rnjbanner
 
Home > RNJ > 2006 > March/April > A Comparison of Stroke Risk Factors Between Men and Women with Disabilities

A Comparison of Stroke Risk Factors Between Men and Women with Disabilities
Janice L. Hinkle, PhD RN CNRN • Rosalind Smith, RN • Karen Revere

There are many adults with disabilities currently in the United States, yet little is known about how gender differences affect stroke risk factors in this population. This article presents a descriptive study that was designed to determine whether males and females living with disabilities differ in self-reported rates of stroke risk factors. Data were collected at conferences and meetings targeted for people living with disabilities. There were 146 participants; 54% were female; and the mean age was 58 years. The primary instrument was the Stroke Risk Screening tool. Stroke risk factors that differed significantly by gender include the incidence of hypertension (48% of men versus 32% of women), current smoking (30% men versus 4% women), history of heart disease (13% men versus 1% women), daily consumption of alcohol (10% men versus 1% women), and use of illicit drugs (10% men versus 0% women). Rehabilitation nurses should focus on earlier assessment of stroke risk factors and appropriate interventions, especially with men living with disabilities.

Much time and effort have gone into increasing the public’s awareness about stroke or brain attack; as a result, most healthcare professionals are now aware that stroke is the third leading cause of death in the United States. Each year 730,000 Americans suffer a new or recurrent stroke (American Stroke Association [ASA], 2004). It has also been estimated that there are 52.6 million people with a disabling condition in the United States (U.S. Department of Commerce, 2001).

The Healthy People 2010 goal for stroke is to improve health and quality of life through prevention, detection, and treatment of risk factors, and early identification and treatment of strokes in the U.S. population (Department of Health and Human Services [DHHS], 2000). Furthermore Healthy People 2010, for the first time, identified people living with disabilities as a subgroup similar to other populations requiring special attention (DHHS). Areas for special attention are health prevention, detection, and treatment of risk factors.

This article presents a review of the literature, methodology, findings, and implications of a study comparing stroke risk factors between 146 men and women with disabilities. It is not currently known whether gender differences affect risk factors for stroke in the disabled population. This is essential information for rehabilitation nurses to have before proceeding with developing targeted health promotion efforts to reduce stroke risk for people with disabilities.

Literature Review

Nonmodifiable risk factors for stroke include advanced age, male gender, Black and Hispanic ethnicities, and family history (Benson & Sacco, 2000; Goldstein et al., 2001; Norris & Hachinski, 2001). Prevention efforts focus on the assessment of modifiable risk factors; the most prevalent risk factors are hypertension (HTN), history of transient ischemic attack (TIA), atrial fibrillation (AF), and diabetes. These are all modifiable because although they cannot be eliminated, they can be delineated and controlled (Benson & Sacco). The incidence of HTN, cardiac conditions, and diabetes are all high in the disabled population (Fried, Bandeen-Roche, Kasper, & Guralnik, 1999). It is not known, however, whether these specific controllable stroke risk factors differ between men and women with disabilities.

Hypertension

The presence of HTN is the most important, prevalent, and treatable risk factor for stroke (Benson & Sacco, 2000; Hyman & Pavlik, 2001). In the United States, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (1997) has defined HTN as a systolic of >140 mm Hg or a diastolic of > 90 mm Hg. An increase in blood pressure (BP) contributes to stroke by aggravating atherosclerosis leading to vascular complications.

It is recommended that patients with a diagnosis of HTN and no comorbid illness receive medical treatment comprised of a low-dose diuretic or beta blocker (The Joint National Committee on Prevention, 1997). Research suggests that lowering the diastolic BP 5–6 mm Hg decreases the incidence of stroke 42% and the rate of fatal stroke by 45% (Wright, 1998). The results of a meta-analysis suggest that diuretics and beta blockers are the only agents that decrease the incidence of stroke in patients with HTN (The Joint National Committee on Prevention).

