Running head: STROKE: A PUBLIC HEALTH PERSPECTIVE
Stroke: A Public Health Perspective
Katelyn R. Strasser
Concordia University Nebraska
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Cardiovascular disease is often first associated with diseases pertaining to the heart,
which are the leading cause of death in the United States. However, cardiovascular
disease also refers to stroke, a disease that requires emergent attention and is the fourth
leading cause of death in the United States (American Stroke Association, 2013). This
paper will discuss the epidemiology and biostatistics of stroke, the medical basis for
stroke, the social and behavioral factors that affect this disease, and ways that the
government is trying to combat stroke through public health initiatives.
Biostatistical data illustrates the implications of stroke. As many as 795,000
Americans suffer from a new or recurrent stroke each year, resulting in one stroke every
forty seconds (American Stroke Association, 2013). Vital statistics from 2009 indicate
that just less than 130,000 people in the United States died of stroke. Cerebrovascular
accidents accounted for 5.3% of all deaths (Kochanek, Xu, Murphy, Miniño, & Kung,
2011). About 6.8 million Americans older than 20 years of age have had a stroke,
making the prevalence from 2007-2010 an estimated 2.8%. It is predicted that by 2030, 4
million more people will have had a stroke, increasing the prevalence by 21.9% from
2013 (American Heart Association, 2013).
A stroke occurs when there is a lack of blood flow to the brain or a hemorrhage
into the brain, causing death of the cells. Strokes may be ischemic or hemorrhagic in
nature. Ischemic strokes occur from a clot in the vessels of the brain and are either
thrombotic or embolic. Thrombotic strokes occur after there has been an injury to the
blood vessel wall (Lewis et. al., 2007). As the vessel attempts to repair itself, fragments
of cholesterol and fat deposit on the cell wall and begin to form a clot (Schneider, 2011).
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The condition of fatty deposits building up in the vessels is called atherosclerosis. When
atherosclerosis occurs to the degree where a vessel becomes occluded, blood cannot
reach the brain and a stroke occurs. Embolic strokes are also due to clots, but these clots
originate from somewhere else in the body such as the heart, and become lodged in a
vessel as they travel through the circulation (Lewis et. al., 2007).
Eighty percent of strokes are ischemic. The other twenty percent of strokes are
hemorrhagic. Hemorrhagic strokes are a result of bleeding into the brain. Hypertension
is the most common cause of hemorrhagic strokes (Moulton, 2009). Other sources
include coagulation disorders, anticoagulant and thrombolytic drugs, trauma, brain
tumors, and ruptured aneurysms (Lewis et. al., 2007). According to Lewis (2007) a
transient ischemic attack, sometimes called a “mini stroke,” is a “temporary loss of
neurologic function caused by ischemia” of part of the brain. The symptoms of most
TIAs resolve within three hours, but it is still important to take TIAs seriously, because
they are warning signs of progressive cerebrovascular disease (Lewis et. al., 2007).
Stroke is the leading cause of disability in the United States (American Stroke
Association, 2013). Strokes can have detrimental effects on the body, depending on
where in the brain the stroke occurred. Side effects of stroke include paralysis of one or
more limbs, loss of sensation in extremities, facial droop, hearing loss, personality
changes, cognitive impairment, visual disturbances, gait impairment, and many other
devastating results. If the stroke occurs on the left side of the brain, the right side of the
body is affected and vice-versa (Lewis et. al., 2007). The treatment and rehabilitation
needed to care for these side effects is very expensive. In 2010, stroke-related medical
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costs and disability totaled about 73.7 billion dollars (American Stroke Association,
2013).
Stroke is caused by both non-modifiable and modifiable risk factors. The nonmodifiable risk factors include advanced age, sex, race, and genetic susceptibility. Risk
factors that are modifiable include diet, exercise, use of tobacco and alcohol (Sherzai,
Heim, Boothby, & Sherzai, 2012). Other factors that can be changed include having high
blood pressure, high cholesterol, atrial fibrillation or other heart disease, carotid artery
disease, or diabetes mellitus (American Stroke Association, 2013).
Biostatistics and epidemiological data describe the relationship between age, gender,
race, and the incidence of stroke. According to the American Heart Association’s latest
report in Circulation, women have a higher lifetime risk of stroke. In the age group of 55
to 75 years, 1 in 5 women suffer from a stroke, while only 1 in 6 men in the same age
group have a stroke. Some data shows that women may have a lower incidence early on
in life, but after menopause the incidence increases to greater than that of men (American
Heart Association, 2013).
