Page 76 - Read Online

Santos et al. Vessel Plus 2021;5:21 https://dx.doi.org/10.20517/2574-1209.2020.69 Page 11 of 16

level and the possibility of lower National Institute of Health Stroke Scale scores, differences in aetiology or
contraindications to thrombolysis or endovascular thrombectomy [41,62,63,68,78] . Besides individual-level risks,
institutional racism plays an important role in reduced access to specialist interventions. There is also
evidence that, even when arriving to hospital in a timely manner, Indigenous Peoples wait longer in the
emergency department . The flow-on effects of lifelong disability related to delayed treatment, no
[63]
treatment or curtailed treatment, are unacceptable.

Whilst our review did not specifically address mortality, several studies have provided evidence that
[11]
Indigenous Peoples have greater mortality rates than non-Indigenous Peoples . In Australia, there are
multiple reports of higher stroke mortality rates in Indigenous Australians compared with non-
Indigenous [36,52,79] . In New Zealand , the 30-day case fatality rate for patients with IS was analysed over 2
[80]
time periods and compared. In 2000-2004 the case fatality rate was larger for Māori than Europeans, and in
2010-2014 it was greater for all ethnic groups than Europeans. In Canada similar results have shown
[62]
Indigenous Peoples have a greater case fatality rate following stroke than non-Indigenous.

In Australia and the United States, greater rates of haemorrhagic stroke are reported amongst Indigenous
Peoples than non-Indigenous people. It is likely that this large rate of haemorrhagic stroke is associated with
greater disability and mortality, given that this type of stroke has significantly poorer outcomes than IS .
[46]
Thus stroke subtype, whilst influenced by the prevalence of risk factors, may also have a causal relationship
with higher case fatality.

The cumulative effects of lower socioeconomic status and Indigenous identity on stroke incidence rates, risk
factors and treatment, have been difficult to elucidate. Many of the referenced authors observed that the
data sources do not directly record socioeconomic status [40,79] ; hence, this variable could not be included in
analyses. Despite this, it is well documented that lower socioeconomic status is a risk factor for
cardiovascular disease , and poorer access to quality health care including access to high volume stroke
[62]
[54]
[63]
centres , particularly in regions where there is residential segregation . Therefore, it is likely that
[46]
socioeconomic status may be one of the mediators of the observed greater incidence rates of stroke and
poorer outcomes in Indigenous Peoples.
A major hindrance to quality data on this topic is the lack of large samples of Indigenous Peoples [40,62] .
Indigenous Peoples commonly represent a minority group in their region, and hence sample sizes are often
small. This makes meaningful statistical comparisons with the non-Indigenous population difficult, as
sample sizes may be underpowered. Points raised relating to this issue include the need for a greater
emphasis on research questions that are driven by the communities identified needs, the Indigenous
consent process, consensus for Indigenous identity procedures and reinforcing the dialogue of Indigenous
governance and data sovereignty [81,82] . Gaining informed consent, which can be compounded by language
barriers, cultural incompetence and insensitivity of researchers, is a difficult issue. However, suggestions for
improvement lie in the involvement of healthcare workers from the selected communities before the
research begins. Community views on the need of the research objective and cultural considerations should
be entwined in the research question and protocol. This should not be an afterthought. Once community
consultation has been sought, healthcare workers that are fluent in the regional dialect can translate
materials for participants. Not only does this bolster the workforce capacity of the community, creating
jobs, but it also ensures appropriate research is undertaken that meets the needs of the community and
incorporates cultural considerations into the entire process, including consent.