Stroke Incidence in African Americans - Research Paper Example

 Factors that influence health seeking behaviors of African American patients experiencing acute stroke Symptoms: A systematic review. Table of Contents Abstract………………………………..………………………………………3 Objectives………………………………………………………..…………….3 Search strategy…………………………………………………………….…....3 Methodological Quality…………………………………………………………3 Data Extraction………………………………………………………………….3 Data Synthesis………………………………………………….………………..3 Results………………………………………………………….………………..3 Conclusions………………………………………………………………………4 Key words………………………………………………………………………..4 Background……………………………………………………...……………….5 Stroke in African Americans………………………………………..……………8 Perceived Contributing Factors for Treatment delays………………..………….9 Objective/ Review Questions……………………………………………………..11 Criteria for Selecting Studies for this Review Types of Studies……………………………………….…..……………..12 Types of Participants/Phenomena………………………..……………….12 Search Strategy………………………………………..………………….12 Assessment of methodological Quality…………..……………………….14 Data Extraction and Synthesis Data Synthesis………………………………..……………………………15 Data Extraction………………………………..…………………………...15 Results………………………………………………..…………………………….16 Stroke Literacy…………………………………..………………………………….17 Delay Times…………………………………………………..…………………….18 Stroke Education ……………………………………………..…………………….19 Factors Associated with Health Seeking Behavior……….………………………...20 References………………………………………………………………………….26 Discussion…………………………………………………………………………..29 Conclusions……………………………………………….………………………..30 Implications for Practice……………………………………………………30 Implications for Research…………………………………………………..31 Appendix I………………………………………………………………………….32 Appendix II…………………………………………………………………………34 Appendix III………………………………………………………………………..35 ABSTRACT Background: African Americans are disproportionately affected by stroke in the United States. Delays in seeking medical attention for acute stroke symptoms are longer for African Americans than for Caucasians. The objective of this review was to appraise and synthesize the best available evidence on factors which contribute to delays among African Americans, in seeking medical help when experiencing stroke symptoms. Objectives: To identify interventions to reduce prehospital delay as well as develop best practice recommendations to avoid and minimize the effects of stroke in African Americans. Search strategy: A comprehensive search of databases covering nursing and medical literature was performed. Studies conducted from 1998-2010 were included. An initial search of the Joanna Briggs Institute for Evidence-Based Nursing and Midwifery, the Cochrane Library, and PubMed's Clinical Inquiry/Find Systematic Review database was conducted. Following this, an extensive three stage search was conducted using PubMed, CINAHL, HealthStar, ScienceDirect, Dissertation Abstracts International, DARE, PsycINFO, BioMedCentral, TRIP, Pre-CINAHL, PsycARTICLES, Psychology and Behavioral Sciences Collection, ISI Current Contents, Science.gov, Web of Science/Web of Knowledge, Scirus.com website. Included was a hand search of reference lists of identified papers to capture all pertinent material as well as a search of websites and search engines such as Google, Google Scholar and the Virginia Henderson Library of Sigma Theta Tau International. Methodological Quality: The principal reviewer and a secondary reviewer each independently assessed each paper prior to inclusion, for methodological quality, using the appropriate standardized JBI (Joanna Briggs Institute for Evidence Based Nursing and Midwifery) critical appraisal instrument. Data Extraction: The reviewers extracted data from included studies using a standardized data extraction tool appropriate to the study design from the JBI Meta Analysis of Statistics Assessment and Review Instrument. (MAStARI). There were no disagreements between the reviewers regarding data extraction. Data Synthesis: Study outcome measures differed to the extent that the results were unable to be pooled. A meta-analysis was unable to be conducted. Instead studies were grouped according to outcomes and presented in a narrative summary . Results: The search yielded six eligible papers which provided data on stroke knowledge and help seeking behaviors by African Americans in acute stroke situations. The factors influencing African Americans’ decision to seek help for stroke symptoms include encouragement by family and friends, presence of a bystander, availability of transportation, stroke literacy and living alone. Conclusions: The factors influencing health seeking behaviors among African Americans for stroke symptoms are multifactorial. When viewed collectively, they present significant challenges for the black community in general. Culturally tailored education that target African Americans is important in enhancing health seeking behavior in acute stroke situations. Since encouragement by families and bystanders played a significant role in health seeking behavior among this subgroup, they should also be targeted for educational intervention in order to decrease the time to treatment and optimize patient outcomes. Key words: African American, Blacks, Negroe, Negroid Race, Stroke, Cerebrovascular Apoplexy, Cerebral Stroke, CVA, Health Care Seeking Behavior, Patient Participation, stroke literacy. Background Stroke, also known as “brain attack”, is the second leading cause of death and the most frequent cause of permanent disability in