In one large study of stroke incidence, the age-adjusted relative risk of stroke in hypertensive participants was 3.1 in men and 2.9 for women (Feinberg, Blackshear, Laupacis, Kronmal, & Hart, 1995). The Working Group on Women’s Health of the Society of General Internal Medicine suggested that there are enough differences between men and women who have HTN to justify developing separate algorithms to guide appropriate treatment (Anastos et al., 1991). It is not known whether these gender differences apply to adults with disabilities.

Exact rates of HTN in persons with disabilities are not known but are believed to be increased compared with the nondisabled population (Fried et al., 1999). It is also not known whether people with certain types of disabilities are more prone to HTN.

Transient Ischemic Attack

A TIA is a focal neurological deficit that resolves completely within 24 hours (Albers et al., 2002). Approximately 200,000 individuals in the United States suffer a TIA each year and about one-third will develop a stroke if untreated (Johnston). Many TIAs are unreported due to the transient nature of the symptoms (Albers et al.). Thus, a self-report mechanism for collecting information on TIA rates may be more accurate than rates reported in the medical literature.

A TIA leaves no permanent neurological deficit but provides healthcare professionals with the opportunity to identify high-risk patients and initiate a program to prevent future permanent deficits (Norris & Hachinski, 2001). The initial approach to preventing a recurrent TIA is to identify and modify risk factors amenable to treatment (Ryan, Combs, & Penix, 1999). Significant risk factors include HTN, smoking, heavy alcohol intake, AF, hyperlipidemia, diabetes (Ryan et al., 1999), cardiac disease, coronary heart disease, left ventricular hypertrophy, and heart failure (Norris & Hachinski, 2001).

The first-line treatment for TIAs is antiplatelet medication, the least costly being acetylsalicylic acid (ASA) also known as aspirin. A clinical trial on the use of ASA to reduce the risk of stroke showed a risk reduction of 48% in men and no significant effect for women (Dyken et al., 1977). Another effective treatment for TIAs caused by a 70% or higher occlusion of the carotid artery is a surgical procedure, carotid endarterectomy (Wolf et al., 1999). The recommendation for this procedure is based on the North American Symptomatic Carotid Endarterectomy Trial that included only 30% women (Barnett et al., 1998). A recent study using 1992 Medicare data revealed that women undergo fewer carotid endarterectomies compared with men (Ramani, 2000).

Women who have a TIA are at a disadvantage compared with men because of ineffective therapy and low rates of surgical intervention. It is not known whether these gender differences apply to people with disabilities. It is also not known whether people with certain types of disabilities are more prone to TIAs.

Atrial Fibrillation

The condition of AF, a cardiac arrhythmia, occurs in 5.9% of individuals older than 65 years (Feinberg et al., 1995). It is estimated that AF causes 75,000 ischemic strokes each year (Wright, 1998), in particular embolic strokes (Norris & Hachinski, 2001). For patients with a diagnosis of AF, treatment prevents TIA and ischemic stroke.

The absolute prevalence of AF in men and women is equal; however, because there are almost twice as many women than men older than 75 in the United States, the absolute number of women with AF is higher than men in this age group. For example, 55% of individuals with AF are women older than 65 years, increasing to 63% after 75 years (Feinberg et al., 1995).

Although cardiac conditions are known to be higher in the disabled population, the percentage of AF in people with disabilities is not known. It is also not known whether there are gender differences in AF in people with disabilities.

Diabetes Mellitus

A diagnosis of diabetes is based on a fasting blood glucose level higher than 126 mg/dL. Diabetes mellitus is a major risk factor for stroke (Norris & Hachinski, 2001). It is also associated with increased mortality, worse functional outcome, more severe disability, and a higher recurrence rate following a stroke (Wright, 1998).