Race and geographic location are also indicative of stroke risk. Data from the
CDC in 2010 reports that 2.4% of non-Hispanic whites over 18 years of age have had a
stroke, compared to 3.9% of non-Hispanic blacks, 1.5% of Asian/Pacific Islanders, 2.5%
of Hispanics, and 5.9% of American Indian or Alaska Natives. From 2006-2010, the
Centers for Disease Control (CDC) analyzed trends in stroke prevalence with data from
the Behavioral Risk Factor Surveillance System. The results of this study were
categorized by sociodemographic characteristics and state of residence. This study
concluded that persons living in the Southeastern United States had the highest stroke
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prevalence. The age-adjusted stroke prevalence in 2010 was greatest in Alabama (4.1%),
while it was lowest in Connecticut (1.5%) (Centers for Disease Control and Prevention,
2012).
Alabama is one state included in the “stroke belt” of the United States, where
people are at an increased risk for stroke. The stroke belt is a geographic region made up
of eight states including North Carolina, South Carolina, Georgia, Tennessee,
Mississippi, Alabama, Louisiana, and Arkansas. The stroke mortality here is 20% higher
than in the rest of the United States. The “stroke buckle” is a small region in the coastal
plain of North Carolina, South Carolina, and Georgia where the stroke mortality is even
greater, averaging 40% higher than the rest of the country (American Heart Association,
2013).
Combating high blood pressure, or hypertension, is one of the most important
steps in reducing the risk of stroke in the stroke belt and across the entire nation. The
advised healthy blood pressure is 120/80, and anything over 140/90 is considered
hypertension. Hypertension is affected by the amount of fat in a person’s blood, or
cholesterol level. Cholesterol is a part of a typical American’s diet that has also been
shown to increase the risk for stroke. Maintaining a total cholesterol level less than 200
is recommended. Foods like eggs, meat, and milk are common sources of cholesterol,
while fish, olive oil, and oat bran have positive effects on blood lipids. Regular exercise
lowers total cholesterol, while smoking lowers HDL (good cholesterol) levels. The
nicotine in tobaccos has also been found to raise blood pressure and place stress on the
heart and blood vessels. Over an extended period of time, this stress and damage can
lead to atherosclerosis. Increasing physical activity can combat hypertension and stroke
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as well. If blood pressure cannot be reduced by these modifications, a medication to
lower blood pressure may be prescribed (Schneider, 2011).
While hypertension is seen across all races, this disease disproportionately afflicts
African Americans. In fact, the prevalence of hypertension in African Americans is
about 34% in males and 31% in females, while the prevalence is 25.4% in white, nonHispanic males and 21% in white females. Research shows that these discrepancies are
related to a variety of causes. African Americans’ socioeconomic status is generally
poorer, resulting in less treatment for hypertension. This group is more likely to wait for
treatment until they notice signs of organ damage. They are less likely to be able to
afford treatment and may not receive the necessary education needed to battle
hypertension (Moulton, 2009).
Hypertension, high cholesterol, smoking, obesity, and inactivity are all factors
that have been linked to cardiovascular disease and stroke. However, other influences,
both individually and linked to the aforementioned factors, can play a role in stroke
incidence. These social influences include marriage status, socioeconomic status, and
place of residence. Other behavioral influences can affect the length of time that it takes
people to seek medical attention after they have experienced stroke symptoms. The
ecological model of health behavior and the health belief model can help examine these
relationships.
According to the ecological model of health behavior, five different levels of
influence exist that determine peoples’ health behaviors. These five levels are
intrapersonal factors, interpersonal factors, institutional factors, community factors, and
public policy. Many of the risk factors for stroke are intrapersonal. Individuals have
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personal attitudes, beliefs, and practices, which may contribute to their food choices,
level of physical activity, or choice to smoke. These three are in turn linked to
hypertension and high cholesterol (Schneider, 2011). Recent research is interested in
how other social factors may be affecting people at the community level. One particular
concern is the effect that the socioeconomic status of a neighborhood could have on the
incidence of stroke (Augustin, Glass, James, & Schwartz, 2008).
A study conducted in Baltimore, Maryland studied the connection between place
of residence and cardiovascular disease. Self-reported incidents of cardiovascular
disease, including cardiovascular accident, transient ischemic attacks, and myocardial
infarction were measured against two the neighborhood psychosocial hazards scale
(NPH) and the townsend index. The NPH measures psychosocial hazards in a
neighborhood such as violent crime rate and the number of off-site liquor licenses. The
townsend index measures neighborhood wealth. The results of the study showed that as
the psychosocial hazards in a neighborhood increased, so did the occurrence of selfreported cardiovascular events such as stroke. Conversely, as the townsend index
increased, cardiovascular events decreased. The conclusion from this study is that
community factors such as social norms of violence or standards of how buildings are
maintained may produce a sense of alarm or threat in inhabitants. This stress may then
activate a physiological stress response, leading to chronic high blood pressure or
inflammatory processes that contribute to cardiovascular disease and ultimately stroke
(Augustin, Glass, James, & Schwartz, 2008).