the world, with more than 3 million cases reported every year.1 According to the World Health Organization (2010), stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. Common symptoms of stroke include sudden onset of numbness on one side of the body, confusion, difficulty speaking and or understanding speech, as well as difficulty with vision. Stroke is also a major cause of adult disability in the United States and approximately 83% of all reported strokes are ischemic in nature, as opposed to hemorrhagic.2 In 2004, there were more than 150,000 stroke related deaths accounting for one of every sixteen deaths in the United States.3 Annually, there are approximately 700,000 persons in the United States who have a new or recurrent stroke; 15% -30% become permanently disabled, and 20% require institutionalization during the first 3 months after the stroke.4 The severity of stroke-related disability can be reduced once timely and appropriate treatment is administered; however, many patients experiencing acute stroke symptoms often arrive at the hospital too late to receive the maximum benefit from these stroke therapies. African Americans bear a disproportionate burden of stroke compared to any other racial and ethnic group in the United States.5 African American men die from strokes at twice the rate of Caucasian men and African American women at a rate of 71% greater than white women.6 The lack of recognition of the warning signs of stroke is a worldwide problem and delays in seeking medical attention for acute stroke symptoms are longer for African Americans than for Caucasians. According to The Minnesota Stroke Survey, of 1895 patients admitted to the hospital with acute stroke symptoms, half arrived within three hours of symptom onset and ninety percent arrived within twenty four hours. 7 The first few hours after the onset, are the most significant for the person suffering from a stroke. The time window for intravenous administration of tissue plasminogen activator (t-PA) is three hours from the time of onset of the first warning signs until drug infusion.8 Patients with an acute stroke must receive urgent treatment, including evaluation for and administration of properly selected antithrombotic agents due to the high risk of ischemia to brain neurons. The longer the delay between symptom onset and treatment with thrombolytic agents the lower the chance of restoring blood flow thus increasing the risk of hemorrhagic complications.9 Studies suggest that less than five percent of stroke patients currently receive the only early acute treatment for stroke that needs to be administered within three hours of onset of symptoms, according to the American Stroke Association. 10 Early strategies recommended for treating stroke symptoms include: (a) reperfusion of the ischemic area quickly, before it dies, and (b) protection of the ischemic brain so that it will survive reperfusion.11 Standards of care recommended by the American Stroke Association (2002) include rapid transport to the hospital or stroke center, and rapid diagnosis of ischemic or hemorrhagic stroke by timely computerized tomography (CT) scan of the brain.12 The time of onset of symptoms and rapid treatment with tissue plasminogen activator (t-PA) if indicated are included in the standards of quality stroke care. The ASA and the Brain Attack Coalition (BAC) have recommended the implementation of Acute Stroke Treatment Programs (ASTP) in every hospital treating stroke patients, to improve the quality of stroke care across the nation.13 Methods designed to prevent ischemic stroke, including discharge protocols and smoking cessation materials, are also recommended. The establishments of ASTP in hospitals and stroke centers recommended by the BAC are focused on increasing accessibility of patients to thrombolytic agents14. Stroke in African Americans African Americans have an increased risk of stroke and stroke mortality than Caucasians.15 An increased risk factor burden may be a reason for the nearly double stroke rate in African Americans than Caucasians: higher prevalence of diabetes, hypertension, smoking, obesity and high cholesterol in blacks compared with other racial and ethnic groups have also been cited.16 Hypertension has been identified as a major risk factor for stroke in Blacks and one in three African Americans are affected. Among Blacks in developed countries, elevated pressure is the major risk factor for stroke.17 Compared to all other ethnic groups, high blood pressure among Blacks is the highest in the world. 18 African Americans have a six-fold tendency to develop kidney failure due to hypertension, compared with Caucasians.19 The incidence of high cholesterol levels in African Americans is no different from other ethnic groups in the US. However, the ways in which the fatty deposits are dispersed in the arterial system are different. In African Americans, atherosclerotic plaques tends to deposit more in the intracranial branches of the major arteries, especially the carotid, while extracranial lesions occur more frequently in Caucasians. Although the precise significance of this manifestation is not entirely clear at present, the proximity of deposits to the brain is likely to cause more frequent serious strokes.19 The incidence of obesity in African Americans is almost one and a half times that of Caucasians; children slightly less so and in the case of women, 80% are either overweight or obese.19 Perceived