MAs reported significantly more pre-stroke spirituality than NHWs, while overall this biethnic stroke population reported high levels of spirituality. The ethnic association of spirituality was consistent across age and gender subgroups. Given that spirituality has been shown to be protective against mortality, in many, but not all, previous studies, ethnic differences in spirituality as demonstrated in the current study may contribute to the improved survival of MA stroke patients (Blumenthal et al. 2007
; Hill et al. 2005
; McCullough et al. 2000
; Strawbridge et al. 1997
). Our previous research found no difference in stroke severity among MA and NHW stroke patients (Morgenstern et al. 2004
). Thus, if spirituality is associated with decreased all-cause mortality, it is likely not via stroke severity. Exploration of the association of spirituality with all-cause mortality requires further study.
As a result of the high level of spirituality demonstrated in MAs, spirituality may provide a unique means to achieve primary or secondary stroke prevention efforts in this population. Church-based interventions have been utilized to access populations that are more difficult to reach via traditional mechanisms (Campbell et al. 2007
) and have been successful in many African American communities (Campbell et al. 1999
; Resnicow et al. 2004
; Voorhees et al. 1996
). In comparison with African American communities, few church-based behavioral intervention projects have been conducted in MA communities (DeHaven et al. 2004
). One successful study utilized promotoras (peer counselors) to increase breast cancer screening awareness (Sauaia et al. 2007
). Currently underway is the Stroke Health And Risk Education (SHARE) project, a culturally tailored, faith-based intervention among MAs and NHWs that targets health-related behaviors to reduce the risk of stroke (Zahuranec et al. 2008
Prior to their strokes, this bi-ethnic population was not depressed and had moderate scores with respect to optimism and fatalism. Interesting patterns of pre-stroke depression, fatalism, and optimism were observed among women. MA women were more optimistic compared to NHW women after adjusting for age and education. Among women, age modified the ethnic associations with pre-stroke depression and fatalism. With age, MA women had less fatalism, whereas NHW women had more fatalism after adjusting for education. Similarly, MA women had less depression with age, while depression scores for NHW women did not change with age. The greater optimism and decreased depression and fatalism with age may, at least partially, contribute to improved post-stroke survival among MA women. This requires further study. Overall, there was no ethnic difference in optimism, depression, or fatalism among men. Exploration of alternate factors mediating improved post-stroke survival among MA men is warranted.
Researchers have found that pre-stroke depression is associated with increased stroke mortality (Everson et al. 1998
; Gump et al. 2005
). However, gender, age, and ethnic variation with respect to pre-stroke depression have not been explored. Within the general population, the association of ethnicity and depression has been mixed. Researchers using the Health and Retirement Survey data have shown that depression is more frequent in elderly Hispanics and African Americans than NHWs (Dunlop et al. 2003
). On the other hand, using two other national surveys, researchers have found that NHWs were more likely to have major depression than Hispanics and African Americans (Hasin et al. 2005
; Riolo et al. 2005
). A recent study using longitudinal Health and Retirement Study data explored the relationship of aging and ethnicity with respect to depression. Researchers found that Hispanics have higher levels of depression, but have a greater decrease in depression symptoms with age compared to NHWs. (Xiao et al. 2010
). To our knowledge, no studies have evaluated ethnic and/or gender, age variation in pre-stroke optimism or fatalism. Thus, our findings of age- and gender-specific ethnic associations with respect to optimism, depression, and fatalism in stroke patients are novel.
There are several limitations to the current work that deserve discussion. Religiosity is very complex and difficult to measure. Currently, there is no standard approach to measure religiosity (Hall et al. 2008
). Most commonly, studies of the association of religion and outcomes query the frequency of religious attendance, termed organizational religiousness (Hall et al. 2008
). However, more personal forms of religion also exist, such as private prayer or meditation, which is often termed spirituality or non-organized religion (Hall et al. 2008
; Strawbridge et al. 1998
). This form of religion lacks social network/support, which may be a component of the protective mechanism of religion (George et al. 2002
). Even in a pre-stroke patient population, measuring religious attendance introduces bias as the person must be healthy enough to attend religious services. Thus, we queried the importance of religious or spiritual beliefs to everyday life and as a source of meaning in stroke patients lives, using a validated measure, to attempt to account for any possible physical limitations, which may prevent participation in religious services.
Due to the highly personal nature of the SDH questions, we did not use proxies for patients who were unable to complete the surveys. Thus, our study is biased towards less severely affected stroke patients. Also, we included patients who have had either TIA, ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage, which may differ with respect to potential mediators of SDH or other factors that influence SDH. In addition, ethnicity was self-reported and based on broad census–based categories. There are likely non-homogeneities within these ethnic groups that we did not capture. Small sample size is a limitation and may have contributed to some of the borderline significant results. Interviews were not recorded, and we are unable to explore the influence of interviewer phraseology on the questionnaire responses. However, the use of structured English and Spanish interviews reduces the likelihood of phraseology problems during interviews. Finally, there are likely other mediators, such as social support and neighborhood characteristics, that may be important components of the pathway by which social determinants affect health that were not explored. We suggest that additional mediators should be examined.
In summary, pre-stroke spirituality was associated with ethnicity. Ethnic associations with pre-stroke depression, fatalism, and optimism varied by gender and age. Spirituality may, in part, explain improved post-stroke survival in MAs compared with NHWs, while less fatalism and depression and more optimism in MA women compared with NHW women may be related to better post-stroke survival in this subgroup. These hypotheses require further study.