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[76]
Cruz-Flores et al. discuss race and ethnicity and describe the reasons why race has been replaced with the
term ethnicity in modern society. In their words, ethnicity describes common ancestry, history or culture
[40]
and emphasises the social rather than biological characteristics. In Australia, Kilkenny et al. note that,
whilst there was agreement between the auditors for recording Indigenous status, there are no available data
on the accuracy of these records to determine the true number of Indigenous patients admitted to hospital
with stroke. Similarly, in the United States [63,68] the NIS remains subject to biases and recording error, as a
large proportion of patients are recorded as “other”. In Norway, Siri et al. comment on the difficulties
[38]
experienced by the Sami population, particularly related to assimilation processes and historically unethical
research leading to a reduced likelihood of disclosing ethnicity. Lastly, the impact of not recording ethnicity
at all may be a reason for lack of available data. The most powerful way to ensure correct identity is with
self-identification. Frontline health care workers should routinely seek information about ethnicity to avoid
prejudice.

Lastly, the sovereignty of data is increasingly being recognised as an important factor in Indigenous self-
determination. The importance of Indigenous voices speaking for the rights and interests of Indigenous
Peoples - “nothing about them without them” - has been missing from past conversations [81,82] . Given
[83]
these data and their application are about Indigenous Peoples, it is imperative that within the protocols,
consent process, interpretation of findings and translation of research, Indigenous involvement should be
forefront and ownership of those data not forgotten.

The future of stroke and its effect on Indigenous Peoples has shifted from documenting the relative
disadvantage of individuals and their communities to finding solutions that can be targeted for improved
Indigenous stroke outcomes. This can only be achieved once Indigenous Peoples write the narrative, for
example, inclusion in the design and delivery of culturally safe health care that understands their lived
experience and meets their needs as Indigenous People. For millennia, Indigenous groups have known the
important influence of Indigenous culture on health outcomes. Culture can act as a protection against social
harms and build community resilience. Health inequities will continue unless government policies address
the needs of Indigenous Peoples and societal systems change to incorporate practices/policies that are
appropriate for those outside the dominant culture. To decrease the incidence of stroke, we need a rapid
shift towards a strength-based approach to stroke prevention and management [11,36,41] . This includes
innovative ideas and health care system redesign, led by Indigenous Peoples, to improve early recognition of
stroke and the quality of, and access to, acute treatment and rehabilitation services with Indigenous health
care providers. We need culturally appropriate services that support the healing process. Examples of these
include Indigenous specialists, Indigenous health workers/navigators, Indigenous community health
professionals, increased use of interpreters, culturally appropriate information about causality and
explanation of medications, and family-focused care. Cultural safety training that teaches non-Indigenous
health professionals how to interact with Indigenous Peoples would help these health professionals improve
health outcomes for their Indigenous patients, while community-based rehabilitation, tele-stroke and tele-
rehabilitation services could extend care to communities [5,64,71] .

LIMITATIONS
Limitations of this study include variation in study design, including quality, data sources and methods.
Furthermore, as this was conducted as a narrative rather than systematic review, we do not provide a
comprehensive overview of all available literature, which may have led to bias in reporting.