Contributing Factors for Treatment delays. Factors such as racism, low socioeconomic status and diminished access to care, and lack of education among this sub group have been linked as major contributing factors as well. Research have demonstrated that African Americans are far more likely than whites to report being treated worse than other ethnic groups when seeking healthcare services and to report being emotionally upset and/or experiencing physical signs and symptoms because of unequal treatment based on race.20 Additionally, many African Americans have diminished access to care21 which may impede their ability to identify and treat these risk factors; also, the cost of medicines aimed at risk modification can impact stroke risk reduction; drugs are costly and people who have less insurance cannot afford them.21 Few studies have extensively investigated factors associated with stroke treatment delays among African Americans in the United States. In most studies of delay in seeking care for stroke symptoms, gender and age differences were not associated with prehospital delay. Although race or ethnicity was unrelated to delay in many studies some investigators found longer delays for blacks . 22 What then are the factors that contribute to delays in seeking medical attention for stroke symptoms among African Americans? This systematic review of the evidence was undertaken, to best address this question. Identification of the factors that contribute to delay time is important in maximizing benefit from stroke therapies in this subgroup. Objective/ Review Questions: To objective of this review was to identify interventions to reduce prehospital delay as well as develop best practice recommendations to avoid and minimize the effects of stroke in African Americans. The questions addressed in this review were: What are the beliefs of African Americans towards seeking medical attention in acute stroke situations? What is the impact of sociological, cultural, environmental and behavioral factors on the health seeking behaviors in acute stroke situations on African Americans? Criteria for Selecting Studies for this Review Types of Studies The review considered all quantitative and qualitative studies as well as text and opinion papers that evaluated the influencing factors in treatment delay for stroke, among African American adults. Delay was considered as the time from stroke symptom onset to initiating help either by calling 911, contacting a family member or friend, or seeking medical assistance from a medical provider or coming to the emergency department. Full text English studies conducted from 1998 through 2010 were included. Excluded were non English papers, papers that did not address stroke in African Americans and papers with non acute stroke situations. Types of Participants/Phenomena The review included studies that described the cultural, social, socioeconomic and environmental factors which contribute to delays in seeking medical help for stroke, by African Americans. These studies were thought to contribute to the development of best practice recommendations for enhancing stroke care in this subgroup. Search Strategy Before initiating the search, the Cochrane library, Virginia Henderson Library of Sigma Theta Tau International and the Joanna Briggs Institute for Evidence-Based Nursing and Midwifery were searched to ensure that there were no pre existing systematic reviews on health seeking behaviors of African Americans experiencing acute stroke symptoms. The aim of the search strategy was to find both published and unpublished studies and papers. An initial three step search strategy was conducted. An initial search of Medline and CINAHL was undertaken followed by an analysis of keywords contained in the title, abstract and index terms. A second search using all identified keywords and index terms was then undertaken based on key words specific to each database (Appendix I). In consultation with two qualified librarians, databases covering medical and nursing literature were searched. The databases searched included: Joanna Briggs Institute for Evidence-Based Nursing and Midwifery Cochrane Library CINAHL PubMed HealthStar Science Direct DARE Dissertation Abstracts/Digital Dissertations BioMedCentral TRIP (Turning Research Into Practice) PsychArticles Psychology and Behavioral Sciences SSI ISS Current Contents Science.gov Scopus Theses Canada Web of Science/ Web of Knowledge Thirdly, the reference lists of all articles were hand searched for additional studies and Journals relevant to the topic, such as (Stroke and Neurology) were hand searched to capture relevant articles. Electronic searches were also undertaken to search for unpublished material such as research reports, dissertation papers and conference reports utilizing Google and Google scholar. Additional search was undertaken using the grey literature sites: Grey Literature Report from The New York Academy of Medicine National Library of Medicine NIH subset and NLM Gateway Proceedings First Institute for Heath and Social Care Research Agency for Health Care Research and Policy Center for Evidence in Ethnicity, Health and Diversity Clinical Medicine Netprints Collection Geneva Foundation for Medication Education and Research HMIC (Health Management Information Consortium) Nurse Scribe The Qualitative Report (http://www.nova.edu/ssss/QR/aindex/html, WHOLIS: WHO Organization Library database. Virginia Henderson Library