingham, England

BACKGROUND

Myocardial infarction (MI) is a leading cause of death in the UK. A good clinical outcome depends on rapid treatment following the onset of symptoms. A person's knowledge of typical symptoms determines how quickly they present to the medical services.

OBJECTIVES

To investigate knowledge of MI symptoms among the general population and the relationship between age, gender and socio-economic status with knowledge.

METHODS

Street survey of 302 participants in Birmingham, UK, using an interviewer-assisted questionnaire.

RESULTS

Of seven symptoms accepted in the medical literature as typical of an MI, central chest pain was the most frequently identified (75% of the sample), followed by arm pain or numbness (40%), shortness of breath (35%), fainting or dizziness (21%) and sweating (21%). Feeling or being sick and neck or jaw pain were mentioned by 8.1% and 5.9%, respectively, while an atypical or inapplicable symptom, collapse (9.9%) was mentioned more often than these. Over half the sample knew only two or fewer MI symptoms. The mean number of typical symptoms identified was 2.2 (SD = 1.28). Respondents from professional occupations and those with previous experience of MI, whether direct or indirect, showed better awareness.

CONCLUSIONS

The study demonstrated a paucity of knowledge of MI symptoms among the general public. Such findings provide a baseline to guide public health campaigns targeting awareness of MI.

Are racial disparities in stroke care still prevalent in certified stroke centers?

Racial differences in stroke risk and risk factor prevalence are well established. The present study explored racial differences in the delivery of care to patients with acute stroke between Joint Commission (JC)-certified hospitals and noncertified hospitals. A retrospective chart review was conducted in patients sustaining ischemic stroke admitted to 5 JC-certified centers and 5 noncertified hospitals. Demographic data, risk factors, utilization of acute stroke therapies, and compliance with core measures were recorded. Racial disparities were investigated in the entire group as well as for JC-certified and noncertified hospitals separately. A total of 574 patients (25.1% African Americans) were included. African Americans were significantly younger and more likely to have previous stroke, whereas Caucasians were more likely to have coronary disease and atrial fibrillation. There were no racial differences in other risk factors or baseline functions. Median National Institutes of Health Stroke Scale scores were similar in African Americans and Caucasians, as were proportions receiving intravenous tissue plasminogen activator (tPA) therapy (2.1% in African Americans, 3.5% in Caucasians; P = .40) and intervention (4.2% in African Americans, 6.8% in Caucasians; P = .26). Caucasians were more likely to arrive by emergency medical services (65.5% vs 51.5%; P = .004), to be evaluated by a stroke team (19.1% vs 7.7%; P = .001), and to have a documented National Institutes of Health Stroke Scale score (40.2% vs 29.9%; P = .03). African Americans often did not receive intravenous tPA because of a delay in arrival. African Americans performed better on virtually all stroke care variables in JC-certified centers. JC certification reduced disparity in certain variables, including tPA and deep venous thrombosis prophylaxis administration. Important racial disparities exist in the delivery of several acute stroke care variables. Efforts must be focused on eliminating disparities in prehospital delays. Guideline-based care tendered at JC-certified centers might help narrow disparities in acute stroke care delivery.

Knowledge of stroke and heart attack symptoms and risk factors among rural elderly people: a questionnaire survey

Background and Objectives

To determine the level of knowledge of stroke and heart attack (HA) symptoms and risk factors of cardiovascular disease (CVD) in rural elderly people who are at risk for CVD.

Subjects and Methods

A total of 444 adults over the age of 60 living in a rural province of Korea with at least one CVD risk factor participated in this survey.

Results

A total of 72.5% of the participants had hypertension and 28.4% had diabetes, whereas approximately 40% exhibited over two CVD risk factors. The mean knowledge scores for HA symptoms (4.3/9) were lower than scores for stroke symptoms (5.8/9), and the mean knowledge score for risk factors was 7.3/11. Stepwise multiple regression analyses showed that old age, low level of education, and low income level were the determining factors for low knowledge levels of stroke and HA symptoms as well as CVD risk factors. A low perceived risk of stroke or HAs also predicted a low knowledge of CVD risk factors.

Conclusion

Community-wide public campaigns are needed, which are designed to help elderly people in rural areas with low education levels and socioeconomic status at risk for CVD to improve the awareness of stroke and HA.

Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

Our goal is to describe the effect of race and ethnicity on stroke epidemiology, personal beliefs, access to care, response to treatment, and participation in clinical research. In addition, we seek to determine the state of knowledge on the main factors that may explain disparities in stroke care, with the goal of identifying gaps in knowledge to guide future research. The intended audience includes physicians, nurses, other healthcare professionals, and policy makers.