The Honolulu Heart Program established a relative risk for ischemic stroke of 2.7 for diabetic men compared with nondiabetic men of Japanese ancestry (Abbott, Donahue, MacMahon, Dwayne, & Yano, 1987). Rates of glucose intolerance and diabetes are higher for women than men (Haseltine & Jacobson, 1997). Rates of diabetes are higher in people with disabilities as well (Fried et al., 1999). These combined factors may put women with disabilities at higher risk of stroke compared with men. However, further investigation of this important risk factor is warranted.

Additional modifiable and nonmodifiable stroke risk factors include carotid artery disease and history of heart disease before stroke (Goldstein et al., 2001), smoking (Benson & Sacco, 2000), family history of heart attack or stroke, excessive alcohol use (Rodgers et al., 1993), high cholesterol (Benson & Sacco), sickle cell disease (Gillum, Gorelick, & Cooper, 1999), and the use of illicit drugs (Blank-Reid, 1996). Individuals with cardiac impairment of any type, whether symptomatic or not, have more than twice the risk of stroke compared with people with normal cardiac function (Summers et al., 2000). Although the presence of cardiac impairment or sickle cell disease cannot be changed, each can be medically managed and the risk of stroke thereby decreased. Cigarette smoking and alcohol consumption increase the blood viscosity thereby increasing the risk of stroke (Benson & Sacco; Rodgers et al.). The use of illicit drugs causes stroke either by the direct effect of the drug or by complications of the administration method (Blank-Reid).

The role of gender and disability are poorly understood for each modifiable stroke risk factor. There are recognized differences between men and women with each risk factor, however, it is not now known whether these differences are generalizable to the population of people with disabilities. This study was implemented to begin to fill this knowledge gap.

The primary purpose of the current study was to compare stroke risk factors between males and females with disabilities. Specific aims were as follows:

  • to determine whether males and females with disabilities differed in self-reported rates of HTN, TIA, AF, diabetes, or other risk factors
  • to determine whether males and females with disabilities differed in their mean systolic BP, diastolic BP, or pulse rate on the day of screening.

Methodology

Overview and Design

The design of the current study was a descriptive, nonexperimental two-group comparison. Data were gathered on the demographic characteristics and the nature of the disability in the sample. Self-reported rates of stroke risk factors between men and women were compared. Men and women were also compared on the mean systolic BP, diastolic BP, and pulse rate on the day of the screening. The study was approved by the investigational review board at Villanova University.

The research team set up tables at various health promotion, awareness, or educational events targeted to people with disabilities. Participants who approached the table were invited to participate. Those who agreed completed the Stroke Risk Screening tool and a short consent with a section to indicate whether they had a disability and to identify the nature of the disability. The disability was self-reported, but, in general, participants considered themselves disabled if they were not gainfully employed or needed assistance with activities of daily living due to their condition. Each participant’s BP was measured and pulse counted (quick check for AF). Research assistants were trained in taking BP in a college of nursing laboratory. Aneroid BP cuffs of the appropriate size for the individual were used and any reading above 140/90 was double checked by another member of the research team. There was 95%–97% agreement among the team members on BP readings.

Each participant received individual counseling about his or her stroke risks using an algorithm that factored in the number of risk factors and the BP reading that day. Each participant was educated on the warning signs of stroke and given a copy of an American Stroke Association pamphlet as a guide to recognizing the signs of stroke (American Stroke Association, 2000). The pamphlet, available in English and Spanish, also served as a reminder for individuals to call 911 immediately if they or someone around them displays any warning signs of a stroke.

Sample Recruitment

A convenience sampling method was used to recruit men and women with a disability to participate in individual stroke risk assessments. The goal was to recruit 64 men and 64 women for a total sample of at least 128 participants. These numbers were arrived at by using a power analysis for ANOVA, a medium effect size (f = .25), power of 0.80, and an alpha of 0.05 (Cohen, 1988). A medium effect size was estimated because the literature on modifiable stroke risk factors reflects differences between nondisabled men and women.