of Sigma Theta Tau International Annual Stroke Conference Proceedings Assessment of methodological Quality Screening The primary reviewer screened all article titles to identify those thought to be relevant. Duplicates were removed. Assessment of eligibility Two reviewers appraised the eligible studies independently, against the standardized critical appraisal checklist from the JBI-QARI (Joanna Briggs Institute Qualitative Assessment and Review Instrument) tool (Appendix II). The JBI tool consisted of six to ten items, each requiring a yes/no response. A yes response was allocated one point and a no/unclear response allocated zero points. Studies scoring six or above on the JBI critical appraisal tool were considered as good quality and were included in the review. There were no disagreements among the two reviewers. Six studies were selected for inclusion. Data Extraction and Synthesis Data Extraction Data was extracted from included studies using a standardized extraction tool appropriate to study design, from the JBI- MAStARI (Appendix III). There were no disagreements regarding data extraction. Data Synthesis Though many of the studies had outcomes that were similar, the outcomes differed to the extent that the results were unable to be pooled statistically; therefore a meta-analysis was unable to be conducted. Studies were grouped according to outcome measures and presented in a narrative summary. RESULTS Description of studies One hundred and eight (108) studies were identified using the search strategy (Figure 1). Duplicate studies were removed. Ninety (96) studies were deemed irrelevant after review of the title and abstract. The remaining twelve (12) studies were assessed for eligibility. Six (6) studies did not meet the eligibility criteria and were not included for this review (Table 1). The remaining six studies met all eligibility criteria and were included in the review (Table 2). The six papers meeting inclusion criteria were papers that provided information on factors that impacted participants’ decision making in seeking help for stroke symptoms. There were variations in study setting, study size and study methodology in the papers reviewed. All of the studies included African Americans that were either high risk (n=1051) or experienced acute stroke symptoms (n=192). Methodology included chart reviews, surveys, interviews and pre and post test. The review provided information on delay times, stroke literacy, stroke education intervention and other factors associated with seeking help. Delayed admission time is considered one of the most important factors why African Americans do not receive thrombolytic therapy for their strokes cites Lisabeth and Kleindorfer.23 Stroke literacy; defined by Lisabeth and Kleindorfer23 as an individual’s awareness of stroke risk factors and symptoms, has been noted to be significantly poor among this high risk group. There is a pressing need to improve stroke prevention and provide access to acute stroke therapy for minority groups, particularly African Americans according to Lisabeth and Kleindorfer.23 Stroke Literacy Wiley et al24 identified in their survey utilizing the Stroke Knowledge questionnaire, that of the African American participants surveyed (n=672), who comprised 65.7% of the survey cohort, 56.3% of respondents identified the brain as the organ where stroke occurred. Among stroke symptoms, hemiparesis, speech disturbance, headache and blurred vision were the best recognized. Primary risk factors for stroke were correctly identified and included hypertension, family history of stroke, obesity, smoking and cocaine abuse. From the perspective on these study results, Wiley et al24 found significant deficiencies in stroke literacy among the African American study sample. Because of poor stroke literacy in Wiley’s et al study24 participants were not likely to activate EMS. Consequently, poor literacy related to stroke symptoms among the African American population, jeopardizes access to early treatment therapy. Delay Times King et al25 in their study aimed to determine whether African American individuals who suffered from stroke (n=103) presented for treatment within the first 3 hours, a critical period needed for effective treatment with recombinant tissue plasminogen activator (rt-PA). Utilizing the Stroke Survey Tool, King et al25 determined that an average time for African American patients to present for treatment constituted 24.68 hours. Percentage analysis revealed that 49% of stroke victims were admitted within the first 3 hours, 54% presented within 12 hours and 83% sought medical help within 24 hours. The most common reasons for delay or not presenting for treatment at all were identified as; misunderstanding of symptoms, confusing them with diabetes manifestation, sleeping in an awkward position and elevated sugar. King et al25 indicated that as a result of late admission for treatment, 97% of participants did not receive thrombolytic therapy. King et al 25 stressed that the patients’ lack of knowledge related to stroke symptoms and their delayed attempts to seek medical assistance are detrimental in stroke successful treatment. Research identified a mean delay in admission to emergency department to be 16 hours. 