METHODS

Members of the writing group were appointed by the American Heart Association Stroke Council Scientific Statement Oversight Committee and represent different areas of expertise in relation to racial-ethnic disparities in stroke care. The writing group reviewed the relevant literature, with an emphasis on reports published since 1972. The statement was approved by the writing group; the statement underwent peer review, then was approved by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

There are limitations in the definitions of racial and ethnic categories currently in use. For the purpose of this statement, we used the racial categories defined by the US federal government: white, black or African American, Asian, American Indian/Alaskan Native, and Native Hawaiian/other Pacific Islander. There are 2 ethnic categories: people of Hispanic/Latino origin or not of Hispanic/Latino origin. There are differences in the distribution of the burden of risk factors, stroke incidence and prevalence, and stroke mortality among different racial and ethnic groups. In addition, there are disparities in stroke care between minority groups compared with whites. These disparities include lack of awareness of stroke symptoms and signs and lack of knowledge about the need for urgent treatment and the causal role of risk factors. There are also differences in attitudes, beliefs, and compliance among minorities compared with whites. Differences in socioeconomic status and insurance coverage, mistrust of the healthcare system, the relatively limited number of providers who are members of minority groups, and system limitations may contribute to disparities in access to or quality of care, which in turn might result in different rates of stroke morbidity and mortality. Cultural and language barriers probably also contribute to some of these disparities. Minorities use emergency medical services systems less, are often delayed in arriving at the emergency department, have longer waiting times in the emergency department, and are less likely to receive thrombolysis for acute ischemic stroke. Although unmeasured factors may play a role in these delays, the presence of bias in the delivery of care cannot be excluded. Minorities have equal access to rehabilitation services, although they experience longer stays and have poorer functional status than whites. Minorities are inadequately treated with both primary and secondary stroke prevention strategies compared with whites. Sparse data exist on racial-ethnic disparities in access to surgical care after intracerebral hemorrhage and subarachnoid hemorrhage. Participation of minorities in clinical research is limited. Barriers to participation in clinical research include beliefs, lack of trust, and limited awareness. Race is a contentious topic in biomedical research because race is not proven to be a surrogate for genetic constitution.

CONCLUSIONS

There are limitations in the current definitions of race and ethnicity. Nevertheless, racial and ethnic disparities in stroke exist and include differences in the biological determinants of disease and disparities throughout the continuum of care, including access to and quality of care. Access to and participation in research is also limited among minority groups. Acknowledging the presence of disparities and understanding the factors that contribute to them are necessary first steps. More research is required to understand these differences and find solutions.

A review of the evidence for disparities in child vs adult health care: a disparity in disparities

Racial and ethnic health disparities in primary care have been well documented in the US healthcare system. However, very little attention has been directed toward inequities in child health. The aim of this review is to provide context for the scope of the challenges associated with addressing pediatric health disparities in primary care by comparing the weight of evidence regarding racial/ethnic health disparities for children vs adults. A multisystem health disparities conceptual model will frame the search strategy and analysis of the review. This paper will: (1) identify knowledge deficits in the understanding of existing disparities in pediatric primary care relative to adult primary care; (2) assess root causes of disparities for children vs adults; and (3) propose recommendations for a research agenda and policy implementation to eliminate disparities in pediatric primary care.

Stroke education: discrepancies among factors influencing prehospital delay and stroke knowledge

BACKGROUND

Time is essential for the treatment of acute stroke. Much time is lost outside the hospital, either due to failure in identifying stroke symptoms or due to a delay in notification or transport. We review studies reporting factors associated with better stroke knowledge and shorter time delays. We summarise the evidences for the effect of stroke knowledge and education on people's reaction in the acute situation of stroke.

METHODS

We searched MEDLINE for studies reporting factors associated with prehospital time of stroke patients, or knowledge of stroke symptoms. Further, we searched for studies reporting educational interventions aimed at increasing stroke symptom knowledge in the population.

FINDINGS

We included a total of 182 studies. Surprisingly, those factors associated with better stroke knowledge such as education and sociodemographic variables were not related to shorter time delays. Few studies report shorter time delays or better stroke knowledge in persons having suffered a previous stroke. Factors associated with shorter time delays were more severe stroke and symptoms regarded as serious, but not better knowledge about the most frequent symptoms such as hemiparesis or disorders of speech. Only 25-56% of patients recognised their own symptoms as stroke. While stroke education increases the knowledge of warning signs, a few population studies measured the impact of education on time delays; in such studies, time delays decreased after education. This may partly be mediated by better organisation of EMS and hospitals.

INTERPRETATION

There is a discrepancy between theoretical stroke knowledge and the reaction in an acute situation. Help-seeking behaviour is more dependent on the perceived severity of symptoms than on symptom knowledge. Bystanders play an important role in the decision to call for help and should be included in stroke education. Education is effective and should be culturally adapted and presented in a social context. It is unclear which educational concept is best suited to enhance symptom recognition in the acute situation of stroke, especially in view of discrepancies between knowledge and action.

