This story comes to you from Sahan Journal through a partnership with MPR News.

By Joey Peters | Sahan Journal

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

The study analyzed 10 years of data from 128 Hmong stroke patients at Regions Hospital in St. Paul. The 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 University of Minnesota 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.

Hussein also currently serves as board director of the Twin Cities chapter of the American Heart Association.

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, the more serious of the two types of strokes, according Hussein.

Hemorrhagic strokes occur when a rupture in an artery leads to bleeding in the brain. Ischemic strokes are caused by blocked arteries that restrict blood flow.

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

While working at Regions Hospital, Hussein noticed over the years that many of the hospital’s Hmong stroke patients were younger than average. At a meeting, a colleague asked for literature about stroke patterns in the Hmong community. She and Hussein looked for research, 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. 

For hemorrhagic strokes, which are more likely to be fatal, the average age of the Hmong patient was 56, while the average age of the white patient was 67. Hmong patients who suffered ischemic strokes were 60 on average, while white patients suffering the same type of stroke averaged 71.

There were challenges in obtaining data on the Hmong population. Regions collects race data on its patients in broad categories like “Asian,” but not by ethnicity. 

“The way we lump them and call them ‘Asian’ limits the research we can do,” Hussein said.

To overcome that, researchers looked at Asian patient data from Regions 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 Hmong as their primary language. 

This method of identifying Hmong patients meant that researchers probably missed data from some Hmong patients, Hussein said. 

“All of these are limitations,” he said, “but we designed it that way so we would have a pure sample.” 

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

Similarly, the study found that just 40 percent of Hmong patients experiencing ischemic strokes arrived at the hospital by ambulance; a majority of white patients used ambulances. This meant that Hmong patients typically arrived at the hospital later—often more than four hours after their stroke symptoms began, Hussein said. 

That’s crucial, Hussein said, because stroke patients can be treated with an injection called tPA in a 4.5-hour window of time from the beginning of the stroke. The treatment can prevent death, and prevent or minimize a stroke’s long term after effects. 

While the study did not analyze high blood pressure, Hussein authored a previous study when he worked at Regions that analyzed a database of 250,000 patients within the HealthPartners system. The study found that Hmong patients were more likely to have uncontrolled hypertension than white patients. 

Uncontrolled hypertension was defined in that study as people diagnosed with hypertension for at least two years who had a blood pressure reading of 140 over 90 or higher. A healthy blood pressure level is typically 120 over 80, or a combination of numbers below that. A reading between 120 over 80 and 140 over 90 is considered borderline hypertension. 

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, starting when she worked with him as a registered nurse at Regions Hospital. 

Xiong, who also serves as secretary of the Hmong Health Care Professionals Coalition, collaborated on the 2020 stroke knowledge survey with Hussein. It made similar findings to Hussein’s more recent study: 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 over western medicine. 

“A lot of times, if they notice someone having trouble speaking or having trouble moving, they might say, ‘We should go find a shaman and figure out what’s wrong,’” Xiong said. 

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 need to 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 be healthcare professionals.”