Participation in the study was open to men and women with a self-identified disability who were older than 18. Informed consent was obtained from each participant.

Measures

The size of the type on the Stroke Risk Screening tool was increased to 14 points. A cover page included an explanation of the study, consent from the participant, and data about the presence and nature of the disability.

The Stroke Risk Screening tool included information on demographics and 15 questions on various stroke risk factors (Barker & Lamonte, 1999). The tool was introduced in 1999, and complete reliability and validity have yet to be reported. Content validity was established by using experts and current literature to develop the instrument (Barker & Lamonte).

Analysis

The Statistical Package for the Social Sciences (SPSS) Version 11 was used to analyze the data (SPSS, 2001). Sample demographics and characteristics were examined with descriptive statistics. Analysis of variance (ANOVA) was used to compare the mean diastolic with systolic BPs of men and women. Chi-square was used to test for differences in the self-reported rates of HTN, TIA, AF, diabetes, and other risk factors (Munro, 2001).

Findings

Over 200 individuals had stroke risk screenings; 146 participants who self-identified as having a disability were included in the current study. The characteristics of the men and women who participated are listed in Table 1. Approximately 92% of participants reported that they had medical insurance (88% of the men and 95% of the women), 93.8% had a healthcare provider, and 92% reported having seen their healthcare provider within the last year.

The nature of the disability for men and women in the study can be found in Table 2. The other category of self-identified disabilities comprised a wide range of conditions. These included arthritis (n = 2), Parkinson’s disease (n = 2), breast cancer (n = 4), back injury (n = 3), fibromyalgia (n = 2), osteoporosis (n = 1), learning disability (n = 2), coronary artery disease (n = 3), cerebral palsy (n = 1), spina bifida (n = 1), multiple sclerosis (n = 1), paralysis (n = 1), prior stroke (n = 1), ankylosis spondylosis (n = 1), asthma (n = 1), diabetes (n = 1), and end-stage renal disease (n = 1).

Self-reported major modifiable risk factors for stroke are summarized in Table 3. On several factors, men had significantly higher rates compared with women. The men reported a significantly higher (p < .05) rate of HTN compared with women. Thirteen percent of men and 1% of women reported having had a heart attack, heart by-pass surgery, angioplasty, or another disease of the heart (Χ2 = 8.4; df = 1; p < .05). Fifty percent of the men and 35% of the women reported having ever smoked cigarettes. Of those who reported currently smoking cigarettes, 30% were men and 4% women, a significant difference (Χ2 = 18.5; df = 1; p < .001). A significantly larger number of men (10%) than women (1%) reported consuming more than 2 ounces of alcohol per day on a daily basis (Χ2 = 5.9; df = 1; p < .01). Similarly, 10.4% of the men and none of the women reported the use of illicit drugs, a significant difference in the two groups (Χ2 = 8.6; df = 1; p <.01).

The mean systolic BP for participants was 135 (mean= 130) mm Hg, the mean diastolic BP was 79 (mean= 78) mm Hg, and the mean pulse rate was 76 (mean= 76). The systolic BP measured on the day of the screening was not significantly different for men (m= 136 mm Hg, + 25) compared with women (m = 133 mm Hg, + 19). There was no significant difference in the diastolic BP with men having a mean of 83 (+15) mm Hg, and women 79 (+11) mm Hg. There was no significant difference in pulse rate between the two groups.

Discussion

The primary purpose of this study was to compare males and females with disability on modifiable risk factors for stroke. HTN, identified as the most common preventable stroke risk factor in the general population (Benson & Sacco, 2000; Lindsey, 2000), was prevalent among both male and female participants. It has been estimated that HTN is present in 38% of people between the ages of 50 and 59 (Norris & Hachinski, 2001). Women in this study, with a self-reported rate of 32%, are within the range of the population at large.