26The main reasons for delay in presentation for treatment were race, no history of stroke, lack of information on stroke symptoms, awoke with manifested symptoms, and did not use 911. Zerwic and Hwang 27identified the lack of general information about stroke and its symptoms as the most contributing factor causing the delay in ED admission. Stroke Education The similar statement was emphasized in the study conducted by Kleindorfer and colleagues 26.They revealed that educational strategies aimed to inform African American individuals (women, n=383) on stroke are effective methods to increase stroke awareness and seek medical assistance once symptoms occur. After educational intervention, participants improved significantly in knowledge on stroke (50% increase from baseline) and the importance of seeking medical assistance early. This increase in knowledge was sustained for up to 5 months after intervention. Zerwic and Hwang 27interviewed patients (n=38) who suffered from an ischemic stroke, in order to determine participants’ knowledge related to symptoms, causes of stroke, as well as patterns of symptom recognition and seeking medical assistance. Zerwic and Hwang 27found that 55.3% of respondents were able to correctly identify at least one stroke symptom, while ten patients (26.3%) were not aware of any of the symptoms of stroke. Factors Associated with Health Seeking Behavior Kothari et al 28conducted a study identifying factors associated with admission to the emergency department within 3 hours of stroke symptom onset, time window for thrombolytic therapy eligibility. The data collection was conducted through EMS run sheets, ED records and interviews with participants (n=151), 41% African American). According to Kothari et al 28one third of participants were admitted to the ED within 3 hours of stroke symptom onset, qualifying patients for thrombolytic therapy. Kothari et al28 found an association between race of patients and their ED arrival time. After stroke symptoms onset, African American patients were found to contact 911 later, and thus they were admitted to the ED significantly later than whites. Kothari et al28 attributed this finding to several factors, particularly blacks living alone, being uninformed about stroke symptoms, being resistant to seek medical attention, and transportation difficulties. Encouragement to seek help by family and friends contributed to seeking prompt assistance for symptoms. Figure 1. Flow chart for identification of papers Table 1 Excluded studies Country Reason for Exclusion 1 Friday GH. Antihypertensive medication compliance in African-American stroke patients: behavioral epidemiology and interventions. Neuroepidemiology. 1999; 18(5):223-30. USA Talks about compliance with antihypertensive medications among African American patients with stroke. Not a research study. 2 Gorelick PB. Antiplatelet therapy to prevent stroke in African Americans. ClinicalTrialsgov [serial on the Internet]. 2000: Available from: http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/839/CN-00295839/frame.html. USA A Randomized Controlled study comparing the efficacy of two anti platelet drugs on preventing repeat stroke in Blacks. Does not address delay issues, nor does it address acute stroke symptoms. 3 Qureshi AI, Suri MF, Zhou J, Divani AA. African American women have poor long-term survival following ischemic stroke. Neurology [serial on the Internet]. 2006; (9): Available from: http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/678/CN-00573678/frame.html. USA A Randomized controlled study comparing gender differences in long term survival after stroke. Not specific to delays in treatment time. 4 Ruland S, Richardson D, Hung E, Brorson JR, Cruz-Florez S, Felton WL, et al. Predictors of recurrent stroke in African Americans. Neurology [serial on the Internet]. 2006: Available from: http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/516/CN-00603516/frame.html. USA A Randomized controlled study to describe the recurrent stroke characteristics and determine the predictability of known vascular risk factors for stroke recurrence in African Americans. Does not address acute stroke symptoms or treatment delay factors. 5 Sacco, R. Preventing stroke among blacks. Journal of the American Medical Association. 2003; 289(22): 3005-3007. USA Addresses issues related to preventing stroke in blacks and causes for disparities in stroke among blacks. Does not address delay issues or health seeking behaviors. 6 Scott KD, Scott AA. Cultural therapeutic awareness and sickle cell anemia. Journal of Black Psychology. 1999;25(3):316-35 USA A qualitative study exploring the systemic barriers to the bio-psychosocial and psycho educational care of two children with sickle cell anemia. Not stroke related and focus on children. 7 Tuhrim S, Cooperman A, Rojas M, Brust JC, Koppel B, Martin K, et al. The association of race and sex with the underuse of stroke prevention measures. J Stroke Cerebrovascular Disease. 2008 Jul-Aug;17(4):226-34 USA A retrospective chart review of prevention measures used in patients after Ischemic stroke. Does not address acute stroke situations. Included Studies Author/publication Design/ Method Settings / Participants Data Collection Methods Comments 1 King DF, Trouth AJ, Adams AO. Factors preventing African Americans from seeking early intervention in the treatment of ischemic strokes. J National Med Association. 