Every three and a half minutes, a person in the United States dies from stroke, according to the Centers for Disease Control and Prevention. Tragically, the majority of these deaths are preventable. But many people — particularly those living in medically underserved areas, as well as people of color — lack access to adequate care, and therefore account for a disproportionate number of stroke deaths.
“Once a person has a stroke, unless you address the underlying factors, they’ll likely have another,” says Ynesse Abdul-Malak, assistant professor of sociology. “That’s why preventative measures are so important.”
Abdul-Malak is co-first author of a study published in PLOS Global Public Health in January 2024 that analyzed 1,731 incidents of stroke occurring between January 2019 and January 2021 through the lens of social determinants of health: non-biological factors that influence a people’s health outcomes. The study was conducted using data from Crouse Hospital, a small community hospital serving patients in and around Syracuse. Located in an officially designated Health Professional Shortage Area, Crouse serves a population consisting of patients from both urban and rural areas and, despite its small size, is a major comprehensive stroke center in central New York.
The study retrospectively analyzed records from the hospital’s emergency department, as well as laboratory analyses and health professional notes recorded electronically during each patient’s hospital stay from admission until discharge. The researchers organized their findings into four categories: demographics, health care access, institutional care factors (including whether a toxicology test was administered, days spent in the hospital, whether medication was administered, stroke severity, and whether the patient returned for a follow-up visit), and where and how the patient was discharged.
To quantify each patient’s access to health care, Abdul-Malak and her co-authors used a score provided by the United States Health Resources and Services Administration, based on the patient’s home address. The score incorporates a variety of relevant metrics, including the ratio of providers to the population in the area, the percentage of the population with incomes below the federal poverty line, and rates of infant mortality and low birth weight. Additionally, they noted the insurance status of each patient and whether they had a primary care provider (PCP) on record.
Demographically, most of the patients in the study were white (87.5%), with Black patients accounting for 9.9%, and patients from other ethnic groups accounting for 2.6%. Female patients made up 51.5% of those studied and males 48.5%. The average age was 72.1 years. Patients from underserved areas accounted for 58.9% of the study population.
In their analysis, Abdul-Malak and her co-authors found significant differences based on whether patients lived in served or underserved areas, as well as on race. Underserved Black patients presented with stroke younger, on average, than patients in any other group, at a mean age of 63.3 years, compared with 75 years for served white patients. Served Black patients were more likely than other groups to have a PCP and to return for a follow-up visit — the latter by a significant margin, returning for follow-up visits in 72.7% of cases, while underserved white patients (the most poorly performing group by this metric) returned for a follow-up in only 53.8% of cases.
“Race is a significant factor, but it’s not only about race,” Abdul-Malak says. “There are lots of white people in rural areas who lack access to resources and institutions that can provide education about strokes, like what the symptoms are [and] when to call 911.”
While the observed patterns were generally in keeping with what other scholars have found, Abdul-Malak was surprised by some of the findings — in particular, that 14% of underserved and 9.1% of served Black patients were given toxicology tests, compared with 3.7% and 5.9% of served and underserved white patients, respectively. These tests are given at the health care professional’s discretion, often when they suspect that a patient is intoxicated or has illicit substances in his or her system, Abdul-Malak notes.
“A patient’s symptoms can sometimes be misleading — what appears to be intoxication can come from other sources, such as food poisoning,” she says. “Studies have shown that Black pregnant women are far more likely than white women to be drug tested in health care settings, so there’s precedent; but I didn’t expect that difference to be as prominent as it was.”
In future studies, Abdul-Malak says, she intends to go beyond looking at data from medical charts.
“With a study like this, the data is only as good as the charting is, and medical records alone never tell the full story,” she says. “I’m a multi-modal, multi-methodologically driven person — I like to work with big databases but also do qualitative research.” In the future, she plans to extend this research to include the human side of the issue, with tools like interviews and surveys.
“I’d also like to look further into how to prevent people from going to the emergency department in the first place,” she adds. “Even though this study was looking into care after stroke, I always say it’s better to prevent than to cure.”
Abdul-Malak, who has spent her career investigating the impact that social factors have on people’s health outcomes, recently won a Public Sociology Award from the Eastern Sociological Society. The national award seeks to “recognize sociologists who have both done cutting-edge sociological research and engaged in meaningful public work using that research.”