In addition, the mean systolic BP of 135 (median = 130) mm Hg., puts both men and women within the new prehypertension range most recently defined by the National Heart, Lung, and Blood Institute (2003). Creative steps should be taken to prevent BP from increasing with age in people with disabilities, particularly men. Strategies include using models of stroke prevention that have been shown to be effective, such as specialized clinics and self-testing (Straus, Majumdar, & McAlister, 2002).

The majority of people with disabilities in the current study had health insurance and a primary healthcare provider whom they had seen during the previous year. These findings mirror what other researchers have found, that many patients with uncontrolled HTN have access to health care and relatively frequent contact with physicians (Hyman & Pavlik, 2001). The current study, as well as others, strongly suggests that healthcare providers need further education on including health promotion efforts for persons with disabilities that are age appropriate, such as specific stroke risk factors like hypertension, and not focus solely on the underlying disability (Clancy & Andresen, 2002).

The comparison of stroke risk factors in men and women with hearing impairments and mental disabilities is unique to our knowledge. In this study, 45% of participants identified their disability as hearing impairment (Table 2) when the investigators set up a table at a 3-day National Hard of Hearing Conference. In the 1997 National Health Interview Survey, 12.4% of adults 18 or older identified their disability to be limited vision, hearing, or both (National Center for Health Statistics, 2000). Five percent of participants in the current study identified their disability as mental, while 6.3% of the National Health Interview Survey participants identified depression or emotional limitation (Statistics, 2000).

In the current study, 27% of participants identified their race as Black (Table 1). The 2000 census data reported that 15.6% of the total U.S. population reported their race as Black; in the northeast section of the country the rate was 18% (U.S. Census Bureau, 2002). The year 2000 death rates per 100,000 people in the United States for stroke were 58.6 for White males and 87.1 for Black males; and 57.8 for White females and 78.1 for Black females (ASA, 2004). Thus it is important to continue programs, such as the one reported here, that include large numbers of Blacks in stroke risk assessment efforts.

Men with a self-reported disability in this study also had significantly higher reported rates of HTN, smoking, heart problems, daily alcohol consumption, and illicit drug use compared with the women. The finding that men with a disability have higher rates of several risk factors compared with women is not surprising; it is well known that stroke is more prevalent among men than women (ASA, 2004; Goldstein et al., 2001). Creative health promotion strategies need to be used to reach out to men with disabilities with an emphasis on identifying and treating these risk factors to reduce their stroke risk.

Face-to-face interviews like those used in the current study involve assessment of each stroke risk factor, but community programs often attract more women than men (Lindsey, 2000), thus missing many in this high-risk group. New strategies for reaching men are warranted. The United States had more than 132 million Internet users by the end of year 2000 and 490 million are projected by the end of 2002 (Duffy, 2002). More men than women use the Internet and the World Wide Web, therefore an online version of a stroke risk screening tool has potential as an effective strategy to engage more men in this important health promotion effort.

Additional strategies include providing continuity of care and culturally sensitive care (Hill, 1999). Evaluations for men with disabilities also need to include consideration of cost-effective treatment of HTN, antiplatelet regimens that are available for secondary prevention of stroke and TIA (Sarasin, Gaspoz, & Bounameaux, 2000), cost-effective smoking cessations programs (Goldstein et al., 2001; Norris & Hachinski, 2001), and appropriate counseling for increased alcohol intake and illicit drug use (Goldstein et al.).

Limitations

There were several limitations of this study. One limitation was the use of a convenience sample; future studies should direct efforts at obtaining a sample more representative of adults with disabilities in the United States. Another limitation was the use of self-reported data. Future studies should compare self-reported stroke risks with actual data on medical records and use a disability rating scale to augment and validate self reports of disability. Although the sample size was adequate for comparisons between males and females, it was inadequate for within-group comparisons of distinct types of disabilities. Further studies need to assess the reliability of the stroke risk screening tool.