2001 Feb; 93(2):43-6. Prospective survey to determine if AA stroke victims presented for treatment within 3 hours. Emergency Room or after admission to unit. 103 African American acute stroke patients or reliable historians were surveyed to determine time lapse between onset of stroke symptoms and effort to seek medical attention Stroke survey Tool Less than half of patients sought ER attention for stroke symptoms. Many patients chose to ignore symptoms or seek help because they thought their symptoms were only transient related symptoms to other diseases, felt prayer more effective than seeking MD evaluation, had other priorities. 2 Kothari R, Jauch E, Broderick J, Brott T, Sauerbeck L, Khoury J, et al. Acute stroke: delays to presentation and emergency department evaluation. Annals of Emergency Medicine. 1999 Jan;33(1):3-8 Retrospective Study. To document time from stroke onset to ED evaluation. And to identify factors associated with presentation to the ED within 3 hours of symptom onset 151 Patients admitted to the hospital with an ED diagnosis of stroke, Intracerebral hemorrhage, Subarachnoid hemorrhage, or Transient Ischemic Attack Participants from a university based teaching hospital and three community based hospitals.59% (whites), 41% blacks Patient’s identified by diagnosis via Review of hospital’s ED/ EMS a logs, and by contact with patients’ neurologists’ office. Patients were interviewed to collect demographic data and collect information regarding first medical contact Blacks took longer to present to ED than whites. Factors that might have contributed to delays for blacks include: Living alone, availability of transportation, knowledge of stroke signs and symptoms, resistance to seeking medical attention. Encouragement by family and friends, was a significant contributor to seeking help. 3 Kleindorfer D, Lisabeth LD, Stroke literacy in high-risk populations: A call for action. Neurology. 2009; 73(23):1940-1. Editorial African Americans/Hispanic Americans There are significant deficiencies in stroke literacy among this high risk population. Poor stroke literacy was not associated with activating EMS. Author/Publication Design/ Method Settings/ Participants Data Collection Methods Comments 4 Kleindorfer D, Miller Rosie, Sailor-Smith Sharion, Moomaw Charles, Khoury J, Frankel M. The Challenges of Community Based Research. The beauty shop stroke education project. Stroke 2008; 39: 2331-2335. Educational Intervention/Survey Using F.A.S.T. African American beauticians in 2 large Metropolitan black communities in Cincinnati and Atlanta. N=30 Pre and post test/survey Knowledge of stroke was a contributing factor to calling 911 for stroke symptoms. Educational intervention increased African American women’s knowledge of stroke and intent to call 911 for stroke symptoms. The improvement in both these areas was sustained for at least 5 months. 5 Wiley Joshua, Williams Olajide, Boden-Albala, Bernadette. Neurology 2009; 73: 1950-1956. Survey evaluating “stroke literacy” (awareness of stroke warning symptoms and risk factors). 10 Community based Sites in Central Harlem. A predominantly black Population. N=1,023 Stroke Knowledge survey adapted from the BRFSS (Behavioral Risk Factor Surveillance Survey). Closed ended questionnaire. Ethnicity, race, nor stroke knowledge was associated with calling 911. Poor “stroke literacy” was not associated with activating EMS. 6 Zerwic J, Hwang, Seon Young. Interpretation of symptoms and delay in seeking treatment by patients who have had a stroke: Exploratory study. Heart and Lung. 2007;36(1): 25-34 Descriptive Cross Sectional. Examining knowledge of stroke risk factors and symptoms in patients with stroke and examine delay factors. Patients admitted with a diagnosis of Ischemic Stroke. Inner City Medical Center and Hospital located in a mid-sized community serving community and rural patients. N=28 Structured Interview tool used in a prior Acute MI study. Questions based on the Common Sense Model. Patients gave narrative description of events Median delay time to ED =16 hours. Factors contributing to delays include: African American, lack of recognition of seriousness of symptoms, primary symptom not motor, not using 911, and residing in an urban setting. REFERENCES 1. World Health Organization. Cerebrovascular Accident Health Topic. 2010 Retrieved 3/24/10 from: http://www.who.int/topics/cerebrovascular_accident/en/. 2. Adams HP, del Zoppo G, Alberts M.J. et al, Guidelines for the early management of adults with ischemic stroke. Stroke. 2007; 38:1655-711. 3. American Heart Association. Heart Disease and Stroke Statistics. 2007 cited 2009 January 10; Available from: http://www.americanheart.org/downloadable/heart/1. 4. Rosamond W, Flegal K, Friday G. Heart disease and stroke statistics: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007; 115:169-171. 5. Ruland S, Gorelick PB. Stroke in Black Americans. Curr Cardiol Rep. 2005 Jan; 7(1):29-33. 6. Gillum R. Stroke mortality in blacks: Disturbing Trends. Stroke.1999; 30:1711-5. 7. Shahar E, McGovern PG, Pankow JS, et al. Stroke rates during the 1980s. The Minnesota stroke survey. Stroke. 1997; 28:275-279 8. Lewandowski C, Lotfipour S. Lessons learned from multicenter randomized clinical trials with intravenous thrombolysis for Acute Ischemic Stroke. Journal of Stroke and Cerebrovascular Diseases. 2002; 11(3):125-36. 9. Hacke W, et.al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS and NINDS rt-PA stroke trials. Lancet. 2004; 363(9411):768-74. 10. Association AS. Recommendations for improving the quality of care through stroke centers and systems: An examination of stroke center identification options. Stroke. 