Besides intrapersonal and community influences, the interpersonal level of
influence can play a role in stroke. The Health and Retirement Study evaluated the
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relationship between gender, marital status, cardiovascular risk factors, and stroke.
Marriage is arguably one of the most dominant aspects of interpersonal influence in a
person’s life. Research agrees with this statement, as people who are currently married
have lower risks of stroke and stroke mortality than those who are not married. This
study deduced that marriage is protective against stroke for both men and women.
Financial stability was one of the variables that made an impact on the differences in risk
for stroke between married and unmarried women. Unmarried women are more likely to
fall into poverty and become economically vulnerable. Married men and women both
benefited from the positive association between marriage and risk factors like a healthier
diet and lower percentage of tobacco use. This study demonstrated that at the
interpersonal level, a spouse might make have a powerful impact on his or her partner’s
health. Couples may be happier, more financially stable, and act as sources of
encouragement in healthy behaviors (Maselko, Bates, Avendaño, & Glymour, 2009).
Much has been written about the influences that cause strokes to occur, but
behavioral factors also play a role in people seeking treatment for stroke. Depending on
pre-existing health conditions, some people are candidates for reperfusion therapy for
ischemic stroke when admitted to the hospital. Reperfusion therapy can decrease the
length of time that a portion of the brain goes without oxygen, lessening the symptoms
and leading to a speedier recovery. However, many are not able to receive this therapy
because they are admitted to the hospital too late after the injury has occurred. The
health belief model is one tool that helps explore the reason for this problem
(Mandelzweig, Goldbourt, Boyko, & Tanne, 2006).
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The health belief model gives factors that establish whether a person is likely to
change a behavior after being faced with a health threat. The first factor is the “extent to
which the individual feels vulnerable to the threat” (Schneider, 2011). Those that feel
that they have control over their symptoms, contribute their symptoms to a different
etiology, or have low anxiety over the symptoms take longer to be treated (Mandelzweig,
Goldbourt, Boyko, & Tanne, 2006). The second factor is the “perceived severity of the
threat” (Schneider, 2011). Research shows that those with milder stroke symptoms such
as dizziness or headaches take longer to seek medical attention, while those who have
major symptoms like motor weakness or speech disturbance are much faster in seeking
care. Those who feel that their symptoms are more commonplace and not a major
medical threat are more likely to delay treatment (Mandelzweig, Goldbourt, Boyko, &
Tanne, 2006). The third factor involves the barriers attributed to taking steps to reduce
the risk. An example of this would be the link between being a woman and a 3-fold risk
in delay of care. One of the reasons for the phenomenon is that many stroke victims are
single, elderly women who may view calling family, friends, or emergency medical
services as a burden, which does not outweigh her symptoms (Mandelzweig, Goldbourt,
Boyko, & Tanne, 2006). The last factor, “the perceived effectiveness of taking an action
to prevent or minimize the problem,” (Schneider, 2011) is illustrated by an outside
influence to the stroke victim. The more that other people comment on the severity of
symptoms, and encourage the person to seek medical care, the more likely that person is
to go to the hospital. This interpersonal influence can help elevate the level of
effectiveness that people feel they will gain from receiving treatment (Mandelzweig,
Goldbourt, Boyko, & Tanne, 2006).
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Biostatistical data on stroke can be very helpful for public health officials to
identify the populations most at risk, and create programs that aim to reduce stroke in
these groups. The Centers for Disease Control supports many public health groups and
initiatives focused on reducing stroke incidence at the national, state, and local levels.
For example, the Paul Coverdell National Stroke registry was created in 2001 as a statebased registry to track data on patients having an acute stroke. This data is then used to
improve interventions for stroke care in eleven different states. Also, the National Heart
Disease and Stroke Prevention program allots money to state health departments in fortyone states to create new policies and implement heart-healthy education programs. The
WISEWOMAN program addresses the needs of women, especially those with little or no
health insurance, to reduce their risk of stroke and other chronic diseases.
WISEWOMAN provides screening and education to women in nineteen states and two
tribal organizations (Centers for Disease Control and Prevention, 2012). Each state
health department also has initiatives to combat stroke through local education programs
and public awareness days.
Stroke is a major concern for the public health field, as it is the fourth leading
cause of death and leading cause of disability in the United States (American Stroke
Association, 2013). Public health professionals should continue to provide surveillance
through epidemiological and biostatistical data. Stroke is a complicated disease, with
many biomedical, social, and behavioral factors. The government at all levels should
continue to learn more about these factors with research, and use those findings to create
policies that will ultimately decrease stroke incidence. With these policies in place and
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increased public education on the topic, the United States can be assured a healthier
population.
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References
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Centers for Disease Control and Prevention. (2012). CDC Addresses Stroke.
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