Conclusion

The most effective way to reduce the burden of stroke is through prevention. This article provides findings on gender differences for stroke risk factors in people with disabilities. Rehabilitation nurses need to continue to increase the number of people (especially men) appropriately screened and counseled about stroke risk factors.

Acknowledgments

This project was funded by the Research Seed Fund of the Health Promotion for Women with Disabilities Project of Villanova University College of Nursing, funded by Bristol-Myers Squibb Foundation.

 

Rosalind Smith’s involvement in this project was sponsored by Project IMPART (Improving Minority Professionals’ Access to Research Tracks) funded by the National Institute of General Medical Science, National Institutes of Health.

About the Authors

Janice L. Hinkle, PhD RN CNRN, was an assistant professor at Villanova University College of Nursing, Philadelphia, PA, at the time this research was conducted. Address correspondence to her at Acute Stroke Programme, Nuffield Department of Clinical Medicine, Level 7, John Radcliffe Hospital, Headington, Oxford 0X3 3DU, or janice.hinkle@ndm.ox.ac.uk.

Rosalind Smith, RN, was a research assistant at Villanova University College of Nursing at the time this research was conducted.

Karen Revere was a research assistant at Villanova University College of Nursing at the time this research was conducted.

References

Abbott, R., Donahue, R. P., MacMahon, S., Dwayne, M. R., & Yano, K. (1987). Diabetes and the risk of stroke. Journal of the American Medical Association, 257(7), 949–952.

Albers, G. W., Caplan, L., Easton, D., Fayad, P. B., Mohr, J. P., Saver, J., et al. (2002). Transient ischemic attack—Proposal for a new definition: Sounding board. New England Journal of Medicine, 347(21), 1713–1716.

American Stroke Association. (2000). Every second counts. Dallas, TX: Author.

American Stroke Association. (2004). Retrieved from www.strokeassociation.org.

Anastos, K., Charney, P., Charon, R., Cohen, E., Jones, C., Marte, C., et al. (1991). Hypertension in Women: What is really known? Annals of Internal Medicine, 115(4), 287–293.

Barker, E., & Lamonte, M. (1999). Stroke risk screening. Greenville, DE. Available at www.destroke.org.

Barnett, H. J. M., Taylor, D. W., Eliasziw, M., Fox, A., Ferguson, G., Haynes, R. B., et al. (1998). Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. New England Journal of Medicine, 339(20), 1415–1425.

Benson, R. T., & Sacco, R. L. (2000). Stroke prevention: Hypertension, diabetes, tobacco, and lipids. Neurologic Clinics, 19(2), 309–319.

Blank-Reid, C. (1996). How to have a stroke at an early age: The effects of crack, cocaine, and other illicit drugs. Journal of Neuroscience Nursing, 28(1), 19–27.

Clancy, C. M., & Andresen, E. (2002). Meeting the health care needs of persons with disabilites. The Milbank Quarterly, 80, 381–391.

Cohen, J. (1988). Statistical power for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates Publishers.

Duffy, M. (2002). Methodological issues in Web-based research. Journal of Nursing Scholarship, 34(1), 83–88.

Dyken, M., Conneally, M., Haerer, A., Gotshall, R., Calanchini, P., Paskanzer, et al. (1977). Cooperative study of hospital frequency and character of transient ischemic attacks. Journal of the American Medical Association, 237(9), 882–886.

Feinberg, W., Blackshear, J., Laupacis, A., Kronmal, R. A., & Hart, R. G. (1995). Prevalence age distribution and gender of patients with atrial fibrillation. Archives of Internal Medicine, 155(Mar 13), 469–473.

Fried, L., Bandeen-Roche, K., Kasper, J., & Guralnik, J. M. (1999). Association of comorbidity with disability in older women: The women’s health and aging study. Journal of Clinical Epidemiology, 52(1), 27–37.

Gillum, R. F., Gorelick, P. B., & Cooper, E. S. (1999). Stroke in blacks: A guide to management and prevention. New York: Karger.