2002; 33:e1-e7 11. Warlow C. Stroke: killer clots and killer drugs. International Society on Thrombosis and Haemostasis. 2003; 1:1422-8.Association AS. Recommendations for improving the quality of care through stroke centers and systems: An examination of stroke center identification options. Stroke. 2002; 33:e1-e7. 12. NINDS study group (2000). A systems approach to immediate evaluation and management of hyperacute stroke. Stroke, 28, 1530-1540. 13. American Heart Association. (2003). Heart Disease and Stroke Statistics. Accessed October 7, 2009, from http://www.americanheart.org/downloadable/heart/1. 15. Qureshi AI, Suri MF, Zhou J, Divani AA. African American women have poor long-term survival following ischemic stroke. Neurology [serial on the Internet]. 2006; (9): Available from: http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/678/CN-00573678/frame.html. 16. Bravada, Dawn. M., et al. (2005) Racial disparities in stroke risk factors. Stroke 36:1507-1511. 17. Power to End Stroke. (2009). African Americans & Stroke: http://www.powertoendstroke.org/stroke-african-americans.html. Accessed 03/16/2010. 18. American Heart Association. (2004). Heart Disease and Stroke Statistics. Accessed October 7, 2008, from http://www.americanheart.org/downloadable/heart/1. 19. Department of Health. (2008). Obesity and African Americans. Office of Minority Health: http://minorityhealth.hhs.gov/templates/content.aspx?ID=6456 Accessed 03/17/2010. 20. Gizlice Z, Ngui EM. Relationships between health and perceived unequal treatment based on race: Results from the 2002 North Carolina BRFSS survey. SCHS Studies, No. 144. State Center for Health Statistics, NC Department of Health and Human Services, September 2004. Available at: www.schs.state.nc.us/SCHS/pdf/SCHS144.pdf. Retrieved 3/10/10. 21. Rodriguez D. Stroke Risk and African-Americans. 2009 [cited 2009 March 5 2010]; Available from: http://www.everydayhealth.com/stroke/stroke-risk-and- african-americans.aspx. 22. Azzimondi G BL, Fiorani L, Nonino F, MontagutiU, Celin D, et al. Variables associated with hospital arrival time after stroke: effect of delay on the clinical efficiency of early treatment. Stroke 1997. 28:537–42 23. Lisabeth LD, Kleindorfer D. Stroke literacy in high-risk populations: A call for action. Neurology. 2009; 73(23):1940-1. 24. Wiley Joshua, Williams Olajide, Boden-Albala, Bernadette. Neurology 2009; 73: 1950-1956. 25. King DF, Trouth AJ, Adams AO. Factors preventing African Americans from seeking early intervention in the treatment of ischemic strokes. J National Med Association. 2001 Feb; 93(2):43-6. 26. Kleindorfer D, Lisabeth LD, Stroke literacy in high-risk populations: A call for action. Neurology. 2009; 73(23):1940-1. 27. Zerwic J, Hwang, Seon Young. Interpretation of symptoms and delay in seeking treatment by patients who have had a stroke: Exploratory study. Heart and Lung. 2007; 36(1): 25-34 28. Kothari R, Jauch E, Broderick J, Brott T, Sauerbeck L, Khoury J, et al. Acute stroke: delays to presentation and emergency department evaluation. Annals of Emergency Medicine. 1999 Jan; 33(1):3-8 29. Gorelick PB, Harris Y, Burnett B, Bonecutter FJ. The recruitment triangle: reasons why African Americans enroll, refuse to enroll, or voluntarily withdraw from a clinical trial. An interim report from the African-American Antiplatelet Stroke Prevention Study (AAASPS). J Natl Med Assoc. 1998 Mar;90(3):141-5. DISCUSSION This review revealed that African Americans’ decisions to seek medical treatment for stroke symptoms are multifactorial. The primary contributing factors include availability of a family member or bystander and living alone. Education and knowledge regarding stroke symptoms was a variable factor in patients’ decision to 911 or contact EMS 24 26 thus leading to inconsistencies in the role that knowledge plays in influencing health seeking behavior for stroke in this subgroup. Black race 26continues to be associated with delayed presentation for stroke symptoms with average time to arrival being as much as 24 hours25 it is clear that African Americans delay in seeking help for stroke symptoms regardless of their knowledge of signs and symptoms. This subgroup continues to remain at high risk and should be targeted for counseling and intense education. Education interventions should not only focus on stroke risk factors, stroke warning signs and importance of calling 911, but should also focus on the availability of thrombolytic therapy, and its benefits. Emphasis should also be placed on education about potential consequences of delay and its impact, on quality of life and long term outcomes. CONCLUSIONS Implications for Practice In summary, this review found that decision to seek medical attention for stroke symptoms was low among African Americans, despite knowledge of warning signs and symptoms. There is a need in this subgroup to address the gap between recognition of stroke warning signs and seeking immediate intervention. This review supports the notion that interventions aimed at motivating individuals towards self efficacy in promptly calling 911, are needed in the African American community. Motivation to seek help can be prompted by enhancing knowledge and awareness of the availability and effectiveness of thrombolytic therapy. The results of this review also reveal that family encouragement and the presence of a bystander plays a significant role on whether African Americans will seek help. Since bystanders and family