Understanding of stroke and coronary heart disease in the UK: an exploratory study

It has been suggested by the UK's 2007 National Stroke strategy for England (NSSFE) that general population awareness is high for coronary heart disease (CHD) but low for stroke. This was investigated in the present study. One hundred eighty-two members of the general public completed a questionnaire about understanding of stroke/CHD. Data were analysed using ANOVA, t-tests and chi square. The main findings were that although members of the general public understood some of the main aspects of stroke and CHD, there was more awareness of general facts about CHD than stroke but symptoms of stroke were better identified compared to CHD. Therefore, our findings only partially supported the NSSFE view.

Stroke prevention: awareness of risk factors for stroke among African American residents in the Mississippi delta region

BACKGROUND

Compared to whites, African Americans have almost a 2-fold increased risk of first-ever stroke. Our study sought to determine awareness of stroke risk factors and management, symptoms, and risk reduction strategies in African Americans in Mississippi, which is part of the "stroke belt.

METHODS

We conducted a cross-sectional survey of African Americans aged 18 to 74. We collected information on awareness, sources of information, stroke risk behavior, diabetes, and hypertension prevalence: and risk reduction relating to nonsmoking, exercise, and knowledge about ideal targets of blood pressure, body mass index, total blood cholesterol, and blood sugar.

RESULTS

The percentage of respondents who identified 1, 2, 3, 4, and 5 warning signs were 21.8%, 11.7%, 15.4%, 10.1%, and 23.9%, respectively; and 17% could not identify any sign. The most factors identified were sudden numbness in the face, arm, or leg, and trouble speaking. Lifestyle factors and their role in stroke were not known to respondents. Specifically, 52.7%, 56.4%, 53.2%, 38.3%, and 28.7% failed to mention lack of physical activity, excessive alcohol consumption, diabetes, smoking, and high cholesterol, respectively, as factors that can contribute to stroke.

CONCLUSION

There is need to improve knowledge of stroke, risk reduction, and appropriate stroke response. Family, friends, and African Americans churches should be utilized to deliver stroke and other health information.

Stroke literacy in Central Harlem: a high-risk stroke population

BACKGROUND

Awareness of stroke warning symptoms and risk factors (stroke literacy), as well as knowledge of available treatment options, may be poor in high-risk populations. We sought to evaluate stroke literacy among residents of Central Harlem, a predominantly African American population, in a cross-sectional study.

METHODS

Ten community-based sites in Central Harlem were identified between 2005 and 2006 for administration of a stroke knowledge survey. Trained volunteers administered in-person closed-ended questionnaires focused on stroke symptoms and risk factors.

RESULTS

A total of 1,023 respondents completed the survey. African Americans comprised 65.7% (n = 672) of the survey cohort. The brain was correctly identified as the site where a stroke occurs by 53.7% of respondents, whereas the heart was incorrectly identified by 20.8%. Chest pain was identified as a symptom of stroke by 39.7%. In multivariable analyses, African Americans (odds ratio [OR] 2.20, 95% confidence interval [CI] 1.09-4.45) and Hispanics (OR 5.27, 95% CI 2.46-11.30) were less likely to identify the brain as the damaged organ in stroke. Hispanics were more likely to incorrectly identify chest pain as a stroke symptom, compared with whites (OR 3.40, 95% CI 1.49-7.77). No associations were found between calling 911 and race/ethnicity and stroke knowledge, although women were more likely than men to call 911 (OR 0.50, 95% CI 0.30-0.80).

CONCLUSION

Significant deficiencies in stroke literacy exist in this high-risk population, especially when compared with national means. Culturally tailored and sustainable educational campaigns should be tested in high-risk populations as part of stroke public health initiatives.

Awareness of heart attack and stroke symptoms among Hispanic male adults living in the United States

There is evidence that Hispanic men are a high risk group for treatment delay for both heart attack and stroke. More targeted research is needed to elucidate this specific population's knowledge of warning signs for these acute events. This study sought to describe within-group disparities in Hispanic men's knowledge of heart attack and stroke symptomology. Multivariate techniques were used to analyze a multi-year Behavioral Risk Factor Surveillance Heart and Stroke module database. The data were cross-sectional and focused on health risk factors and behaviors. The research participants were U.S. male Hispanic adults aged 18-99. The main outcome measure for the study was heart attack and stroke symptom knowledge score. Multivariate logistic regression analysis yielded that Hispanic men aged >or=18 years who earned low scores on the composite heart attack and stroke knowledge questions (range 0-8 points) were more likely to: have less than a high school education, have deferred medical care because of cost, not have an identified health care provider, and be uninsured. There were significant within-group differences. Targeting educational efforts toward older (>or=55 years) Hispanic men with less than high school education, those who do not have an identified health care provider or health insurance, and who defer health care because of cost could be ways to improve the outcome of acute vascular events among the U.S. Hispanic adult male population.

Cognitive Risks of Dyslipidemia

This review discusses evidence-based perspectives on the relationship between dyslipidemia and cognitive decline, including strategic implications for risk reduction in primary care and empirically driven public policy initiatives to prevent cognitive dysfunction.