Goldstein, L. B., Adams, R., Becker, K., Furberg, C. D., Gorelick, P. B., Hademenos, G., et al. (2001). Primary prevention of ischemic stroke: A statement for healthcare professionals from the stroke council of the American Heart Association. Circulation, 103, 163–182.

Haseltine, F. P., & Jacobson (Eds.). (1997). Women’s Health Research: A medical and policy primer. Washington, DC: Health Press International.

Hill, M. (1999). Prevention and treatment of hypertension in Black Americans. In A. S. Hinshaw, S. Feetham, & Shayer (Eds.), Handbook of Clinical Nursing Research. Thousand Oaks, CA: Sage Publications, 289-308.

Hyman, D., & Pavlik, V. (2001). Characteristics of patients with uncontrolled hypertension in the United States. New England Journal of Medicine, 345(7), 479–486.

Johnston, S. C. (2002). Transient ischemic attack: Clinical practice. The New England Journal of Medicine, 347(21), 1687–1692.

Lindsey, J. (2000). Implementing a stroke risk assessment program in a community setting. Journal of Neuroscience Nursing, 32(5), 266–270.

Munro, B. (2001). Statistical methods for health care research (4th ed.). Philadelphia: J. B. Lippincott.

National Center for Health Statistics (2000). National Health Interview Survey, 1997 [CD-ROM]. Hyattsville, MD: Data File Documentation.

National Heart, Lung, and Blood Institute. (2003). The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Department of Health and Human Services. Retrieved November 21, 2003, from www.nhlbi.nih.gov/guidelines/hypertension.

Norris, J. W., & Hachinski, V. C. (2001). Stroke prevention. Oxford: University Press.

Ramani, S., Byrne-Logan, S., Freund, K., Ash, A., Yu, W., & Moskowitz, M. (2000). Gender differences in the treatment of cerebrovascular disease. Journal of the American Geriatrics Society, 48, 741–745.

Rodgers, H., Aitken, P., French, J., Curless, R., Bates, D., & James, O. (1993). Alcohol and stroke: A case-control study of drinking habits past and present. Stroke, 24, 1473–1477.

Ryan, M., Combs, G., & Penix, L. (1999). Preventing stroke in patients with transient ischemic attacks. American Family Physician, 60(8), 2329–2336.

Sarasin, F. P., Gaspoz, J. M., & Bounameaux, H. (2000). Cost-effectiveness of new antiplatelet regimens used as secondary prevention of stroke or transient ischemic attack. Archives of Internal Medicine, 160(18), 2773–2778.

SPSS. (2001). Statistical Package for the Social Sciences: SPSS base version 11 for Windows. Chicago: SPSS INC.

Straus, S., Majumdar, S., & McAlister, F. (2002). New evidence for stroke prevention. Journal of the American Medical Association, 288(11), 1396–1398.

Summers, D., Pyle, J., Stahl, M., & Hileman, J. (2000). The heart-brain connection. Journal of Neuroscience Nursing, 32(2), 108–116.

The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (1997). The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Archives of Internal Medicine, 157, 2413–2446.

United States Census Bureau. (2002). A census 2000 profile of the Black population. United States Government. Retrieved, March 4, 2003, from www.census.gov

United States Department of Commerce. (2001). Americans with Disabilities: Household Economic Studies. Washington, DC: Bureau of the Census.

United States Department of Health and Human Services. (2000). Healthy people 2010: Understanding and improving health. Washington, DC: US Government Printing Office.

Wolf, P. A., Clagett, G. P., Easton, D., Goldstein, L. B., Gorelick, P. B., Kelly-Hayes, M., et al. (1999). Preventing ischemic stroke in patients with prior stroke and transient ischemic attack. Stroke, 30, 1991–1994.

Wright, C. (1998). A brief update on stroke. American Journal of Nursing, 98(5), 62, 64–65, 67–68.