members are the decision makers, they should be integrated in educational interventions to help them identify symptoms should their family members who are at risk for stroke exhibit them. African American Nurse practitioners can work more closely with communities of color, through involvement of the clergy, sororities, beauty shops, barber shops, and black media, to bring awareness related to stroke prevalence, risk and impact of stroke in this subgroup. Implementation projects by health care providers and Nurse Practioners that include community health fairs and community awareness programs should be implemented. Nurses should target at risk patients and work closely with them and their families to develop strategies that they can implement in the event stroke symptoms are identified. Implications for Research Continued research efforts should be directed at investigating factors that could potentially “motivate” African Americans to seek help. While the emphasis on this review was on factors influencing decision making, it might be important to explore motivational theoretical models and there application in improving health seeking behavior for stroke symptoms, in communities of color. Appendix I A. Results of Search Database Searched Papers: #found PubMed 30 MEDLINE 44 EMBASE 58 CINAHL 3 HealthStar 0 ScienceDirect 0 Dissertation Abstracts International/Digital Dissertations 10 Theses Canada 0 DARE 0 PsycINFO 14 BioMedCentral 0 TRIP (Turning Research into Practice) 0 Pre-CINAHL – for research still being indexed in CINAHL 0 PsycARTICLES 0 Psychology and Behavioural Sciences CollectionI 0 ISS Current Contents, 2 Science.gov 0 Web of Science/Web of Knowledge 0 Scirus.com website 0 Scopus 29 ‘Grey Literature Report’ from New York Academy of Medicine 0 National Library of Medicine and NIH subset and NLM Gateway 0 Proceedings First 0 Institute for Health & Social Care Research (IHSCR), 0 AHRQ (Agency for Healthcare Research and Quality) 0 CEEHD (Centre for Evidence in Ethnicity, Health and Diversity 0 Clinical Medicine Netprints Collection 0 Geneva Foundation for Medication Education and Research (GFMER) 0 Grey Source: A Selection of Web-Based Resources in Grey Literature 0 HMIC (Health Management Information Consortium) 0 NurseScribe 0 The Qualitative Report 0 WHOLIS: WHO Organization Library database 0 Virginia Henderson Library of Sigma Theta Tau International 0 Conference Proceedings 0 Hand searching reference lists 12 Hand searching selected journals 8 Google Scholar/Google 2 B. Search Strategy Key words: African American, blacks, stroke, cerebrovascular disease, health seeking behaviors, prehospital delays, time factors, stroke literacy. 1. African Americans.tw. 2. (blacks or Negro* or Negroid Race* or Negroid).tw. 3. or/1-2 4. Strokes.tw. 5. (acute stroke* or cerebral stroke* or cerebrovascular stroke*).tw. 6. (brain vascular accident* or cerebrovascular apoplexy, or CVA or cerebrovascular tw. 7. or/4-6 8. (health care seeking behavior* or health care seeking behavior*).tw. 9. (healthcare patient acceptance* or program* acceptability or 10. (patient preference or patient participation).tw. 11. or/8-10 12 1 and 7 13 3 and 7 and 11 14. ("systematic review*" or meta-analys*).mp. 15. ((Program* adj3 (evaluat* or assess* or outcome* or effect*)).mp 16. ((Intervent* adj3 (evaluat* or assess* or outcome* or effect*)).mp. 17. (Randomized controlled trial or controlled clinical trial or clinical trial).pt. 18. (Placebos or Research Design or Comparative Study or Evaluation Studies or Follow-up Studies or Prospective studies or Cross-over studies or Randomized controlled trials or Random allocation or Double-blind method or Single-blind method or Clinical trials).sh. 19. ("clinical trial" or ((singl* or doubl* or trebl* or tripl*) and (mask* or blind*)) or "latin square" or placebo* or random* or control* or prospective*).tw. 20. Or/14-19 21. 13 AND 20 22. Limit 21 to (English language and human) Appendix II- JBI- QUARI Critical Appraisal Tool Reviewer: Date: Author: Year: Record No Criteria Yes No Unclear 1) There is congruity between the stated philosophical perspective and the research methodology. 2) There is congruity between the research methodology and the research question or objectives. 3) There is congruity between the research methodology and the methods used to collect data. 4) There is congruity between the research methodology and the representation and analysis of data. 5) There is congruity between the research methodology and the interpretation of results. 6) There is a statement locating the researcher culturally or theoretically. 7) The influence of the researcher on the research, and vice-versa is addressed. 8) Participants, and their voices, are adequately represented. 9) The research is ethical according to current criteria or, for Recent studies, there is evidence of ethical approval by an appropriate body. 10) Conclusions drawn in the research report do appear to flow from the analysis, or interpretation, of the data. TOTAL Reviewer’s Comments: Appendix III JBI-Qualitative Data Extraction Instrument Author: ______________________ Record Number: _______ Journal: ______________________ Year: ________ Reviewer: _____________________ Method Methodology Data Analysis Setting & Context Geographical Context Cultural Context Participants: Number: Description: Interventions Findings Narrative Description Qual of Evid. Rating 1,2,3 Authors conclusion Reviewers conclusion Read More