University of Minnesota study: Hmong patients more likely than whites to suffer strokes

Hmong patients are twice as likely to suffer strokes as their white counterparts, and at younger ages, according to a first-of-its-kind study by a University of Minnesota researcher.

The study analyzed 10 years of data from 128 Hmong stroke patients at Regions Hospital in St. Paul. Its findings were published this month in the Journal of the American Heart Association by lead author Dr. Haitham Hussein, a neurologist at M Health Fairview who also serves as an associate professor at the U's Medical School.

"What this tells me is we have to focus on prevention, and we have to also focus on young Hmong people before they suffer a stroke — before they suffer a brain hemorrhage," said Hussein, who formerly worked as medical director of Regions Hospital's Comprehensive Stroke Center.

The study found that Hmong patients who experience strokes are on average 11 years younger than their white counterparts. Hmong patients are also twice more likely than white patients to suffer hemorrhagic strokes, which occur when a rupture in an artery leads to bleeding in the brain.

The study cited poorly managed diabetes and hypertension as contributing factors to the disparities between Hmong and white stroke patients.

While working at Regions Hospital, Hussein noticed over the years that the hospital's Hmong stroke patients tended to be younger. He looked with a colleague for research about stroke patterns in the Hmong community, but couldn't find any.

"We had our own experiences, and we had some suspicions," Hussein said.

The study identified 128 Hmong patients who suffered strokes between 2010 and 2019, and compared them with around 3,000 white patients who also suffered strokes.

The average age of a Hmong patient suffering a hemorrhagic stroke was 56, while the average age of a white patient suffering the same stroke was 67. Hmong patients who suffered less-serious ischemic strokes were 60 on average, while white patients suffering the same type of stroke averaged 71.

Regions collects race data on its patients in broad categories like "Asian," but not by ethnicity, so obtaining data on the Hmong population was challenging.

To overcome that, researchers looked at Asian patient data and searched for last names using 51 spelling variations of the 18 Hmong clan surnames that most Hmong people use. Researchers also selected patients who put down Hmong as their primary language.

The most common causes of strokes in all communities are diabetes and high blood pressure, also called hypertension. Hmong patients who experienced ischemic strokes —caused by blocked arteries that restrict blood flow — typically had poorly controlled diabetes compared to white patients, according to the study.

Similarly, the study found that just 40% of Hmong patients experiencing ischemic strokes arrived at the hospital by ambulance, as compared with most white patients. This meant that Hmong patients typically arrived at the hospital later, Hussein said.

That's crucial, he said, because stroke patients can be treated with an injection called tPA in a 4.5-hour window of time following the start of a stroke. The treatment can prevent death, and also prevent or minimize a stroke's longterm effects.

Hussein authored a previous study when he worked at Regions finding that Hmong patients were more likely to have uncontrolled hypertension than white patients, using a database of 250,000 patients within the HealthPartners system.

A separate 2020 "knowledge survey" that Hussein also authored asked around 120 people in the Hmong community about their knowledge of stroke symptoms — and found a health literacy gap.

"The most striking information we learned is that there is not an equivalent word for stroke in the Hmong language," Hussein said. "The first question in the survey was, what is the name of the disease that makes people paralyzed on one side, and we got different answers. That was kind of eye-opening."

Zong Xiong, a nurse with St. Paul-Ramsey County Public Health, has been working with Hussein on this topic for years and collaborated with him on the 2020 survey that found Hmong people experiencing strokes sometimes delayed hospital visits or calls to 911 until symptoms grew very severe.

The reasons for this are many, she said. The 2020 survey, for example, found that some in the Hmong community preferred being diagnosed through traditional shaman ceremonies rather than western medicine. That survey also found that Hmong stroke patients didn't want to seek transitional care or rehabilitation after receiving western medical treatment.

"They would rather go home," she said.

As a result of the 2020 survey, the local branch of the American Heart Association put out educational videos and materials about strokes in the Hmong language. Xiong said more materials like that should be made available to the Hmong community.

All of this, Hussein said, means that primary healthcare for Hmong patients is inadequate. The first thing the medical industry needs to do, he said, is fix that with education.

"We need to engage the Hmong community and listen to them instead of preaching to them," he said. "We also have to encourage Hmong people to [become] health care professionals."